hospital_name,last_updated_on,version,location_name,hospital_address,type_2_npi,license_number|WI,attester_name,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",,,,,,,,,,,,,,,,,,,
ST VINCENT HOSPITAL,2026-03-24,3.0.0,ST VINCENT HOSPITAL (ACU)|ST VINCENT HOSPITAL (REH),"835 SOUTH VAN BUREN STREET, GREEN BAY, WI 54307|835 SOUTH VAN BUREN STREET, GREEN BAY, WI 54307",1114908001|1801813399,19,Michael Scialdone,TRUE,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,modifiers,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|min,standard_charge|max,standard_charge|methodology,additional_generic_notes
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,AETNA,AETNA HSHS,553.60,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $856.97 in Billed Charges for Rev 278 = $553.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,AETNA,ALL COMMERCIAL AETNA,856.97,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $856.97 in Billed Charges for Rev 278 = $856.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,856.97,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $856.97 in Billed Charges for Rev 278 = $856.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,CENPATICO,ALL MEDICAID CENPATICO,856.97,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $856.97 in Billed Charges for Rev 278 = $856.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,728.42,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $856.97 in Billed Charges for Rev 278 = $728.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,CIGNA,ALL COMMERCIAL CIGNA,599.88,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $856.97 in Billed Charges for Rev 278 = $599.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,COFINITY,COFINITY,856.97,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $856.97 in Billed Charges for Rev 278 = $856.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,814.12,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $856.97 in Billed Charges for Rev 278 = $814.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,719.85,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $856.97 in Billed Charges for Rev 278 = $719.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,608.45,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $856.97 in Billed Charges for Rev 278 = $608.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,625.59,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $856.97 in Billed Charges for Rev 278 = $625.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,416.49,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $856.97 in Billed Charges for Rev 278 = $416.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,728.42,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $856.97 in Billed Charges for Rev 278 = $728.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,HUMANA,HUMANA CHOICE CARE PPO,728.42,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $856.97 in Billed Charges for Rev 278 = $728.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,625.59,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $856.97 in Billed Charges for Rev 278 = $625.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,856.97,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $856.97 in Billed Charges for Rev 278 = $856.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,428.49,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $856.97 in Billed Charges for Rev 278 = $428.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,719.85,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $856.97 in Billed Charges for Rev 278 = $719.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,642.73,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $856.97 in Billed Charges for Rev 278 = $642.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,788.41,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $856.97 in Billed Charges for Rev 278 = $788.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,547.00,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $856.97 in Billed Charges for Rev 278 = $547.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,617.02,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $856.97 in Billed Charges for Rev 278 = $617.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,617.02,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $856.97 in Billed Charges for Rev 278 = $617.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,531.32,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $856.97 in Billed Charges for Rev 278 = $531.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,617.02,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $856.97 in Billed Charges for Rev 278 = $617.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,617.02,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $856.97 in Billed Charges for Rev 278 = $617.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURSYM STANDARD PERMANENT CURVED 15.3MM,278,RC,10069277,CDM,,,,,,both,,,856.9700,565.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,514.18,,,,,,,416.4900,856.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $856.97 in Billed Charges for Rev 278 = $514.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,AETNA,AETNA HSHS,532.28,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $823.97 in Billed Charges for Rev 278 = $532.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,AETNA,ALL COMMERCIAL AETNA,823.97,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.97 in Billed Charges for Rev 278 = $823.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,823.97,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.97 in Billed Charges for Rev 278 = $823.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,CENPATICO,ALL MEDICAID CENPATICO,823.97,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.97 in Billed Charges for Rev 278 = $823.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,700.37,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.97 in Billed Charges for Rev 278 = $700.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,CIGNA,ALL COMMERCIAL CIGNA,576.78,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $823.97 in Billed Charges for Rev 278 = $576.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,COFINITY,COFINITY,823.97,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.97 in Billed Charges for Rev 278 = $823.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,782.77,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $823.97 in Billed Charges for Rev 278 = $782.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,692.13,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $823.97 in Billed Charges for Rev 278 = $692.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,585.02,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $823.97 in Billed Charges for Rev 278 = $585.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,601.50,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $823.97 in Billed Charges for Rev 278 = $601.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,400.45,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $823.97 in Billed Charges for Rev 278 = $400.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,700.37,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.97 in Billed Charges for Rev 278 = $700.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,HUMANA,HUMANA CHOICE CARE PPO,700.37,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.97 in Billed Charges for Rev 278 = $700.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,601.50,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $823.97 in Billed Charges for Rev 278 = $601.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,823.97,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.97 in Billed Charges for Rev 278 = $823.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,411.99,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $823.97 in Billed Charges for Rev 278 = $411.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,692.13,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $823.97 in Billed Charges for Rev 278 = $692.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,617.98,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $823.97 in Billed Charges for Rev 278 = $617.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,758.05,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $823.97 in Billed Charges for Rev 278 = $758.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,525.94,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $823.97 in Billed Charges for Rev 278 = $525.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,593.26,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.97 in Billed Charges for Rev 278 = $593.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,593.26,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.97 in Billed Charges for Rev 278 = $593.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,510.86,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $823.97 in Billed Charges for Rev 278 = $510.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,593.26,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.97 in Billed Charges for Rev 278 = $593.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,593.26,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.97 in Billed Charges for Rev 278 = $593.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD CURVED 6.4MM,278,RC,10001212,CDM,,,,,,both,,,823.9700,543.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,494.38,,,,,,,400.4500,823.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $823.97 in Billed Charges for Rev 278 = $494.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,AETNA,AETNA HSHS,23.26,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $36.00 in Billed Charges for Rev 278 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,AETNA,ALL COMMERCIAL AETNA,36.00,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.00 in Billed Charges for Rev 278 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,36.00,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.00 in Billed Charges for Rev 278 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,CENPATICO,ALL MEDICAID CENPATICO,36.00,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.00 in Billed Charges for Rev 278 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,30.60,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.00 in Billed Charges for Rev 278 = $30.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,CIGNA,ALL COMMERCIAL CIGNA,25.20,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $36.00 in Billed Charges for Rev 278 = $25.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,COFINITY,COFINITY,36.00,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.00 in Billed Charges for Rev 278 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,34.20,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $36.00 in Billed Charges for Rev 278 = $34.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,30.24,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $36.00 in Billed Charges for Rev 278 = $30.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,25.56,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $36.00 in Billed Charges for Rev 278 = $25.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,26.28,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $36.00 in Billed Charges for Rev 278 = $26.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,17.50,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $36.00 in Billed Charges for Rev 278 = $17.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,30.60,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.00 in Billed Charges for Rev 278 = $30.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,HUMANA,HUMANA CHOICE CARE PPO,30.60,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.00 in Billed Charges for Rev 278 = $30.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,26.28,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $36.00 in Billed Charges for Rev 278 = $26.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,36.00,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.00 in Billed Charges for Rev 278 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,18.00,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $36.00 in Billed Charges for Rev 278 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,30.24,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $36.00 in Billed Charges for Rev 278 = $30.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,27.00,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $36.00 in Billed Charges for Rev 278 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,33.12,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $36.00 in Billed Charges for Rev 278 = $33.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,22.98,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $36.00 in Billed Charges for Rev 278 = $22.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,25.92,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.00 in Billed Charges for Rev 278 = $25.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,25.92,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.00 in Billed Charges for Rev 278 = $25.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,22.32,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $36.00 in Billed Charges for Rev 278 = $22.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,25.92,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.00 in Billed Charges for Rev 278 = $25.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,25.92,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.00 in Billed Charges for Rev 278 = $25.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONFORMER CLEAR VENT MEDIUM,278,RC,10043547,CDM,,,,,,both,,,36.0000,23.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,21.60,,,,,,,17.5000,36.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $36.00 in Billed Charges for Rev 278 = $21.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,AETNA,AETNA HSHS,697.91,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,080.35 in Billed Charges for Rev 278 = $697.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,AETNA,ALL COMMERCIAL AETNA,1080.35,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.35 in Billed Charges for Rev 278 = $1,080.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,ANTHEM,ANTHEM POS/HMO,561.78,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,080.35 in Billed Charges for Rev 278 = $561.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,ANTHEM,ANTHEM PPO,561.78,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,080.35 in Billed Charges for Rev 278 = $561.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1080.35,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.35 in Billed Charges for Rev 278 = $1,080.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,CENPATICO,ALL MEDICAID CENPATICO,1080.35,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.35 in Billed Charges for Rev 278 = $1,080.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,918.30,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,080.35 in Billed Charges for Rev 278 = $918.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,CIGNA,ALL COMMERCIAL CIGNA,756.25,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,080.35 in Billed Charges for Rev 278 = $756.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,COFINITY,COFINITY,1080.35,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.35 in Billed Charges for Rev 278 = $1,080.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1026.33,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,080.35 in Billed Charges for Rev 278 = $1,026.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,HEALTH CARE ALLIANCE,THE ALLIANCE,907.49,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,080.35 in Billed Charges for Rev 278 = $907.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,767.05,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,080.35 in Billed Charges for Rev 278 = $767.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,788.66,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,080.35 in Billed Charges for Rev 278 = $788.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,HSHS EMPLOYEES,HSHS EMPLOYEES,525.05,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,080.35 in Billed Charges for Rev 278 = $525.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,918.30,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,080.35 in Billed Charges for Rev 278 = $918.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,HUMANA,HUMANA CHOICE CARE PPO,918.30,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,080.35 in Billed Charges for Rev 278 = $918.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,788.66,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,080.35 in Billed Charges for Rev 278 = $788.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1080.35,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.35 in Billed Charges for Rev 278 = $1,080.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,540.18,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,080.35 in Billed Charges for Rev 278 = $540.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,907.49,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,080.35 in Billed Charges for Rev 278 = $907.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,810.26,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,080.35 in Billed Charges for Rev 278 = $810.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,993.92,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,080.35 in Billed Charges for Rev 278 = $993.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,689.59,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,080.35 in Billed Charges for Rev 278 = $689.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,777.85,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,080.35 in Billed Charges for Rev 278 = $777.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,777.85,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,080.35 in Billed Charges for Rev 278 = $777.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,669.82,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,080.35 in Billed Charges for Rev 278 = $669.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,777.85,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,080.35 in Billed Charges for Rev 278 = $777.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,777.85,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,080.35 in Billed Charges for Rev 278 = $777.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 30 DEG 11MM,278,RC,70409889,CDM,,,,,,both,,,1080.3500,713.0300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,648.21,,,,,,,525.0500,1080.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,080.35 in Billed Charges for Rev 278 = $648.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,AETNA,AETNA HSHS,1219.68,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,888.05 in Billed Charges for Rev 278 = $1,219.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,AETNA,ALL COMMERCIAL AETNA,1888.05,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,888.05 in Billed Charges for Rev 278 = $1,888.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,ANTHEM,ANTHEM POS/HMO,981.79,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,888.05 in Billed Charges for Rev 278 = $981.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,ANTHEM,ANTHEM PPO,981.79,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,888.05 in Billed Charges for Rev 278 = $981.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1888.05,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,888.05 in Billed Charges for Rev 278 = $1,888.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,CENPATICO,ALL MEDICAID CENPATICO,1888.05,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,888.05 in Billed Charges for Rev 278 = $1,888.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1604.84,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,888.05 in Billed Charges for Rev 278 = $1,604.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,CIGNA,ALL COMMERCIAL CIGNA,1321.64,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,888.05 in Billed Charges for Rev 278 = $1,321.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,COFINITY,COFINITY,1888.05,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,888.05 in Billed Charges for Rev 278 = $1,888.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1793.65,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,888.05 in Billed Charges for Rev 278 = $1,793.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,1585.96,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,888.05 in Billed Charges for Rev 278 = $1,585.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1340.52,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,888.05 in Billed Charges for Rev 278 = $1,340.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1378.28,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,888.05 in Billed Charges for Rev 278 = $1,378.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,917.59,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,888.05 in Billed Charges for Rev 278 = $917.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1604.84,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,888.05 in Billed Charges for Rev 278 = $1,604.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,HUMANA,HUMANA CHOICE CARE PPO,1604.84,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,888.05 in Billed Charges for Rev 278 = $1,604.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1378.28,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,888.05 in Billed Charges for Rev 278 = $1,378.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1888.05,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,888.05 in Billed Charges for Rev 278 = $1,888.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,944.03,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,888.05 in Billed Charges for Rev 278 = $944.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1585.96,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,888.05 in Billed Charges for Rev 278 = $1,585.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1416.04,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,888.05 in Billed Charges for Rev 278 = $1,416.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1737.01,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,888.05 in Billed Charges for Rev 278 = $1,737.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1205.14,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,888.05 in Billed Charges for Rev 278 = $1,205.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1359.40,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,888.05 in Billed Charges for Rev 278 = $1,359.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1359.40,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,888.05 in Billed Charges for Rev 278 = $1,359.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1170.59,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,888.05 in Billed Charges for Rev 278 = $1,170.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1359.40,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,888.05 in Billed Charges for Rev 278 = $1,359.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1359.40,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,888.05 in Billed Charges for Rev 278 = $1,359.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO PIN 4/5/6MM PINS,278,RC,10071098,CDM,,,,,,both,,,1888.0500,1246.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1132.83,,,,,,,917.5900,1888.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,888.05 in Billed Charges for Rev 278 = $1,132.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,AETNA,AETNA HSHS,1116.38,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,728.15 in Billed Charges for Rev 278 = $1,116.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,AETNA,ALL COMMERCIAL AETNA,1728.15,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,728.15 in Billed Charges for Rev 278 = $1,728.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,ANTHEM,ANTHEM POS/HMO,898.64,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,728.15 in Billed Charges for Rev 278 = $898.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,ANTHEM,ANTHEM PPO,898.64,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,728.15 in Billed Charges for Rev 278 = $898.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1728.15,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,728.15 in Billed Charges for Rev 278 = $1,728.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,CENPATICO,ALL MEDICAID CENPATICO,1728.15,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,728.15 in Billed Charges for Rev 278 = $1,728.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1468.93,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,728.15 in Billed Charges for Rev 278 = $1,468.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,CIGNA,ALL COMMERCIAL CIGNA,1209.71,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,728.15 in Billed Charges for Rev 278 = $1,209.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,COFINITY,COFINITY,1728.15,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,728.15 in Billed Charges for Rev 278 = $1,728.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1641.74,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,728.15 in Billed Charges for Rev 278 = $1,641.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,1451.65,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,728.15 in Billed Charges for Rev 278 = $1,451.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1226.99,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,728.15 in Billed Charges for Rev 278 = $1,226.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1261.55,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,728.15 in Billed Charges for Rev 278 = $1,261.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,839.88,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,728.15 in Billed Charges for Rev 278 = $839.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1468.93,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,728.15 in Billed Charges for Rev 278 = $1,468.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,HUMANA,HUMANA CHOICE CARE PPO,1468.93,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,728.15 in Billed Charges for Rev 278 = $1,468.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1261.55,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,728.15 in Billed Charges for Rev 278 = $1,261.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1728.15,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,728.15 in Billed Charges for Rev 278 = $1,728.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,864.08,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,728.15 in Billed Charges for Rev 278 = $864.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1451.65,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,728.15 in Billed Charges for Rev 278 = $1,451.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1296.11,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,728.15 in Billed Charges for Rev 278 = $1,296.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1589.90,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,728.15 in Billed Charges for Rev 278 = $1,589.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1103.08,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,728.15 in Billed Charges for Rev 278 = $1,103.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1244.27,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,728.15 in Billed Charges for Rev 278 = $1,244.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1244.27,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,728.15 in Billed Charges for Rev 278 = $1,244.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1071.45,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,728.15 in Billed Charges for Rev 278 = $1,071.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1244.27,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,728.15 in Billed Charges for Rev 278 = $1,244.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1244.27,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,728.15 in Billed Charges for Rev 278 = $1,244.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 DELTA PIN TO ROD 4/5/6MM PINS,278,RC,10071097,CDM,,,,,,both,,,1728.1500,1140.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1036.89,,,,,,,839.8800,1728.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,728.15 in Billed Charges for Rev 278 = $1,036.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,AETNA,AETNA HSHS,1318.72,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,041.36 in Billed Charges for Rev 278 = $1,318.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,AETNA,ALL COMMERCIAL AETNA,2041.36,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,041.36 in Billed Charges for Rev 278 = $2,041.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,ANTHEM,ANTHEM POS/HMO,1061.51,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,041.36 in Billed Charges for Rev 278 = $1,061.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,ANTHEM,ANTHEM PPO,1061.51,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,041.36 in Billed Charges for Rev 278 = $1,061.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2041.36,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,041.36 in Billed Charges for Rev 278 = $2,041.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,CENPATICO,ALL MEDICAID CENPATICO,2041.36,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,041.36 in Billed Charges for Rev 278 = $2,041.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1735.16,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,041.36 in Billed Charges for Rev 278 = $1,735.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,CIGNA,ALL COMMERCIAL CIGNA,1428.95,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,041.36 in Billed Charges for Rev 278 = $1,428.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,COFINITY,COFINITY,2041.36,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,041.36 in Billed Charges for Rev 278 = $2,041.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1939.29,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,041.36 in Billed Charges for Rev 278 = $1,939.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,1714.74,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,041.36 in Billed Charges for Rev 278 = $1,714.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1449.37,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,041.36 in Billed Charges for Rev 278 = $1,449.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1490.19,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,041.36 in Billed Charges for Rev 278 = $1,490.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,992.10,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,041.36 in Billed Charges for Rev 278 = $992.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1735.16,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,041.36 in Billed Charges for Rev 278 = $1,735.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,HUMANA,HUMANA CHOICE CARE PPO,1735.16,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,041.36 in Billed Charges for Rev 278 = $1,735.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1490.19,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,041.36 in Billed Charges for Rev 278 = $1,490.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2041.36,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,041.36 in Billed Charges for Rev 278 = $2,041.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1020.68,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,041.36 in Billed Charges for Rev 278 = $1,020.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1714.74,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,041.36 in Billed Charges for Rev 278 = $1,714.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1531.02,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,041.36 in Billed Charges for Rev 278 = $1,531.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1878.05,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,041.36 in Billed Charges for Rev 278 = $1,878.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1303.00,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,041.36 in Billed Charges for Rev 278 = $1,303.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1469.78,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,041.36 in Billed Charges for Rev 278 = $1,469.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1469.78,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,041.36 in Billed Charges for Rev 278 = $1,469.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1265.64,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,041.36 in Billed Charges for Rev 278 = $1,265.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1469.78,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,041.36 in Billed Charges for Rev 278 = $1,469.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1469.78,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,041.36 in Billed Charges for Rev 278 = $1,469.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COUPLING STRYKER HOFFMAN 3 PIN TO ROD 4/5/6MM 5/8/11MM,278,RC,70409887,CDM,,,,,,both,,,2041.3600,1347.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1224.82,,,,,,,992.1000,2041.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,041.36 in Billed Charges for Rev 278 = $1,224.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,AETNA,AETNA HSHS,2856.48,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,421.79 in Billed Charges for Rev 278 = $2,856.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,AETNA,ALL COMMERCIAL AETNA,4421.79,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,421.79 in Billed Charges for Rev 278 = $4,421.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,ANTHEM,ANTHEM POS/HMO,2299.33,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,421.79 in Billed Charges for Rev 278 = $2,299.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,ANTHEM,ANTHEM PPO,2299.33,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,421.79 in Billed Charges for Rev 278 = $2,299.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4421.79,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,421.79 in Billed Charges for Rev 278 = $4,421.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,CENPATICO,ALL MEDICAID CENPATICO,4421.79,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,421.79 in Billed Charges for Rev 278 = $4,421.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3758.52,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,421.79 in Billed Charges for Rev 278 = $3,758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,CIGNA,ALL COMMERCIAL CIGNA,3095.25,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,421.79 in Billed Charges for Rev 278 = $3,095.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,COFINITY,COFINITY,4421.79,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,421.79 in Billed Charges for Rev 278 = $4,421.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4200.70,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,421.79 in Billed Charges for Rev 278 = $4,200.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,3714.30,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,421.79 in Billed Charges for Rev 278 = $3,714.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3139.47,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,421.79 in Billed Charges for Rev 278 = $3,139.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3227.91,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,421.79 in Billed Charges for Rev 278 = $3,227.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,2148.99,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,421.79 in Billed Charges for Rev 278 = $2,148.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3758.52,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,421.79 in Billed Charges for Rev 278 = $3,758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,HUMANA,HUMANA CHOICE CARE HMO,2210.90,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,421.79 in Billed Charges for Rev 278 = $2,210.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,HUMANA,HUMANA CHOICE CARE PPO,3758.52,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,421.79 in Billed Charges for Rev 278 = $3,758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,HUMANA,HUMANA NATIIONAL POS HMO,2210.90,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,421.79 in Billed Charges for Rev 278 = $2,210.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3227.91,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,421.79 in Billed Charges for Rev 278 = $3,227.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,4421.79,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,421.79 in Billed Charges for Rev 278 = $4,421.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2210.90,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,421.79 in Billed Charges for Rev 278 = $2,210.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3714.30,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,421.79 in Billed Charges for Rev 278 = $3,714.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3316.34,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,421.79 in Billed Charges for Rev 278 = $3,316.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4068.05,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,421.79 in Billed Charges for Rev 278 = $4,068.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2822.43,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,421.79 in Billed Charges for Rev 278 = $2,822.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3183.69,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,421.79 in Billed Charges for Rev 278 = $3,183.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3183.69,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,421.79 in Billed Charges for Rev 278 = $3,183.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2741.51,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,421.79 in Billed Charges for Rev 278 = $2,741.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3183.69,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,421.79 in Billed Charges for Rev 278 = $3,183.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3183.69,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,421.79 in Billed Charges for Rev 278 = $3,183.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 70MM X 40MM,278,RC,10049593,CDM,,,,,,both,,,4421.7900,2918.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2653.07,,,,,,,2148.9900,4421.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,421.79 in Billed Charges for Rev 278 = $2,653.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,AETNA,AETNA HSHS,494.14,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $764.93 in Billed Charges for Rev 278 = $494.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,AETNA,ALL COMMERCIAL AETNA,764.93,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $764.93 in Billed Charges for Rev 278 = $764.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,764.93,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $764.93 in Billed Charges for Rev 278 = $764.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,CENPATICO,ALL MEDICAID CENPATICO,764.93,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $764.93 in Billed Charges for Rev 278 = $764.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,650.19,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $764.93 in Billed Charges for Rev 278 = $650.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,CIGNA,ALL COMMERCIAL CIGNA,535.45,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $764.93 in Billed Charges for Rev 278 = $535.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,COFINITY,COFINITY,764.93,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $764.93 in Billed Charges for Rev 278 = $764.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,726.68,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $764.93 in Billed Charges for Rev 278 = $726.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,HEALTH CARE ALLIANCE,THE ALLIANCE,642.54,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $764.93 in Billed Charges for Rev 278 = $642.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,543.10,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $764.93 in Billed Charges for Rev 278 = $543.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,558.40,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $764.93 in Billed Charges for Rev 278 = $558.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,HSHS EMPLOYEES,HSHS EMPLOYEES,371.76,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $764.93 in Billed Charges for Rev 278 = $371.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,650.19,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $764.93 in Billed Charges for Rev 278 = $650.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,HUMANA,HUMANA CHOICE CARE PPO,650.19,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $764.93 in Billed Charges for Rev 278 = $650.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,558.40,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $764.93 in Billed Charges for Rev 278 = $558.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,LIVE360,LIVE360 HSHS HEALTHY PLAN,764.93,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $764.93 in Billed Charges for Rev 278 = $764.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,382.47,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $764.93 in Billed Charges for Rev 278 = $382.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,642.54,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $764.93 in Billed Charges for Rev 278 = $642.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,573.70,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $764.93 in Billed Charges for Rev 278 = $573.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,703.74,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $764.93 in Billed Charges for Rev 278 = $703.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,488.25,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $764.93 in Billed Charges for Rev 278 = $488.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,550.75,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $764.93 in Billed Charges for Rev 278 = $550.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,550.75,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $764.93 in Billed Charges for Rev 278 = $550.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,474.26,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $764.93 in Billed Charges for Rev 278 = $474.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,550.75,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $764.93 in Billed Charges for Rev 278 = $550.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,550.75,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $764.93 in Billed Charges for Rev 278 = $550.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX  ONLAY 1 X 3  (CDSLM13),278,RC,10033204,CDM,,,,,,both,,,764.9300,504.8500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,458.96,,,,,,,371.7600,764.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $764.93 in Billed Charges for Rev 278 = $458.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,AETNA,AETNA HSHS,1066.15,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,650.39 in Billed Charges for Rev 278 = $1,066.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,AETNA,ALL COMMERCIAL AETNA,1650.39,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,650.39 in Billed Charges for Rev 278 = $1,650.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,ANTHEM,ANTHEM POS/HMO,858.20,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,650.39 in Billed Charges for Rev 278 = $858.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,ANTHEM,ANTHEM PPO,858.20,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,650.39 in Billed Charges for Rev 278 = $858.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1650.39,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,650.39 in Billed Charges for Rev 278 = $1,650.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,CENPATICO,ALL MEDICAID CENPATICO,1650.39,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,650.39 in Billed Charges for Rev 278 = $1,650.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1402.83,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,650.39 in Billed Charges for Rev 278 = $1,402.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,CIGNA,ALL COMMERCIAL CIGNA,1155.27,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,650.39 in Billed Charges for Rev 278 = $1,155.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,COFINITY,COFINITY,1650.39,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,650.39 in Billed Charges for Rev 278 = $1,650.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1567.87,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,650.39 in Billed Charges for Rev 278 = $1,567.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,1386.33,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,650.39 in Billed Charges for Rev 278 = $1,386.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1171.78,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,650.39 in Billed Charges for Rev 278 = $1,171.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1204.78,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,650.39 in Billed Charges for Rev 278 = $1,204.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,802.09,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,650.39 in Billed Charges for Rev 278 = $802.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1402.83,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,650.39 in Billed Charges for Rev 278 = $1,402.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,HUMANA,HUMANA CHOICE CARE PPO,1402.83,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,650.39 in Billed Charges for Rev 278 = $1,402.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1204.78,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,650.39 in Billed Charges for Rev 278 = $1,204.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1650.39,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,650.39 in Billed Charges for Rev 278 = $1,650.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,825.20,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,650.39 in Billed Charges for Rev 278 = $825.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1386.33,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,650.39 in Billed Charges for Rev 278 = $1,386.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1237.79,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,650.39 in Billed Charges for Rev 278 = $1,237.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1518.36,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,650.39 in Billed Charges for Rev 278 = $1,518.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1053.44,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,650.39 in Billed Charges for Rev 278 = $1,053.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1188.28,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,650.39 in Billed Charges for Rev 278 = $1,188.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1188.28,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,650.39 in Billed Charges for Rev 278 = $1,188.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1023.24,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,650.39 in Billed Charges for Rev 278 = $1,023.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1188.28,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,650.39 in Billed Charges for Rev 278 = $1,188.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1188.28,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,650.39 in Billed Charges for Rev 278 = $1,188.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY 3 X 3  (CDSLM33),278,RC,10033206,CDM,,,,,,both,,,1650.3900,1089.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,990.23,,,,,,,802.0900,1650.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,650.39 in Billed Charges for Rev 278 = $990.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,AETNA,AETNA HSHS,1291.37,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,999.02 in Billed Charges for Rev 278 = $1,291.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,AETNA,ALL COMMERCIAL AETNA,1999.02,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,999.02 in Billed Charges for Rev 278 = $1,999.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,ANTHEM,ANTHEM POS/HMO,1039.49,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,999.02 in Billed Charges for Rev 278 = $1,039.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,ANTHEM,ANTHEM PPO,1039.49,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,999.02 in Billed Charges for Rev 278 = $1,039.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1999.02,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,999.02 in Billed Charges for Rev 278 = $1,999.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,CENPATICO,ALL MEDICAID CENPATICO,1999.02,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,999.02 in Billed Charges for Rev 278 = $1,999.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1699.17,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,999.02 in Billed Charges for Rev 278 = $1,699.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,CIGNA,ALL COMMERCIAL CIGNA,1399.31,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,999.02 in Billed Charges for Rev 278 = $1,399.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,COFINITY,COFINITY,1999.02,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,999.02 in Billed Charges for Rev 278 = $1,999.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1899.07,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,999.02 in Billed Charges for Rev 278 = $1,899.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,1679.18,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,999.02 in Billed Charges for Rev 278 = $1,679.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1419.30,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,999.02 in Billed Charges for Rev 278 = $1,419.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1459.28,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,999.02 in Billed Charges for Rev 278 = $1,459.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,971.52,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,999.02 in Billed Charges for Rev 278 = $971.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1699.17,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,999.02 in Billed Charges for Rev 278 = $1,699.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,HUMANA,HUMANA CHOICE CARE PPO,1699.17,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,999.02 in Billed Charges for Rev 278 = $1,699.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1459.28,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,999.02 in Billed Charges for Rev 278 = $1,459.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1999.02,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,999.02 in Billed Charges for Rev 278 = $1,999.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,999.51,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,999.02 in Billed Charges for Rev 278 = $999.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1679.18,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,999.02 in Billed Charges for Rev 278 = $1,679.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1499.27,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,999.02 in Billed Charges for Rev 278 = $1,499.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1839.10,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,999.02 in Billed Charges for Rev 278 = $1,839.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1275.97,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,999.02 in Billed Charges for Rev 278 = $1,275.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1439.29,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,999.02 in Billed Charges for Rev 278 = $1,439.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1439.29,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,999.02 in Billed Charges for Rev 278 = $1,439.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1239.39,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,999.02 in Billed Charges for Rev 278 = $1,239.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1439.29,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,999.02 in Billed Charges for Rev 278 = $1,439.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1439.29,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,999.02 in Billed Charges for Rev 278 = $1,439.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL EXACT SPINE 5ML,278,RC,10063933,CDM,,,,,,both,,,1999.0200,1319.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1199.41,,,,,,,971.5200,1999.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,999.02 in Billed Charges for Rev 278 = $1,199.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,AETNA,AETNA HSHS,444.45,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $688.00 in Billed Charges for Rev 278 = $444.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,AETNA,ALL COMMERCIAL AETNA,688.00,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $688.00 in Billed Charges for Rev 278 = $688.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,688.00,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $688.00 in Billed Charges for Rev 278 = $688.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,CENPATICO,ALL MEDICAID CENPATICO,688.00,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $688.00 in Billed Charges for Rev 278 = $688.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,584.80,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $688.00 in Billed Charges for Rev 278 = $584.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,CIGNA,ALL COMMERCIAL CIGNA,481.60,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $688.00 in Billed Charges for Rev 278 = $481.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,COFINITY,COFINITY,688.00,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $688.00 in Billed Charges for Rev 278 = $688.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,653.60,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $688.00 in Billed Charges for Rev 278 = $653.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,577.92,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $688.00 in Billed Charges for Rev 278 = $577.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,488.48,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $688.00 in Billed Charges for Rev 278 = $488.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,502.24,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $688.00 in Billed Charges for Rev 278 = $502.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,334.37,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $688.00 in Billed Charges for Rev 278 = $334.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,584.80,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $688.00 in Billed Charges for Rev 278 = $584.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,HUMANA,HUMANA CHOICE CARE PPO,584.80,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $688.00 in Billed Charges for Rev 278 = $584.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,502.24,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $688.00 in Billed Charges for Rev 278 = $502.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,688.00,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $688.00 in Billed Charges for Rev 278 = $688.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,344.00,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $688.00 in Billed Charges for Rev 278 = $344.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,577.92,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $688.00 in Billed Charges for Rev 278 = $577.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,516.00,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $688.00 in Billed Charges for Rev 278 = $516.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,632.96,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $688.00 in Billed Charges for Rev 278 = $632.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,439.15,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $688.00 in Billed Charges for Rev 278 = $439.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,495.36,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $688.00 in Billed Charges for Rev 278 = $495.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,495.36,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $688.00 in Billed Charges for Rev 278 = $495.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,426.56,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $688.00 in Billed Charges for Rev 278 = $426.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,495.36,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $688.00 in Billed Charges for Rev 278 = $495.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,495.36,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $688.00 in Billed Charges for Rev 278 = $495.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENDOTINE TRANSBLEPH BROW FIXATION DEVICE 3.5MM,278,RC,10051466,CDM,,,,,,both,,,688.0000,454.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,412.80,,,,,,,334.3700,688.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $688.00 in Billed Charges for Rev 278 = $412.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,AETNA,AETNA HSHS,583.34,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $903.00 in Billed Charges for Rev 278 = $583.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,AETNA,ALL COMMERCIAL AETNA,903.00,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $903.00 in Billed Charges for Rev 278 = $903.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,903.00,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $903.00 in Billed Charges for Rev 278 = $903.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,CENPATICO,ALL MEDICAID CENPATICO,903.00,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $903.00 in Billed Charges for Rev 278 = $903.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,767.55,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $903.00 in Billed Charges for Rev 278 = $767.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,CIGNA,ALL COMMERCIAL CIGNA,632.10,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $903.00 in Billed Charges for Rev 278 = $632.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,COFINITY,COFINITY,903.00,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $903.00 in Billed Charges for Rev 278 = $903.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,857.85,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $903.00 in Billed Charges for Rev 278 = $857.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,758.52,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $903.00 in Billed Charges for Rev 278 = $758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,641.13,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $903.00 in Billed Charges for Rev 278 = $641.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,659.19,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $903.00 in Billed Charges for Rev 278 = $659.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,438.86,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $903.00 in Billed Charges for Rev 278 = $438.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,767.55,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $903.00 in Billed Charges for Rev 278 = $767.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,HUMANA,HUMANA CHOICE CARE PPO,767.55,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $903.00 in Billed Charges for Rev 278 = $767.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,659.19,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $903.00 in Billed Charges for Rev 278 = $659.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,903.00,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $903.00 in Billed Charges for Rev 278 = $903.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,451.50,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $903.00 in Billed Charges for Rev 278 = $451.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,758.52,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $903.00 in Billed Charges for Rev 278 = $758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,677.25,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $903.00 in Billed Charges for Rev 278 = $677.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,830.76,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $903.00 in Billed Charges for Rev 278 = $830.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,576.38,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $903.00 in Billed Charges for Rev 278 = $576.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,650.16,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $903.00 in Billed Charges for Rev 278 = $650.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,650.16,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $903.00 in Billed Charges for Rev 278 = $650.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,559.86,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $903.00 in Billed Charges for Rev 278 = $559.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,650.16,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $903.00 in Billed Charges for Rev 278 = $650.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,650.16,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $903.00 in Billed Charges for Rev 278 = $650.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE 16MM CORE ALLOGRAFT CM2,278,RC,10069677,CDM,,,,,,both,,,903.0000,595.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,541.80,,,,,,,438.8600,903.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $903.00 in Billed Charges for Rev 278 = $541.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,AETNA,AETNA HSHS,361.45,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $559.52 in Billed Charges for Rev 278 = $361.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,AETNA,ALL COMMERCIAL AETNA,559.52,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.52 in Billed Charges for Rev 278 = $559.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,559.52,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.52 in Billed Charges for Rev 278 = $559.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,CENPATICO,ALL MEDICAID CENPATICO,559.52,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.52 in Billed Charges for Rev 278 = $559.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,475.59,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.52 in Billed Charges for Rev 278 = $475.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,CIGNA,ALL COMMERCIAL CIGNA,391.66,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $559.52 in Billed Charges for Rev 278 = $391.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,COFINITY,COFINITY,559.52,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.52 in Billed Charges for Rev 278 = $559.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,531.54,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $559.52 in Billed Charges for Rev 278 = $531.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,470.00,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $559.52 in Billed Charges for Rev 278 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,397.26,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $559.52 in Billed Charges for Rev 278 = $397.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,408.45,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $559.52 in Billed Charges for Rev 278 = $408.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,271.93,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $559.52 in Billed Charges for Rev 278 = $271.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,475.59,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.52 in Billed Charges for Rev 278 = $475.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,HUMANA,HUMANA CHOICE CARE PPO,475.59,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.52 in Billed Charges for Rev 278 = $475.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,408.45,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $559.52 in Billed Charges for Rev 278 = $408.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,559.52,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.52 in Billed Charges for Rev 278 = $559.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,279.76,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $559.52 in Billed Charges for Rev 278 = $279.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,470.00,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $559.52 in Billed Charges for Rev 278 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,419.64,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $559.52 in Billed Charges for Rev 278 = $419.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,514.76,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $559.52 in Billed Charges for Rev 278 = $514.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,357.14,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $559.52 in Billed Charges for Rev 278 = $357.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,402.85,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.52 in Billed Charges for Rev 278 = $402.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,402.85,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.52 in Billed Charges for Rev 278 = $402.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,346.90,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $559.52 in Billed Charges for Rev 278 = $346.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,402.85,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.52 in Billed Charges for Rev 278 = $402.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,402.85,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.52 in Billed Charges for Rev 278 = $402.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAL PERICARDIUM BP 2CM X 7CM INTEGRA,278,RC,10068157,CDM,,,,,,both,,,559.5200,369.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,335.71,,,,,,,271.9300,559.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $559.52 in Billed Charges for Rev 278 = $335.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,AETNA,AETNA HSHS,6860.52,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $10,620.00 in Billed Charges for Rev 278 = $6,860.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,AETNA,ALL COMMERCIAL AETNA,10620.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,620.00 in Billed Charges for Rev 278 = $10,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,ANTHEM,ANTHEM POS/HMO,5522.40,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,620.00 in Billed Charges for Rev 278 = $5,522.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,ANTHEM,ANTHEM PPO,5522.40,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,620.00 in Billed Charges for Rev 278 = $5,522.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10620.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,620.00 in Billed Charges for Rev 278 = $10,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,CENPATICO,ALL MEDICAID CENPATICO,10620.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,620.00 in Billed Charges for Rev 278 = $10,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9027.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,620.00 in Billed Charges for Rev 278 = $9,027.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,CIGNA,ALL COMMERCIAL CIGNA,7434.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $10,620.00 in Billed Charges for Rev 278 = $7,434.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,COFINITY,COFINITY,10620.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,620.00 in Billed Charges for Rev 278 = $10,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10089.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $10,620.00 in Billed Charges for Rev 278 = $10,089.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,8920.80,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,620.00 in Billed Charges for Rev 278 = $8,920.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7540.20,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $10,620.00 in Billed Charges for Rev 278 = $7,540.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7752.60,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,620.00 in Billed Charges for Rev 278 = $7,752.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,5161.32,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $10,620.00 in Billed Charges for Rev 278 = $5,161.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9027.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,620.00 in Billed Charges for Rev 278 = $9,027.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,HUMANA,HUMANA CHOICE CARE HMO,5310.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,620.00 in Billed Charges for Rev 278 = $5,310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,HUMANA,HUMANA CHOICE CARE PPO,9027.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,620.00 in Billed Charges for Rev 278 = $9,027.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,HUMANA,HUMANA NATIIONAL POS HMO,5310.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,620.00 in Billed Charges for Rev 278 = $5,310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7752.60,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,620.00 in Billed Charges for Rev 278 = $7,752.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,10620.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,620.00 in Billed Charges for Rev 278 = $10,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5310.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,620.00 in Billed Charges for Rev 278 = $5,310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8920.80,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,620.00 in Billed Charges for Rev 278 = $8,920.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7965.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $10,620.00 in Billed Charges for Rev 278 = $7,965.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9770.40,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $10,620.00 in Billed Charges for Rev 278 = $9,770.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5310.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,620.00 in Billed Charges for Rev 278 = $5,310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5310.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,620.00 in Billed Charges for Rev 278 = $5,310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,PREVEA HEALTH NETWORK,PREVEA360,5310.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,620.00 in Billed Charges for Rev 278 = $5,310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5310.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,620.00 in Billed Charges for Rev 278 = $5,310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6778.75,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $10,620.00 in Billed Charges for Rev 278 = $6,778.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7646.40,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,620.00 in Billed Charges for Rev 278 = $7,646.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4948.92,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,620.00 in Billed Charges for Rev 278 = $4,948.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,4948.92,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,620.00 in Billed Charges for Rev 278 = $4,948.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,4948.92,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,620.00 in Billed Charges for Rev 278 = $4,948.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7646.40,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,620.00 in Billed Charges for Rev 278 = $7,646.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6584.40,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $10,620.00 in Billed Charges for Rev 278 = $6,584.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7646.40,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,620.00 in Billed Charges for Rev 278 = $7,646.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7646.40,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,620.00 in Billed Charges for Rev 278 = $7,646.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE MEDIUM,278,RC,10005435,CDM,,,,,,both,,,10620.0000,7009.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6372.00,,,,,,,4948.9200,10620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $10,620.00 in Billed Charges for Rev 278 = $6,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,AETNA,AETNA HSHS,1730.63,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,679.00 in Billed Charges for Rev 278 = $1,730.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,AETNA,ALL COMMERCIAL AETNA,2679.00,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,679.00 in Billed Charges for Rev 278 = $2,679.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,ANTHEM,ANTHEM POS/HMO,1393.08,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,679.00 in Billed Charges for Rev 278 = $1,393.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,ANTHEM,ANTHEM PPO,1393.08,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,679.00 in Billed Charges for Rev 278 = $1,393.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2679.00,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,679.00 in Billed Charges for Rev 278 = $2,679.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,CENPATICO,ALL MEDICAID CENPATICO,2679.00,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,679.00 in Billed Charges for Rev 278 = $2,679.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2277.15,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,679.00 in Billed Charges for Rev 278 = $2,277.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,CIGNA,ALL COMMERCIAL CIGNA,1875.30,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,679.00 in Billed Charges for Rev 278 = $1,875.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,COFINITY,COFINITY,2679.00,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,679.00 in Billed Charges for Rev 278 = $2,679.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2545.05,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,679.00 in Billed Charges for Rev 278 = $2,545.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,2250.36,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,679.00 in Billed Charges for Rev 278 = $2,250.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1902.09,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,679.00 in Billed Charges for Rev 278 = $1,902.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1955.67,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,679.00 in Billed Charges for Rev 278 = $1,955.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,1301.99,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,679.00 in Billed Charges for Rev 278 = $1,301.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2277.15,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,679.00 in Billed Charges for Rev 278 = $2,277.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,HUMANA,HUMANA CHOICE CARE HMO,1339.50,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,679.00 in Billed Charges for Rev 278 = $1,339.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,HUMANA,HUMANA CHOICE CARE PPO,2277.15,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,679.00 in Billed Charges for Rev 278 = $2,277.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,HUMANA,HUMANA NATIIONAL POS HMO,1339.50,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,679.00 in Billed Charges for Rev 278 = $1,339.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1955.67,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,679.00 in Billed Charges for Rev 278 = $1,955.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2679.00,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,679.00 in Billed Charges for Rev 278 = $2,679.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1339.50,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,679.00 in Billed Charges for Rev 278 = $1,339.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2250.36,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,679.00 in Billed Charges for Rev 278 = $2,250.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2009.25,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,679.00 in Billed Charges for Rev 278 = $2,009.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2464.68,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,679.00 in Billed Charges for Rev 278 = $2,464.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1710.01,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,679.00 in Billed Charges for Rev 278 = $1,710.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1928.88,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,679.00 in Billed Charges for Rev 278 = $1,928.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1928.88,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,679.00 in Billed Charges for Rev 278 = $1,928.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1660.98,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,679.00 in Billed Charges for Rev 278 = $1,660.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1928.88,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,679.00 in Billed Charges for Rev 278 = $1,928.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1928.88,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,679.00 in Billed Charges for Rev 278 = $1,928.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 2X1.5CM GRFX CORE 3SQ CM PLCNT MEMBRN ALOGRFT,278,RC,10068383,CDM,,,,,,both,,,2679.0000,1768.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1607.40,,,,,,,1301.9900,2679.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,679.00 in Billed Charges for Rev 278 = $1,607.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,AETNA,AETNA HSHS,1660.67,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,570.70 in Billed Charges for Rev 278 = $1,660.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,AETNA,ALL COMMERCIAL AETNA,2570.70,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,570.70 in Billed Charges for Rev 278 = $2,570.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,ANTHEM,ANTHEM POS/HMO,1336.76,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,570.70 in Billed Charges for Rev 278 = $1,336.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,ANTHEM,ANTHEM PPO,1336.76,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,570.70 in Billed Charges for Rev 278 = $1,336.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2570.70,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,570.70 in Billed Charges for Rev 278 = $2,570.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,CENPATICO,ALL MEDICAID CENPATICO,2570.70,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,570.70 in Billed Charges for Rev 278 = $2,570.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2185.10,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,570.70 in Billed Charges for Rev 278 = $2,185.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,CIGNA,ALL COMMERCIAL CIGNA,1799.49,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,570.70 in Billed Charges for Rev 278 = $1,799.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,COFINITY,COFINITY,2570.70,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,570.70 in Billed Charges for Rev 278 = $2,570.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2442.17,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,570.70 in Billed Charges for Rev 278 = $2,442.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,2159.39,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,570.70 in Billed Charges for Rev 278 = $2,159.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1825.20,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,570.70 in Billed Charges for Rev 278 = $1,825.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1876.61,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,570.70 in Billed Charges for Rev 278 = $1,876.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,1249.36,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,570.70 in Billed Charges for Rev 278 = $1,249.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2185.10,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,570.70 in Billed Charges for Rev 278 = $2,185.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,HUMANA,HUMANA CHOICE CARE HMO,1285.35,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,570.70 in Billed Charges for Rev 278 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,HUMANA,HUMANA CHOICE CARE PPO,2185.10,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,570.70 in Billed Charges for Rev 278 = $2,185.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,HUMANA,HUMANA NATIIONAL POS HMO,1285.35,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,570.70 in Billed Charges for Rev 278 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1876.61,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,570.70 in Billed Charges for Rev 278 = $1,876.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2570.70,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,570.70 in Billed Charges for Rev 278 = $2,570.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1285.35,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,570.70 in Billed Charges for Rev 278 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2159.39,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,570.70 in Billed Charges for Rev 278 = $2,159.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1928.03,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,570.70 in Billed Charges for Rev 278 = $1,928.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2365.04,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,570.70 in Billed Charges for Rev 278 = $2,365.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1640.88,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,570.70 in Billed Charges for Rev 278 = $1,640.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1850.90,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,570.70 in Billed Charges for Rev 278 = $1,850.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1850.90,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,570.70 in Billed Charges for Rev 278 = $1,850.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1593.83,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,570.70 in Billed Charges for Rev 278 = $1,593.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1850.90,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,570.70 in Billed Charges for Rev 278 = $1,850.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1850.90,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,570.70 in Billed Charges for Rev 278 = $1,850.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX 8SQ CM AMNIO MEMBRN ALOGRFT MULT LYR,278,RC,10068215,CDM,,,,,,both,,,2570.7000,1696.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1542.42,,,,,,,1249.3600,2570.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,570.70 in Billed Charges for Rev 278 = $1,542.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,AETNA,AETNA HSHS,1787.09,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,766.40 in Billed Charges for Rev 278 = $1,787.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,AETNA,ALL COMMERCIAL AETNA,2766.40,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,766.40 in Billed Charges for Rev 278 = $2,766.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,ANTHEM,ANTHEM POS/HMO,1438.53,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,766.40 in Billed Charges for Rev 278 = $1,438.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,ANTHEM,ANTHEM PPO,1438.53,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,766.40 in Billed Charges for Rev 278 = $1,438.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2766.40,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,766.40 in Billed Charges for Rev 278 = $2,766.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,CENPATICO,ALL MEDICAID CENPATICO,2766.40,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,766.40 in Billed Charges for Rev 278 = $2,766.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2351.44,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,766.40 in Billed Charges for Rev 278 = $2,351.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,CIGNA,ALL COMMERCIAL CIGNA,1936.48,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,766.40 in Billed Charges for Rev 278 = $1,936.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,COFINITY,COFINITY,2766.40,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,766.40 in Billed Charges for Rev 278 = $2,766.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2628.08,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,766.40 in Billed Charges for Rev 278 = $2,628.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,2323.78,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,766.40 in Billed Charges for Rev 278 = $2,323.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1964.14,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,766.40 in Billed Charges for Rev 278 = $1,964.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2019.47,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,766.40 in Billed Charges for Rev 278 = $2,019.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,1344.47,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,766.40 in Billed Charges for Rev 278 = $1,344.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2351.44,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,766.40 in Billed Charges for Rev 278 = $2,351.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,HUMANA,HUMANA CHOICE CARE HMO,1383.20,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,766.40 in Billed Charges for Rev 278 = $1,383.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,HUMANA,HUMANA CHOICE CARE PPO,2351.44,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,766.40 in Billed Charges for Rev 278 = $2,351.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,HUMANA,HUMANA NATIIONAL POS HMO,1383.20,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,766.40 in Billed Charges for Rev 278 = $1,383.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2019.47,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,766.40 in Billed Charges for Rev 278 = $2,019.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2766.40,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,766.40 in Billed Charges for Rev 278 = $2,766.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1383.20,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,766.40 in Billed Charges for Rev 278 = $1,383.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2323.78,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,766.40 in Billed Charges for Rev 278 = $2,323.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2074.80,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,766.40 in Billed Charges for Rev 278 = $2,074.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2545.09,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,766.40 in Billed Charges for Rev 278 = $2,545.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1765.79,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,766.40 in Billed Charges for Rev 278 = $1,765.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1991.81,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,766.40 in Billed Charges for Rev 278 = $1,991.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1991.81,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,766.40 in Billed Charges for Rev 278 = $1,991.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1715.17,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,766.40 in Billed Charges for Rev 278 = $1,715.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1991.81,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,766.40 in Billed Charges for Rev 278 = $1,991.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1991.81,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,766.40 in Billed Charges for Rev 278 = $1,991.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS EPIFIX PURION 8SQ CM 2X4CM DHACM ALOGRFT MULT,278,RC,10065962,CDM,,,,,,both,,,2766.4000,1825.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1659.84,,,,,,,1344.4700,2766.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,766.40 in Billed Charges for Rev 278 = $1,659.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,AETNA,AETNA HSHS,345.84,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $535.35 in Billed Charges for Rev 278 = $345.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,AETNA,ALL COMMERCIAL AETNA,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,CENPATICO,ALL MEDICAID CENPATICO,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,455.05,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.35 in Billed Charges for Rev 278 = $455.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,CIGNA,ALL COMMERCIAL CIGNA,374.75,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $535.35 in Billed Charges for Rev 278 = $374.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,COFINITY,COFINITY,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,508.58,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $535.35 in Billed Charges for Rev 278 = $508.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,449.69,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $535.35 in Billed Charges for Rev 278 = $449.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,380.10,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $535.35 in Billed Charges for Rev 278 = $380.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,390.81,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $535.35 in Billed Charges for Rev 278 = $390.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,260.18,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $535.35 in Billed Charges for Rev 278 = $260.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,455.05,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.35 in Billed Charges for Rev 278 = $455.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,HUMANA,HUMANA CHOICE CARE PPO,455.05,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.35 in Billed Charges for Rev 278 = $455.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,390.81,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $535.35 in Billed Charges for Rev 278 = $390.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,267.68,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $535.35 in Billed Charges for Rev 278 = $267.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,449.69,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $535.35 in Billed Charges for Rev 278 = $449.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,401.51,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $535.35 in Billed Charges for Rev 278 = $401.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,492.52,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $535.35 in Billed Charges for Rev 278 = $492.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,341.71,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $535.35 in Billed Charges for Rev 278 = $341.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,385.45,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.35 in Billed Charges for Rev 278 = $385.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,385.45,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.35 in Billed Charges for Rev 278 = $385.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,331.92,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $535.35 in Billed Charges for Rev 278 = $331.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,385.45,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.35 in Billed Charges for Rev 278 = $385.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,385.45,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.35 in Billed Charges for Rev 278 = $385.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SKIN 6X2CM OLOGEN,278,RC,10044724,CDM,,,,,,both,,,535.3500,353.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,321.21,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $535.35 in Billed Charges for Rev 278 = $321.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,AETNA,AETNA HSHS,1317.68,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,039.75 in Billed Charges for Rev 278 = $1,317.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,AETNA,ALL COMMERCIAL AETNA,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,ANTHEM,ANTHEM POS/HMO,1060.67,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,039.75 in Billed Charges for Rev 278 = $1,060.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,ANTHEM,ANTHEM PPO,1060.67,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,039.75 in Billed Charges for Rev 278 = $1,060.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,CENPATICO,ALL MEDICAID CENPATICO,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1733.79,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,039.75 in Billed Charges for Rev 278 = $1,733.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,CIGNA,ALL COMMERCIAL CIGNA,1427.83,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,039.75 in Billed Charges for Rev 278 = $1,427.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,COFINITY,COFINITY,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1937.76,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,039.75 in Billed Charges for Rev 278 = $1,937.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,1713.39,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,039.75 in Billed Charges for Rev 278 = $1,713.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1448.22,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,039.75 in Billed Charges for Rev 278 = $1,448.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1489.02,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,039.75 in Billed Charges for Rev 278 = $1,489.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,991.32,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,039.75 in Billed Charges for Rev 278 = $991.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1733.79,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,039.75 in Billed Charges for Rev 278 = $1,733.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,HUMANA,HUMANA CHOICE CARE PPO,1733.79,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,039.75 in Billed Charges for Rev 278 = $1,733.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1489.02,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,039.75 in Billed Charges for Rev 278 = $1,489.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1019.88,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,039.75 in Billed Charges for Rev 278 = $1,019.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1713.39,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,039.75 in Billed Charges for Rev 278 = $1,713.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1529.81,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,039.75 in Billed Charges for Rev 278 = $1,529.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1876.57,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,039.75 in Billed Charges for Rev 278 = $1,876.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1301.97,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,039.75 in Billed Charges for Rev 278 = $1,301.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1468.62,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,039.75 in Billed Charges for Rev 278 = $1,468.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1468.62,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,039.75 in Billed Charges for Rev 278 = $1,468.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1264.65,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,039.75 in Billed Charges for Rev 278 = $1,264.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1468.62,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,039.75 in Billed Charges for Rev 278 = $1,468.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1468.62,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,039.75 in Billed Charges for Rev 278 = $1,468.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X3CM GRAFIX CORE,278,RC,10077124,CDM,,,,,,both,,,2039.7500,1346.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1223.85,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,039.75 in Billed Charges for Rev 278 = $1,223.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,AETNA,AETNA HSHS,6558.19,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $10,152.00 in Billed Charges for Rev 278 = $6,558.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,AETNA,ALL COMMERCIAL AETNA,10152.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,152.00 in Billed Charges for Rev 278 = $10,152.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,ANTHEM,ANTHEM POS/HMO,5279.04,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,152.00 in Billed Charges for Rev 278 = $5,279.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,ANTHEM,ANTHEM PPO,5279.04,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,152.00 in Billed Charges for Rev 278 = $5,279.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10152.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,152.00 in Billed Charges for Rev 278 = $10,152.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,CENPATICO,ALL MEDICAID CENPATICO,10152.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,152.00 in Billed Charges for Rev 278 = $10,152.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8629.20,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,152.00 in Billed Charges for Rev 278 = $8,629.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,CIGNA,ALL COMMERCIAL CIGNA,7106.40,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $10,152.00 in Billed Charges for Rev 278 = $7,106.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,COFINITY,COFINITY,10152.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,152.00 in Billed Charges for Rev 278 = $10,152.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9644.40,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $10,152.00 in Billed Charges for Rev 278 = $9,644.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,8527.68,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,152.00 in Billed Charges for Rev 278 = $8,527.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7207.92,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $10,152.00 in Billed Charges for Rev 278 = $7,207.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7410.96,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,152.00 in Billed Charges for Rev 278 = $7,410.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,4933.87,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $10,152.00 in Billed Charges for Rev 278 = $4,933.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8629.20,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,152.00 in Billed Charges for Rev 278 = $8,629.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,HUMANA,HUMANA CHOICE CARE HMO,5076.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,152.00 in Billed Charges for Rev 278 = $5,076.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,HUMANA,HUMANA CHOICE CARE PPO,8629.20,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,152.00 in Billed Charges for Rev 278 = $8,629.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,HUMANA,HUMANA NATIIONAL POS HMO,5076.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,152.00 in Billed Charges for Rev 278 = $5,076.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7410.96,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,152.00 in Billed Charges for Rev 278 = $7,410.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,10152.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,152.00 in Billed Charges for Rev 278 = $10,152.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5076.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,152.00 in Billed Charges for Rev 278 = $5,076.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8527.68,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,152.00 in Billed Charges for Rev 278 = $8,527.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7614.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $10,152.00 in Billed Charges for Rev 278 = $7,614.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9339.84,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $10,152.00 in Billed Charges for Rev 278 = $9,339.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5076.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,152.00 in Billed Charges for Rev 278 = $5,076.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5076.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,152.00 in Billed Charges for Rev 278 = $5,076.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,PREVEA HEALTH NETWORK,PREVEA360,5076.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,152.00 in Billed Charges for Rev 278 = $5,076.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5076.00,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,152.00 in Billed Charges for Rev 278 = $5,076.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6480.02,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $10,152.00 in Billed Charges for Rev 278 = $6,480.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7309.44,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,152.00 in Billed Charges for Rev 278 = $7,309.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4730.83,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,152.00 in Billed Charges for Rev 278 = $4,730.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,4730.83,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,152.00 in Billed Charges for Rev 278 = $4,730.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,4730.83,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,152.00 in Billed Charges for Rev 278 = $4,730.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7309.44,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,152.00 in Billed Charges for Rev 278 = $7,309.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6294.24,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $10,152.00 in Billed Charges for Rev 278 = $6,294.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7309.44,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,152.00 in Billed Charges for Rev 278 = $7,309.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7309.44,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,152.00 in Billed Charges for Rev 278 = $7,309.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 4X3CM GRAFIX CORE ALLOGRAFT,278,RC,10068385,CDM,,,,,,both,,,10152.0000,6700.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6091.20,,,,,,,4730.8300,10152.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $10,152.00 in Billed Charges for Rev 278 = $6,091.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,AETNA,AETNA HSHS,1320.33,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,043.85 in Billed Charges for Rev 278 = $1,320.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,AETNA,ALL COMMERCIAL AETNA,2043.85,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.85 in Billed Charges for Rev 278 = $2,043.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,ANTHEM,ANTHEM POS/HMO,1062.80,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,043.85 in Billed Charges for Rev 278 = $1,062.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,ANTHEM,ANTHEM PPO,1062.80,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,043.85 in Billed Charges for Rev 278 = $1,062.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2043.85,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.85 in Billed Charges for Rev 278 = $2,043.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,CENPATICO,ALL MEDICAID CENPATICO,2043.85,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.85 in Billed Charges for Rev 278 = $2,043.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1737.27,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,043.85 in Billed Charges for Rev 278 = $1,737.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,CIGNA,ALL COMMERCIAL CIGNA,1430.70,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,043.85 in Billed Charges for Rev 278 = $1,430.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,COFINITY,COFINITY,2043.85,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.85 in Billed Charges for Rev 278 = $2,043.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1941.66,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,043.85 in Billed Charges for Rev 278 = $1,941.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,1716.83,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,043.85 in Billed Charges for Rev 278 = $1,716.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1451.13,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,043.85 in Billed Charges for Rev 278 = $1,451.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1492.01,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,043.85 in Billed Charges for Rev 278 = $1,492.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,993.31,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,043.85 in Billed Charges for Rev 278 = $993.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1737.27,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,043.85 in Billed Charges for Rev 278 = $1,737.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,HUMANA,HUMANA CHOICE CARE PPO,1737.27,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,043.85 in Billed Charges for Rev 278 = $1,737.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1492.01,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,043.85 in Billed Charges for Rev 278 = $1,492.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2043.85,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.85 in Billed Charges for Rev 278 = $2,043.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1021.93,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,043.85 in Billed Charges for Rev 278 = $1,021.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1716.83,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,043.85 in Billed Charges for Rev 278 = $1,716.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1532.89,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,043.85 in Billed Charges for Rev 278 = $1,532.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1880.34,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,043.85 in Billed Charges for Rev 278 = $1,880.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1304.59,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,043.85 in Billed Charges for Rev 278 = $1,304.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1471.57,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,043.85 in Billed Charges for Rev 278 = $1,471.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1471.57,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,043.85 in Billed Charges for Rev 278 = $1,471.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1267.19,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,043.85 in Billed Charges for Rev 278 = $1,267.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1471.57,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,043.85 in Billed Charges for Rev 278 = $1,471.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1471.57,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,043.85 in Billed Charges for Rev 278 = $1,471.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS 38X50X.85MM POLYETH PORS MDPR 1 CHNL SHT,278,RC,10004522,CDM,,,,,,both,,,2043.8500,1348.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1226.31,,,,,,,993.3100,2043.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,043.85 in Billed Charges for Rev 278 = $1,226.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,AETNA,AETNA HSHS,613.87,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $950.26 in Billed Charges for Rev 278 = $613.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,AETNA,ALL COMMERCIAL AETNA,950.26,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $950.26 in Billed Charges for Rev 278 = $950.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,950.26,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $950.26 in Billed Charges for Rev 278 = $950.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,CENPATICO,ALL MEDICAID CENPATICO,950.26,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $950.26 in Billed Charges for Rev 278 = $950.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,807.72,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $950.26 in Billed Charges for Rev 278 = $807.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,CIGNA,ALL COMMERCIAL CIGNA,665.18,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $950.26 in Billed Charges for Rev 278 = $665.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,COFINITY,COFINITY,950.26,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $950.26 in Billed Charges for Rev 278 = $950.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,902.75,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $950.26 in Billed Charges for Rev 278 = $902.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,798.22,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $950.26 in Billed Charges for Rev 278 = $798.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,674.68,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $950.26 in Billed Charges for Rev 278 = $674.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,693.69,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $950.26 in Billed Charges for Rev 278 = $693.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,461.83,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $950.26 in Billed Charges for Rev 278 = $461.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,807.72,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $950.26 in Billed Charges for Rev 278 = $807.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,HUMANA,HUMANA CHOICE CARE PPO,807.72,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $950.26 in Billed Charges for Rev 278 = $807.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,693.69,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $950.26 in Billed Charges for Rev 278 = $693.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,950.26,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $950.26 in Billed Charges for Rev 278 = $950.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,475.13,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $950.26 in Billed Charges for Rev 278 = $475.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,798.22,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $950.26 in Billed Charges for Rev 278 = $798.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,712.70,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $950.26 in Billed Charges for Rev 278 = $712.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,874.24,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $950.26 in Billed Charges for Rev 278 = $874.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,606.55,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $950.26 in Billed Charges for Rev 278 = $606.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,684.19,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $950.26 in Billed Charges for Rev 278 = $684.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,684.19,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $950.26 in Billed Charges for Rev 278 = $684.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,589.16,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $950.26 in Billed Charges for Rev 278 = $589.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,684.19,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $950.26 in Billed Charges for Rev 278 = $684.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,684.19,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $950.26 in Billed Charges for Rev 278 = $684.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT SYNTH TISS MICROTHIN 50X38X.4MM POLYETH PORS MDPR SHT,278,RC,10004582,CDM,,,,,,both,,,950.2600,627.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,570.16,,,,,,,461.8300,950.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $950.26 in Billed Charges for Rev 278 = $570.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,AETNA,AETNA HSHS,268.03,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $414.90 in Billed Charges for Rev 278 = $268.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,AETNA,ALL COMMERCIAL AETNA,414.90,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.90 in Billed Charges for Rev 278 = $414.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,414.90,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.90 in Billed Charges for Rev 278 = $414.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,CENPATICO,ALL MEDICAID CENPATICO,414.90,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.90 in Billed Charges for Rev 278 = $414.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,352.67,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $414.90 in Billed Charges for Rev 278 = $352.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,CIGNA,ALL COMMERCIAL CIGNA,290.43,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $414.90 in Billed Charges for Rev 278 = $290.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,COFINITY,COFINITY,414.90,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.90 in Billed Charges for Rev 278 = $414.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,394.16,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $414.90 in Billed Charges for Rev 278 = $394.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,348.52,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $414.90 in Billed Charges for Rev 278 = $348.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,294.58,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $414.90 in Billed Charges for Rev 278 = $294.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,302.88,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $414.90 in Billed Charges for Rev 278 = $302.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,201.64,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $414.90 in Billed Charges for Rev 278 = $201.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,352.67,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $414.90 in Billed Charges for Rev 278 = $352.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,HUMANA,HUMANA CHOICE CARE PPO,352.67,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $414.90 in Billed Charges for Rev 278 = $352.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,302.88,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $414.90 in Billed Charges for Rev 278 = $302.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,414.90,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.90 in Billed Charges for Rev 278 = $414.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,207.45,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $414.90 in Billed Charges for Rev 278 = $207.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,348.52,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $414.90 in Billed Charges for Rev 278 = $348.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,311.18,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $414.90 in Billed Charges for Rev 278 = $311.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,381.71,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $414.90 in Billed Charges for Rev 278 = $381.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,264.83,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $414.90 in Billed Charges for Rev 278 = $264.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,298.73,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $414.90 in Billed Charges for Rev 278 = $298.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,298.73,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $414.90 in Billed Charges for Rev 278 = $298.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,257.24,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $414.90 in Billed Charges for Rev 278 = $257.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,298.73,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $414.90 in Billed Charges for Rev 278 = $298.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,298.73,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $414.90 in Billed Charges for Rev 278 = $298.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 1,278,RC,70406787,CDM,,,,,,both,,,414.9000,273.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,248.94,,,,,,,201.6400,414.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $414.90 in Billed Charges for Rev 278 = $248.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,AETNA,AETNA HSHS,928.16,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,436.78 in Billed Charges for Rev 278 = $928.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,AETNA,ALL COMMERCIAL AETNA,1436.78,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,436.78 in Billed Charges for Rev 278 = $1,436.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,ANTHEM,ANTHEM POS/HMO,747.13,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,436.78 in Billed Charges for Rev 278 = $747.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,ANTHEM,ANTHEM PPO,747.13,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,436.78 in Billed Charges for Rev 278 = $747.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1436.78,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,436.78 in Billed Charges for Rev 278 = $1,436.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,CENPATICO,ALL MEDICAID CENPATICO,1436.78,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,436.78 in Billed Charges for Rev 278 = $1,436.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1221.26,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,436.78 in Billed Charges for Rev 278 = $1,221.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,CIGNA,ALL COMMERCIAL CIGNA,1005.75,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,436.78 in Billed Charges for Rev 278 = $1,005.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,COFINITY,COFINITY,1436.78,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,436.78 in Billed Charges for Rev 278 = $1,436.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1364.94,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,436.78 in Billed Charges for Rev 278 = $1,364.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,1206.90,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,436.78 in Billed Charges for Rev 278 = $1,206.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1020.11,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,436.78 in Billed Charges for Rev 278 = $1,020.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1048.85,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,436.78 in Billed Charges for Rev 278 = $1,048.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,698.28,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,436.78 in Billed Charges for Rev 278 = $698.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1221.26,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,436.78 in Billed Charges for Rev 278 = $1,221.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,HUMANA,HUMANA CHOICE CARE PPO,1221.26,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,436.78 in Billed Charges for Rev 278 = $1,221.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1048.85,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,436.78 in Billed Charges for Rev 278 = $1,048.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1436.78,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,436.78 in Billed Charges for Rev 278 = $1,436.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,718.39,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,436.78 in Billed Charges for Rev 278 = $718.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1206.90,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,436.78 in Billed Charges for Rev 278 = $1,206.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1077.59,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,436.78 in Billed Charges for Rev 278 = $1,077.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1321.84,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,436.78 in Billed Charges for Rev 278 = $1,321.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,917.10,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,436.78 in Billed Charges for Rev 278 = $917.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1034.48,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,436.78 in Billed Charges for Rev 278 = $1,034.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1034.48,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,436.78 in Billed Charges for Rev 278 = $1,034.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,890.80,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,436.78 in Billed Charges for Rev 278 = $890.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1034.48,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,436.78 in Billed Charges for Rev 278 = $1,034.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1034.48,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,436.78 in Billed Charges for Rev 278 = $1,034.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 3 X 3,278,RC,10008975,CDM,,,,,,both,,,1436.7800,948.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,862.07,,,,,,,698.2800,1436.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,436.78 in Billed Charges for Rev 278 = $862.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,AETNA,AETNA HSHS,1308.74,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,025.91 in Billed Charges for Rev 278 = $1,308.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,AETNA,ALL COMMERCIAL AETNA,2025.91,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,025.91 in Billed Charges for Rev 278 = $2,025.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,ANTHEM,ANTHEM POS/HMO,1053.47,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,025.91 in Billed Charges for Rev 278 = $1,053.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,ANTHEM,ANTHEM PPO,1053.47,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,025.91 in Billed Charges for Rev 278 = $1,053.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2025.91,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,025.91 in Billed Charges for Rev 278 = $2,025.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,CENPATICO,ALL MEDICAID CENPATICO,2025.91,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,025.91 in Billed Charges for Rev 278 = $2,025.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1722.02,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,025.91 in Billed Charges for Rev 278 = $1,722.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,CIGNA,ALL COMMERCIAL CIGNA,1418.14,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,025.91 in Billed Charges for Rev 278 = $1,418.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,COFINITY,COFINITY,2025.91,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,025.91 in Billed Charges for Rev 278 = $2,025.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1924.61,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,025.91 in Billed Charges for Rev 278 = $1,924.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,1701.76,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,025.91 in Billed Charges for Rev 278 = $1,701.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1438.40,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,025.91 in Billed Charges for Rev 278 = $1,438.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1478.91,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,025.91 in Billed Charges for Rev 278 = $1,478.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,984.59,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,025.91 in Billed Charges for Rev 278 = $984.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1722.02,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,025.91 in Billed Charges for Rev 278 = $1,722.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,HUMANA,HUMANA CHOICE CARE PPO,1722.02,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,025.91 in Billed Charges for Rev 278 = $1,722.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1478.91,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,025.91 in Billed Charges for Rev 278 = $1,478.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2025.91,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,025.91 in Billed Charges for Rev 278 = $2,025.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1012.96,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,025.91 in Billed Charges for Rev 278 = $1,012.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1701.76,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,025.91 in Billed Charges for Rev 278 = $1,701.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1519.43,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,025.91 in Billed Charges for Rev 278 = $1,519.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1863.84,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,025.91 in Billed Charges for Rev 278 = $1,863.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1293.14,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,025.91 in Billed Charges for Rev 278 = $1,293.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1458.66,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,025.91 in Billed Charges for Rev 278 = $1,458.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1458.66,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,025.91 in Billed Charges for Rev 278 = $1,458.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1256.06,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,025.91 in Billed Charges for Rev 278 = $1,256.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1458.66,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,025.91 in Billed Charges for Rev 278 = $1,458.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1458.66,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,025.91 in Billed Charges for Rev 278 = $1,458.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 4 X 5,278,RC,10030396,CDM,,,,,,both,,,2025.9100,1337.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1215.55,,,,,,,984.5900,2025.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,025.91 in Billed Charges for Rev 278 = $1,215.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,AETNA,AETNA HSHS,896.02,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,387.03 in Billed Charges for Rev 278 = $896.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,AETNA,ALL COMMERCIAL AETNA,1387.03,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.03 in Billed Charges for Rev 278 = $1,387.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,ANTHEM,ANTHEM POS/HMO,721.26,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,387.03 in Billed Charges for Rev 278 = $721.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,ANTHEM,ANTHEM PPO,721.26,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,387.03 in Billed Charges for Rev 278 = $721.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1387.03,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.03 in Billed Charges for Rev 278 = $1,387.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,CENPATICO,ALL MEDICAID CENPATICO,1387.03,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.03 in Billed Charges for Rev 278 = $1,387.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1178.98,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,387.03 in Billed Charges for Rev 278 = $1,178.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,CIGNA,ALL COMMERCIAL CIGNA,970.92,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,387.03 in Billed Charges for Rev 278 = $970.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,COFINITY,COFINITY,1387.03,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.03 in Billed Charges for Rev 278 = $1,387.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1317.68,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,387.03 in Billed Charges for Rev 278 = $1,317.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,1165.11,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,387.03 in Billed Charges for Rev 278 = $1,165.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,984.79,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,387.03 in Billed Charges for Rev 278 = $984.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1012.53,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,387.03 in Billed Charges for Rev 278 = $1,012.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,674.10,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,387.03 in Billed Charges for Rev 278 = $674.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1178.98,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,387.03 in Billed Charges for Rev 278 = $1,178.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,HUMANA,HUMANA CHOICE CARE PPO,1178.98,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,387.03 in Billed Charges for Rev 278 = $1,178.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1012.53,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,387.03 in Billed Charges for Rev 278 = $1,012.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1387.03,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.03 in Billed Charges for Rev 278 = $1,387.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,693.52,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,387.03 in Billed Charges for Rev 278 = $693.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1165.11,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,387.03 in Billed Charges for Rev 278 = $1,165.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1040.27,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,387.03 in Billed Charges for Rev 278 = $1,040.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1276.07,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,387.03 in Billed Charges for Rev 278 = $1,276.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,885.34,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,387.03 in Billed Charges for Rev 278 = $885.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,998.66,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,387.03 in Billed Charges for Rev 278 = $998.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,998.66,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,387.03 in Billed Charges for Rev 278 = $998.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,859.96,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,387.03 in Billed Charges for Rev 278 = $859.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,998.66,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,387.03 in Billed Charges for Rev 278 = $998.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,998.66,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,387.03 in Billed Charges for Rev 278 = $998.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 3 X 3,278,RC,10010368,CDM,,,,,,both,,,1387.0300,915.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,832.22,,,,,,,674.1000,1387.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,387.03 in Billed Charges for Rev 278 = $832.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,AETNA,AETNA HSHS,239.83,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $371.25 in Billed Charges for Rev 278 = $239.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,AETNA,ALL COMMERCIAL AETNA,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,CENPATICO,ALL MEDICAID CENPATICO,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,315.56,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $371.25 in Billed Charges for Rev 278 = $315.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,CIGNA,ALL COMMERCIAL CIGNA,259.88,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $371.25 in Billed Charges for Rev 278 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,COFINITY,COFINITY,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,352.69,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $371.25 in Billed Charges for Rev 278 = $352.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,HEALTH CARE ALLIANCE,THE ALLIANCE,311.85,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $371.25 in Billed Charges for Rev 278 = $311.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,263.59,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $371.25 in Billed Charges for Rev 278 = $263.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,271.01,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $371.25 in Billed Charges for Rev 278 = $271.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,HSHS EMPLOYEES,HSHS EMPLOYEES,180.43,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $371.25 in Billed Charges for Rev 278 = $180.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,315.56,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $371.25 in Billed Charges for Rev 278 = $315.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,HUMANA,HUMANA CHOICE CARE PPO,315.56,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $371.25 in Billed Charges for Rev 278 = $315.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,271.01,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $371.25 in Billed Charges for Rev 278 = $271.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,LIVE360,LIVE360 HSHS HEALTHY PLAN,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,185.63,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $371.25 in Billed Charges for Rev 278 = $185.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,311.85,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $371.25 in Billed Charges for Rev 278 = $311.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,278.44,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $371.25 in Billed Charges for Rev 278 = $278.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,341.55,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $371.25 in Billed Charges for Rev 278 = $341.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,236.97,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $371.25 in Billed Charges for Rev 278 = $236.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,267.30,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $371.25 in Billed Charges for Rev 278 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,267.30,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $371.25 in Billed Charges for Rev 278 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,230.18,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $371.25 in Billed Charges for Rev 278 = $230.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,267.30,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $371.25 in Billed Charges for Rev 278 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,267.30,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $371.25 in Billed Charges for Rev 278 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT FAC BOVN DERM COLGN MTRX ZYPLAST INJ SYR 1CC,278,RC,10021510,CDM,,,,,,both,,,371.2500,245.0300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,222.75,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $371.25 in Billed Charges for Rev 278 = $222.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,AETNA,AETNA HSHS,17.15,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $26.55 in Billed Charges for Rev 278 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,AETNA,ALL COMMERCIAL AETNA,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,CENPATICO,ALL MEDICAID CENPATICO,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,22.57,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.55 in Billed Charges for Rev 278 = $22.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,CIGNA,ALL COMMERCIAL CIGNA,18.59,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $26.55 in Billed Charges for Rev 278 = $18.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,COFINITY,COFINITY,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,25.22,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $26.55 in Billed Charges for Rev 278 = $25.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,22.30,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.55 in Billed Charges for Rev 278 = $22.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,18.85,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $26.55 in Billed Charges for Rev 278 = $18.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,19.38,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.55 in Billed Charges for Rev 278 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,12.90,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $26.55 in Billed Charges for Rev 278 = $12.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,22.57,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.55 in Billed Charges for Rev 278 = $22.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,HUMANA,HUMANA CHOICE CARE PPO,22.57,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.55 in Billed Charges for Rev 278 = $22.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,19.38,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.55 in Billed Charges for Rev 278 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.28,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $26.55 in Billed Charges for Rev 278 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,22.30,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.55 in Billed Charges for Rev 278 = $22.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,19.91,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $26.55 in Billed Charges for Rev 278 = $19.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,24.43,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $26.55 in Billed Charges for Rev 278 = $24.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,16.95,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $26.55 in Billed Charges for Rev 278 = $16.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,19.12,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.55 in Billed Charges for Rev 278 = $19.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,19.12,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.55 in Billed Charges for Rev 278 = $19.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.46,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $26.55 in Billed Charges for Rev 278 = $16.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,19.12,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.55 in Billed Charges for Rev 278 = $19.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,19.12,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.55 in Billed Charges for Rev 278 = $19.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 282 (TIRE),278,RC,10043795,CDM,,,,,,both,,,26.5500,17.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.93,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.55 in Billed Charges for Rev 278 = $15.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,AETNA,AETNA HSHS,22.47,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $34.79 in Billed Charges for Rev 278 = $22.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,AETNA,ALL COMMERCIAL AETNA,34.79,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.79 in Billed Charges for Rev 278 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,34.79,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.79 in Billed Charges for Rev 278 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,CENPATICO,ALL MEDICAID CENPATICO,34.79,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.79 in Billed Charges for Rev 278 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,29.57,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.79 in Billed Charges for Rev 278 = $29.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,CIGNA,ALL COMMERCIAL CIGNA,24.35,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $34.79 in Billed Charges for Rev 278 = $24.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,COFINITY,COFINITY,34.79,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.79 in Billed Charges for Rev 278 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,33.05,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $34.79 in Billed Charges for Rev 278 = $33.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,29.22,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $34.79 in Billed Charges for Rev 278 = $29.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,24.70,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $34.79 in Billed Charges for Rev 278 = $24.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,25.40,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $34.79 in Billed Charges for Rev 278 = $25.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,16.91,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $34.79 in Billed Charges for Rev 278 = $16.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,29.57,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.79 in Billed Charges for Rev 278 = $29.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,HUMANA,HUMANA CHOICE CARE PPO,29.57,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.79 in Billed Charges for Rev 278 = $29.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,25.40,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $34.79 in Billed Charges for Rev 278 = $25.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,34.79,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.79 in Billed Charges for Rev 278 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,17.40,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $34.79 in Billed Charges for Rev 278 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,29.22,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $34.79 in Billed Charges for Rev 278 = $29.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,26.09,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $34.79 in Billed Charges for Rev 278 = $26.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,32.01,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $34.79 in Billed Charges for Rev 278 = $32.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,22.21,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $34.79 in Billed Charges for Rev 278 = $22.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,25.05,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.79 in Billed Charges for Rev 278 = $25.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,25.05,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.79 in Billed Charges for Rev 278 = $25.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,21.57,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $34.79 in Billed Charges for Rev 278 = $21.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,25.05,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.79 in Billed Charges for Rev 278 = $25.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,25.05,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.79 in Billed Charges for Rev 278 = $25.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 287 (TIRE),278,RC,10043801,CDM,,,,,,both,,,34.7900,22.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,20.87,,,,,,,16.9100,34.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $34.79 in Billed Charges for Rev 278 = $20.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,AETNA,AETNA HSHS,13.08,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.25 in Billed Charges for Rev 278 = $13.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,AETNA,ALL COMMERCIAL AETNA,20.25,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.25 in Billed Charges for Rev 278 = $20.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.25,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.25 in Billed Charges for Rev 278 = $20.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,CENPATICO,ALL MEDICAID CENPATICO,20.25,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.25 in Billed Charges for Rev 278 = $20.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.21,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.25 in Billed Charges for Rev 278 = $17.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,CIGNA,ALL COMMERCIAL CIGNA,14.18,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.25 in Billed Charges for Rev 278 = $14.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,COFINITY,COFINITY,20.25,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.25 in Billed Charges for Rev 278 = $20.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.24,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.25 in Billed Charges for Rev 278 = $19.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,17.01,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.25 in Billed Charges for Rev 278 = $17.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.38,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.25 in Billed Charges for Rev 278 = $14.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.78,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.25 in Billed Charges for Rev 278 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,9.84,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.25 in Billed Charges for Rev 278 = $9.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.21,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.25 in Billed Charges for Rev 278 = $17.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,HUMANA,HUMANA CHOICE CARE PPO,17.21,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.25 in Billed Charges for Rev 278 = $17.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.78,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.25 in Billed Charges for Rev 278 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.25,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.25 in Billed Charges for Rev 278 = $20.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.13,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.25 in Billed Charges for Rev 278 = $10.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.01,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.25 in Billed Charges for Rev 278 = $17.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.19,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.25 in Billed Charges for Rev 278 = $15.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.63,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.25 in Billed Charges for Rev 278 = $18.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.93,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.25 in Billed Charges for Rev 278 = $12.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.58,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.25 in Billed Charges for Rev 278 = $14.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.58,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.25 in Billed Charges for Rev 278 = $14.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.56,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.25 in Billed Charges for Rev 278 = $12.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.58,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.25 in Billed Charges for Rev 278 = $14.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.58,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.25 in Billed Charges for Rev 278 = $14.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 31 (STRIP),278,RC,70500467,CDM,,,,,,both,,,20.2500,13.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.15,,,,,,,9.8400,20.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.25 in Billed Charges for Rev 278 = $12.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,AETNA,AETNA HSHS,50.87,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $78.75 in Billed Charges for Rev 278 = $50.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,AETNA,ALL COMMERCIAL AETNA,78.75,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.75 in Billed Charges for Rev 278 = $78.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,78.75,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.75 in Billed Charges for Rev 278 = $78.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,CENPATICO,ALL MEDICAID CENPATICO,78.75,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.75 in Billed Charges for Rev 278 = $78.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,66.94,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.75 in Billed Charges for Rev 278 = $66.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,CIGNA,ALL COMMERCIAL CIGNA,55.13,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $78.75 in Billed Charges for Rev 278 = $55.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,COFINITY,COFINITY,78.75,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.75 in Billed Charges for Rev 278 = $78.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,74.81,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $78.75 in Billed Charges for Rev 278 = $74.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,66.15,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $78.75 in Billed Charges for Rev 278 = $66.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,55.91,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $78.75 in Billed Charges for Rev 278 = $55.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,57.49,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $78.75 in Billed Charges for Rev 278 = $57.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,38.27,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $78.75 in Billed Charges for Rev 278 = $38.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,66.94,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.75 in Billed Charges for Rev 278 = $66.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,HUMANA,HUMANA CHOICE CARE PPO,66.94,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.75 in Billed Charges for Rev 278 = $66.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,57.49,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $78.75 in Billed Charges for Rev 278 = $57.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,78.75,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.75 in Billed Charges for Rev 278 = $78.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,39.38,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $78.75 in Billed Charges for Rev 278 = $39.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,66.15,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $78.75 in Billed Charges for Rev 278 = $66.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,59.06,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $78.75 in Billed Charges for Rev 278 = $59.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,72.45,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $78.75 in Billed Charges for Rev 278 = $72.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,50.27,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $78.75 in Billed Charges for Rev 278 = $50.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,56.70,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.75 in Billed Charges for Rev 278 = $56.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,56.70,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.75 in Billed Charges for Rev 278 = $56.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,48.83,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $78.75 in Billed Charges for Rev 278 = $48.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,56.70,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.75 in Billed Charges for Rev 278 = $56.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,56.70,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.75 in Billed Charges for Rev 278 = $56.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 508 (OBLONG SPONGE),278,RC,70500897,CDM,,,,,,both,,,78.7500,51.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,47.25,,,,,,,38.2700,78.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $78.75 in Billed Charges for Rev 278 = $47.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,AETNA,AETNA HSHS,71.86,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $111.24 in Billed Charges for Rev 278 = $71.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,AETNA,ALL COMMERCIAL AETNA,111.24,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.24 in Billed Charges for Rev 278 = $111.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,111.24,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.24 in Billed Charges for Rev 278 = $111.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,CENPATICO,ALL MEDICAID CENPATICO,111.24,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.24 in Billed Charges for Rev 278 = $111.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,94.55,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $111.24 in Billed Charges for Rev 278 = $94.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,CIGNA,ALL COMMERCIAL CIGNA,77.87,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $111.24 in Billed Charges for Rev 278 = $77.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,COFINITY,COFINITY,111.24,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.24 in Billed Charges for Rev 278 = $111.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,105.68,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $111.24 in Billed Charges for Rev 278 = $105.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,93.44,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $111.24 in Billed Charges for Rev 278 = $93.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,78.98,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $111.24 in Billed Charges for Rev 278 = $78.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,81.21,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $111.24 in Billed Charges for Rev 278 = $81.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,54.06,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $111.24 in Billed Charges for Rev 278 = $54.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,94.55,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $111.24 in Billed Charges for Rev 278 = $94.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,HUMANA,HUMANA CHOICE CARE PPO,94.55,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $111.24 in Billed Charges for Rev 278 = $94.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,81.21,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $111.24 in Billed Charges for Rev 278 = $81.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,111.24,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.24 in Billed Charges for Rev 278 = $111.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,55.62,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $111.24 in Billed Charges for Rev 278 = $55.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,93.44,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $111.24 in Billed Charges for Rev 278 = $93.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,83.43,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $111.24 in Billed Charges for Rev 278 = $83.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,102.34,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $111.24 in Billed Charges for Rev 278 = $102.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,71.00,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $111.24 in Billed Charges for Rev 278 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,80.09,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $111.24 in Billed Charges for Rev 278 = $80.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,80.09,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $111.24 in Billed Charges for Rev 278 = $80.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,68.97,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $111.24 in Billed Charges for Rev 278 = $68.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,80.09,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $111.24 in Billed Charges for Rev 278 = $80.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,80.09,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $111.24 in Billed Charges for Rev 278 = $80.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 509G (GROOVED SPONGE),278,RC,70500898,CDM,,,,,,both,,,111.2400,73.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,66.74,,,,,,,54.0600,111.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $111.24 in Billed Charges for Rev 278 = $66.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,AETNA,AETNA HSHS,35.76,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $55.35 in Billed Charges for Rev 278 = $35.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,AETNA,ALL COMMERCIAL AETNA,55.35,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.35 in Billed Charges for Rev 278 = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,55.35,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.35 in Billed Charges for Rev 278 = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,CENPATICO,ALL MEDICAID CENPATICO,55.35,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.35 in Billed Charges for Rev 278 = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,47.05,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.35 in Billed Charges for Rev 278 = $47.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,CIGNA,ALL COMMERCIAL CIGNA,38.75,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $55.35 in Billed Charges for Rev 278 = $38.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,COFINITY,COFINITY,55.35,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.35 in Billed Charges for Rev 278 = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,52.58,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $55.35 in Billed Charges for Rev 278 = $52.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,HEALTH CARE ALLIANCE,THE ALLIANCE,46.49,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $55.35 in Billed Charges for Rev 278 = $46.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,39.30,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $55.35 in Billed Charges for Rev 278 = $39.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,40.41,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $55.35 in Billed Charges for Rev 278 = $40.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,HSHS EMPLOYEES,HSHS EMPLOYEES,26.90,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $55.35 in Billed Charges for Rev 278 = $26.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,47.05,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.35 in Billed Charges for Rev 278 = $47.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,HUMANA,HUMANA CHOICE CARE PPO,47.05,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.35 in Billed Charges for Rev 278 = $47.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,40.41,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $55.35 in Billed Charges for Rev 278 = $40.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,LIVE360,LIVE360 HSHS HEALTHY PLAN,55.35,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.35 in Billed Charges for Rev 278 = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27.68,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $55.35 in Billed Charges for Rev 278 = $27.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,46.49,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $55.35 in Billed Charges for Rev 278 = $46.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,41.51,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $55.35 in Billed Charges for Rev 278 = $41.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,50.92,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $55.35 in Billed Charges for Rev 278 = $50.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,35.33,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $55.35 in Billed Charges for Rev 278 = $35.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,39.85,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.35 in Billed Charges for Rev 278 = $39.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,39.85,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.35 in Billed Charges for Rev 278 = $39.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,34.32,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $55.35 in Billed Charges for Rev 278 = $34.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,39.85,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.35 in Billed Charges for Rev 278 = $39.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,39.85,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.35 in Billed Charges for Rev 278 = $39.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL MERIDONAL STYLE 106 (TIRE),278,RC,10060189,CDM,,,,,,both,,,55.3500,36.5300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,33.21,,,,,,,26.9000,55.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $55.35 in Billed Charges for Rev 278 = $33.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,AETNA,AETNA HSHS,40.70,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $63.00 in Billed Charges for Rev 278 = $40.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,AETNA,ALL COMMERCIAL AETNA,63.00,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.00 in Billed Charges for Rev 278 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,63.00,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.00 in Billed Charges for Rev 278 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,CENPATICO,ALL MEDICAID CENPATICO,63.00,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.00 in Billed Charges for Rev 278 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,53.55,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.00 in Billed Charges for Rev 278 = $53.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,CIGNA,ALL COMMERCIAL CIGNA,44.10,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $63.00 in Billed Charges for Rev 278 = $44.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,COFINITY,COFINITY,63.00,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.00 in Billed Charges for Rev 278 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,59.85,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $63.00 in Billed Charges for Rev 278 = $59.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,52.92,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $63.00 in Billed Charges for Rev 278 = $52.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,44.73,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $63.00 in Billed Charges for Rev 278 = $44.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,45.99,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $63.00 in Billed Charges for Rev 278 = $45.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,30.62,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $63.00 in Billed Charges for Rev 278 = $30.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,53.55,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.00 in Billed Charges for Rev 278 = $53.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,HUMANA,HUMANA CHOICE CARE PPO,53.55,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.00 in Billed Charges for Rev 278 = $53.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,45.99,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $63.00 in Billed Charges for Rev 278 = $45.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,63.00,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.00 in Billed Charges for Rev 278 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,31.50,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $63.00 in Billed Charges for Rev 278 = $31.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,52.92,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $63.00 in Billed Charges for Rev 278 = $52.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,47.25,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $63.00 in Billed Charges for Rev 278 = $47.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,57.96,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $63.00 in Billed Charges for Rev 278 = $57.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,40.21,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $63.00 in Billed Charges for Rev 278 = $40.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,45.36,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.00 in Billed Charges for Rev 278 = $45.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,45.36,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.00 in Billed Charges for Rev 278 = $45.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,39.06,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $63.00 in Billed Charges for Rev 278 = $39.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,45.36,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.00 in Billed Charges for Rev 278 = $45.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,45.36,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.00 in Billed Charges for Rev 278 = $45.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE (S4050),278,RC,10043803,CDM,,,,,,both,,,63.0000,41.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,37.80,,,,,,,30.6200,63.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $63.00 in Billed Charges for Rev 278 = $37.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,AETNA,AETNA HSHS,4186.08,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,480.00 in Billed Charges for Rev 278 = $4,186.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,AETNA,ALL COMMERCIAL AETNA,6480.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,480.00 in Billed Charges for Rev 278 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,ANTHEM,ANTHEM POS/HMO,3369.60,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,480.00 in Billed Charges for Rev 278 = $3,369.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,ANTHEM,ANTHEM PPO,3369.60,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,480.00 in Billed Charges for Rev 278 = $3,369.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6480.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,480.00 in Billed Charges for Rev 278 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,CENPATICO,ALL MEDICAID CENPATICO,6480.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,480.00 in Billed Charges for Rev 278 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5508.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,480.00 in Billed Charges for Rev 278 = $5,508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,CIGNA,ALL COMMERCIAL CIGNA,4536.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,480.00 in Billed Charges for Rev 278 = $4,536.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,COFINITY,COFINITY,6480.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,480.00 in Billed Charges for Rev 278 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6156.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,480.00 in Billed Charges for Rev 278 = $6,156.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,5443.20,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,480.00 in Billed Charges for Rev 278 = $5,443.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4600.80,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,480.00 in Billed Charges for Rev 278 = $4,600.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4730.40,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,480.00 in Billed Charges for Rev 278 = $4,730.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,3149.28,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,480.00 in Billed Charges for Rev 278 = $3,149.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5508.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,480.00 in Billed Charges for Rev 278 = $5,508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,HUMANA,HUMANA CHOICE CARE HMO,3240.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,480.00 in Billed Charges for Rev 278 = $3,240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,HUMANA,HUMANA CHOICE CARE PPO,5508.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,480.00 in Billed Charges for Rev 278 = $5,508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,HUMANA,HUMANA NATIIONAL POS HMO,3240.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,480.00 in Billed Charges for Rev 278 = $3,240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4730.40,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,480.00 in Billed Charges for Rev 278 = $4,730.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,6480.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,480.00 in Billed Charges for Rev 278 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3240.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,480.00 in Billed Charges for Rev 278 = $3,240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5443.20,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,480.00 in Billed Charges for Rev 278 = $5,443.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4860.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,480.00 in Billed Charges for Rev 278 = $4,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5961.60,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,480.00 in Billed Charges for Rev 278 = $5,961.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3240.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,480.00 in Billed Charges for Rev 278 = $3,240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3240.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,480.00 in Billed Charges for Rev 278 = $3,240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,PREVEA HEALTH NETWORK,PREVEA360,3240.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,480.00 in Billed Charges for Rev 278 = $3,240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3240.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,480.00 in Billed Charges for Rev 278 = $3,240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4136.18,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,480.00 in Billed Charges for Rev 278 = $4,136.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4665.60,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,480.00 in Billed Charges for Rev 278 = $4,665.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4665.60,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,480.00 in Billed Charges for Rev 278 = $4,665.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4017.60,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,480.00 in Billed Charges for Rev 278 = $4,017.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4665.60,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,480.00 in Billed Charges for Rev 278 = $4,665.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4665.60,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,480.00 in Billed Charges for Rev 278 = $4,665.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA 8MM,278,RC,10073634,CDM,,,,,,both,,,6480.0000,4276.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3888.00,,,,,,,3149.2800,6480.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,480.00 in Billed Charges for Rev 278 = $3,888.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,AETNA,AETNA HSHS,1595.62,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,470.00 in Billed Charges for Rev 278 = $1,595.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,AETNA,ALL COMMERCIAL AETNA,2470.00,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,470.00 in Billed Charges for Rev 278 = $2,470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,ANTHEM,ANTHEM POS/HMO,1284.40,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,470.00 in Billed Charges for Rev 278 = $1,284.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,ANTHEM,ANTHEM PPO,1284.40,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,470.00 in Billed Charges for Rev 278 = $1,284.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2470.00,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,470.00 in Billed Charges for Rev 278 = $2,470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,CENPATICO,ALL MEDICAID CENPATICO,2470.00,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,470.00 in Billed Charges for Rev 278 = $2,470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2099.50,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,470.00 in Billed Charges for Rev 278 = $2,099.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,CIGNA,ALL COMMERCIAL CIGNA,1729.00,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,470.00 in Billed Charges for Rev 278 = $1,729.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,COFINITY,COFINITY,2470.00,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,470.00 in Billed Charges for Rev 278 = $2,470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2346.50,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,470.00 in Billed Charges for Rev 278 = $2,346.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,2074.80,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,470.00 in Billed Charges for Rev 278 = $2,074.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1753.70,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,470.00 in Billed Charges for Rev 278 = $1,753.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1803.10,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,470.00 in Billed Charges for Rev 278 = $1,803.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,1200.42,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,470.00 in Billed Charges for Rev 278 = $1,200.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2099.50,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,470.00 in Billed Charges for Rev 278 = $2,099.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,HUMANA,HUMANA CHOICE CARE PPO,2099.50,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,470.00 in Billed Charges for Rev 278 = $2,099.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1803.10,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,470.00 in Billed Charges for Rev 278 = $1,803.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2470.00,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,470.00 in Billed Charges for Rev 278 = $2,470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1235.00,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,470.00 in Billed Charges for Rev 278 = $1,235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2074.80,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,470.00 in Billed Charges for Rev 278 = $2,074.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1852.50,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,470.00 in Billed Charges for Rev 278 = $1,852.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2272.40,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,470.00 in Billed Charges for Rev 278 = $2,272.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1576.60,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,470.00 in Billed Charges for Rev 278 = $1,576.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1778.40,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,470.00 in Billed Charges for Rev 278 = $1,778.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1778.40,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,470.00 in Billed Charges for Rev 278 = $1,778.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1531.40,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,470.00 in Billed Charges for Rev 278 = $1,531.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1778.40,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,470.00 in Billed Charges for Rev 278 = $1,778.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1778.40,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,470.00 in Billed Charges for Rev 278 = $1,778.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK,278,RC,10010371,CDM,,,,,,both,,,2470.0000,1630.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1482.00,,,,,,,1200.4200,2470.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,470.00 in Billed Charges for Rev 278 = $1,482.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,AETNA,AETNA HSHS,1187.63,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,838.44 in Billed Charges for Rev 278 = $1,187.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,AETNA,ALL COMMERCIAL AETNA,1838.44,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,838.44 in Billed Charges for Rev 278 = $1,838.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,ANTHEM,ANTHEM POS/HMO,955.99,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,838.44 in Billed Charges for Rev 278 = $955.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,ANTHEM,ANTHEM PPO,955.99,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,838.44 in Billed Charges for Rev 278 = $955.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1838.44,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,838.44 in Billed Charges for Rev 278 = $1,838.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,CENPATICO,ALL MEDICAID CENPATICO,1838.44,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,838.44 in Billed Charges for Rev 278 = $1,838.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1562.67,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,838.44 in Billed Charges for Rev 278 = $1,562.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,CIGNA,ALL COMMERCIAL CIGNA,1286.91,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,838.44 in Billed Charges for Rev 278 = $1,286.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,COFINITY,COFINITY,1838.44,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,838.44 in Billed Charges for Rev 278 = $1,838.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1746.52,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,838.44 in Billed Charges for Rev 278 = $1,746.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,1544.29,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,838.44 in Billed Charges for Rev 278 = $1,544.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1305.29,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,838.44 in Billed Charges for Rev 278 = $1,305.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1342.06,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,838.44 in Billed Charges for Rev 278 = $1,342.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,893.48,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,838.44 in Billed Charges for Rev 278 = $893.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1562.67,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,838.44 in Billed Charges for Rev 278 = $1,562.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,HUMANA,HUMANA CHOICE CARE PPO,1562.67,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,838.44 in Billed Charges for Rev 278 = $1,562.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1342.06,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,838.44 in Billed Charges for Rev 278 = $1,342.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1838.44,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,838.44 in Billed Charges for Rev 278 = $1,838.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,919.22,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,838.44 in Billed Charges for Rev 278 = $919.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1544.29,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,838.44 in Billed Charges for Rev 278 = $1,544.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1378.83,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,838.44 in Billed Charges for Rev 278 = $1,378.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1691.36,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,838.44 in Billed Charges for Rev 278 = $1,691.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1173.48,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,838.44 in Billed Charges for Rev 278 = $1,173.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1323.68,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,838.44 in Billed Charges for Rev 278 = $1,323.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1323.68,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,838.44 in Billed Charges for Rev 278 = $1,323.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1139.83,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,838.44 in Billed Charges for Rev 278 = $1,139.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1323.68,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,838.44 in Billed Charges for Rev 278 = $1,323.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1323.68,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,838.44 in Billed Charges for Rev 278 = $1,323.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MASTERGRAFT SOFAMOR DANEK 10ML,278,RC,10060566,CDM,,,,,,both,,,1838.4400,1213.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1103.06,,,,,,,893.4800,1838.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,838.44 in Billed Charges for Rev 278 = $1,103.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,AETNA,AETNA HSHS,1479.51,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,290.26 in Billed Charges for Rev 278 = $1,479.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,AETNA,ALL COMMERCIAL AETNA,2290.26,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,290.26 in Billed Charges for Rev 278 = $2,290.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,ANTHEM,ANTHEM POS/HMO,1190.94,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,290.26 in Billed Charges for Rev 278 = $1,190.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,ANTHEM,ANTHEM PPO,1190.94,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,290.26 in Billed Charges for Rev 278 = $1,190.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2290.26,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,290.26 in Billed Charges for Rev 278 = $2,290.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,CENPATICO,ALL MEDICAID CENPATICO,2290.26,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,290.26 in Billed Charges for Rev 278 = $2,290.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1946.72,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,290.26 in Billed Charges for Rev 278 = $1,946.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,CIGNA,ALL COMMERCIAL CIGNA,1603.18,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,290.26 in Billed Charges for Rev 278 = $1,603.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,COFINITY,COFINITY,2290.26,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,290.26 in Billed Charges for Rev 278 = $2,290.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2175.75,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,290.26 in Billed Charges for Rev 278 = $2,175.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,1923.82,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,290.26 in Billed Charges for Rev 278 = $1,923.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1626.08,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,290.26 in Billed Charges for Rev 278 = $1,626.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1671.89,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,290.26 in Billed Charges for Rev 278 = $1,671.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,1113.07,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,290.26 in Billed Charges for Rev 278 = $1,113.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1946.72,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,290.26 in Billed Charges for Rev 278 = $1,946.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,HUMANA,HUMANA CHOICE CARE PPO,1946.72,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,290.26 in Billed Charges for Rev 278 = $1,946.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1671.89,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,290.26 in Billed Charges for Rev 278 = $1,671.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,2290.26,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,290.26 in Billed Charges for Rev 278 = $2,290.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1145.13,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,290.26 in Billed Charges for Rev 278 = $1,145.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1923.82,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,290.26 in Billed Charges for Rev 278 = $1,923.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1717.70,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,290.26 in Billed Charges for Rev 278 = $1,717.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2107.04,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,290.26 in Billed Charges for Rev 278 = $2,107.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1461.87,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,290.26 in Billed Charges for Rev 278 = $1,461.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1648.99,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,290.26 in Billed Charges for Rev 278 = $1,648.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1648.99,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,290.26 in Billed Charges for Rev 278 = $1,648.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1419.96,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,290.26 in Billed Charges for Rev 278 = $1,419.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1648.99,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,290.26 in Billed Charges for Rev 278 = $1,648.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1648.99,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,290.26 in Billed Charges for Rev 278 = $1,648.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ORBITAL WALL & FLOOR POREX,278,RC,10049255,CDM,,,,,,both,,,2290.2600,1511.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1374.16,,,,,,,1113.0700,2290.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,290.26 in Billed Charges for Rev 278 = $1,374.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,AETNA,AETNA HSHS,510.00,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $789.48 in Billed Charges for Rev 278 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,AETNA,ALL COMMERCIAL AETNA,789.48,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $789.48 in Billed Charges for Rev 278 = $789.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,789.48,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $789.48 in Billed Charges for Rev 278 = $789.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,CENPATICO,ALL MEDICAID CENPATICO,789.48,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $789.48 in Billed Charges for Rev 278 = $789.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,671.06,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $789.48 in Billed Charges for Rev 278 = $671.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,CIGNA,ALL COMMERCIAL CIGNA,552.64,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $789.48 in Billed Charges for Rev 278 = $552.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,COFINITY,COFINITY,789.48,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $789.48 in Billed Charges for Rev 278 = $789.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,750.01,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $789.48 in Billed Charges for Rev 278 = $750.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,663.16,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $789.48 in Billed Charges for Rev 278 = $663.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,560.53,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $789.48 in Billed Charges for Rev 278 = $560.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,576.32,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $789.48 in Billed Charges for Rev 278 = $576.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,383.69,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $789.48 in Billed Charges for Rev 278 = $383.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,671.06,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $789.48 in Billed Charges for Rev 278 = $671.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,HUMANA,HUMANA CHOICE CARE PPO,671.06,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $789.48 in Billed Charges for Rev 278 = $671.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,576.32,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $789.48 in Billed Charges for Rev 278 = $576.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,789.48,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $789.48 in Billed Charges for Rev 278 = $789.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,394.74,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $789.48 in Billed Charges for Rev 278 = $394.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,663.16,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $789.48 in Billed Charges for Rev 278 = $663.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,592.11,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $789.48 in Billed Charges for Rev 278 = $592.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,726.32,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $789.48 in Billed Charges for Rev 278 = $726.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,503.93,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $789.48 in Billed Charges for Rev 278 = $503.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,568.43,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $789.48 in Billed Charges for Rev 278 = $568.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,568.43,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $789.48 in Billed Charges for Rev 278 = $568.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,489.48,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $789.48 in Billed Charges for Rev 278 = $489.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,568.43,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $789.48 in Billed Charges for Rev 278 = $568.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,568.43,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $789.48 in Billed Charges for Rev 278 = $568.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURA 2X2IN DUREPAIR,278,RC,10009155,CDM,,,,,,both,,,789.4800,521.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,473.69,,,,,,,383.6900,789.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $789.48 in Billed Charges for Rev 278 = $473.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,AETNA,AETNA HSHS,2049.76,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,173.00 in Billed Charges for Rev 278 = $2,049.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,AETNA,ALL COMMERCIAL AETNA,3173.00,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,173.00 in Billed Charges for Rev 278 = $3,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,ANTHEM,ANTHEM POS/HMO,1649.96,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,173.00 in Billed Charges for Rev 278 = $1,649.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,ANTHEM,ANTHEM PPO,1649.96,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,173.00 in Billed Charges for Rev 278 = $1,649.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3173.00,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,173.00 in Billed Charges for Rev 278 = $3,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,CENPATICO,ALL MEDICAID CENPATICO,3173.00,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,173.00 in Billed Charges for Rev 278 = $3,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2697.05,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,173.00 in Billed Charges for Rev 278 = $2,697.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,CIGNA,ALL COMMERCIAL CIGNA,2221.10,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,173.00 in Billed Charges for Rev 278 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,COFINITY,COFINITY,3173.00,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,173.00 in Billed Charges for Rev 278 = $3,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3014.35,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,173.00 in Billed Charges for Rev 278 = $3,014.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,2665.32,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,173.00 in Billed Charges for Rev 278 = $2,665.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2252.83,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,173.00 in Billed Charges for Rev 278 = $2,252.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2316.29,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,173.00 in Billed Charges for Rev 278 = $2,316.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,1542.08,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,173.00 in Billed Charges for Rev 278 = $1,542.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2697.05,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,173.00 in Billed Charges for Rev 278 = $2,697.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,HUMANA,HUMANA CHOICE CARE HMO,1586.50,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,173.00 in Billed Charges for Rev 278 = $1,586.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,HUMANA,HUMANA CHOICE CARE PPO,2697.05,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,173.00 in Billed Charges for Rev 278 = $2,697.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,HUMANA,HUMANA NATIIONAL POS HMO,1586.50,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,173.00 in Billed Charges for Rev 278 = $1,586.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2316.29,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,173.00 in Billed Charges for Rev 278 = $2,316.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3173.00,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,173.00 in Billed Charges for Rev 278 = $3,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1586.50,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,173.00 in Billed Charges for Rev 278 = $1,586.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2665.32,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,173.00 in Billed Charges for Rev 278 = $2,665.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2379.75,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,173.00 in Billed Charges for Rev 278 = $2,379.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2919.16,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,173.00 in Billed Charges for Rev 278 = $2,919.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2025.33,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,173.00 in Billed Charges for Rev 278 = $2,025.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2284.56,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,173.00 in Billed Charges for Rev 278 = $2,284.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2284.56,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,173.00 in Billed Charges for Rev 278 = $2,284.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1967.26,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,173.00 in Billed Charges for Rev 278 = $1,967.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2284.56,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,173.00 in Billed Charges for Rev 278 = $2,284.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2284.56,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,173.00 in Billed Charges for Rev 278 = $2,284.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE-TEX PRECLUDE PERI MEMBRANE 15 X 20 X 0.1,278,RC,10003859,CDM,,,,,,both,,,3173.0000,2094.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1903.80,,,,,,,1542.0800,3173.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,173.00 in Billed Charges for Rev 278 = $1,903.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,AETNA,AETNA HSHS,247.83,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $383.63 in Billed Charges for Rev 278 = $247.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,AETNA,ALL COMMERCIAL AETNA,383.63,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $383.63 in Billed Charges for Rev 278 = $383.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,383.63,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $383.63 in Billed Charges for Rev 278 = $383.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,CENPATICO,ALL MEDICAID CENPATICO,383.63,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $383.63 in Billed Charges for Rev 278 = $383.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,326.09,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $383.63 in Billed Charges for Rev 278 = $326.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,CIGNA,ALL COMMERCIAL CIGNA,268.54,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $383.63 in Billed Charges for Rev 278 = $268.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,COFINITY,COFINITY,383.63,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $383.63 in Billed Charges for Rev 278 = $383.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,364.45,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $383.63 in Billed Charges for Rev 278 = $364.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,322.25,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $383.63 in Billed Charges for Rev 278 = $322.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,272.38,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $383.63 in Billed Charges for Rev 278 = $272.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,280.05,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $383.63 in Billed Charges for Rev 278 = $280.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,186.44,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $383.63 in Billed Charges for Rev 278 = $186.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,326.09,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $383.63 in Billed Charges for Rev 278 = $326.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,HUMANA,HUMANA CHOICE CARE PPO,326.09,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $383.63 in Billed Charges for Rev 278 = $326.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,280.05,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $383.63 in Billed Charges for Rev 278 = $280.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,383.63,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $383.63 in Billed Charges for Rev 278 = $383.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,191.82,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $383.63 in Billed Charges for Rev 278 = $191.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,322.25,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $383.63 in Billed Charges for Rev 278 = $322.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,287.72,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $383.63 in Billed Charges for Rev 278 = $287.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,352.94,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $383.63 in Billed Charges for Rev 278 = $352.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,244.87,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $383.63 in Billed Charges for Rev 278 = $244.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,276.21,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $383.63 in Billed Charges for Rev 278 = $276.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,276.21,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $383.63 in Billed Charges for Rev 278 = $276.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,237.85,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $383.63 in Billed Charges for Rev 278 = $237.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,276.21,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $383.63 in Billed Charges for Rev 278 = $276.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,276.21,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $383.63 in Billed Charges for Rev 278 = $276.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM 20FR BLM-SNG TE INDWELL LABL FLNG INTRO GEL,278,RC,10037455,CDM,,,,,,both,,,383.6300,253.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,230.18,,,,,,,186.4400,383.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $383.63 in Billed Charges for Rev 278 = $230.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,AETNA,AETNA HSHS,268.90,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $416.25 in Billed Charges for Rev 278 = $268.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,AETNA,ALL COMMERCIAL AETNA,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,CENPATICO,ALL MEDICAID CENPATICO,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,353.81,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $416.25 in Billed Charges for Rev 278 = $353.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,CIGNA,ALL COMMERCIAL CIGNA,291.38,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $416.25 in Billed Charges for Rev 278 = $291.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,COFINITY,COFINITY,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,395.44,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $416.25 in Billed Charges for Rev 278 = $395.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,349.65,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $416.25 in Billed Charges for Rev 278 = $349.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,295.54,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $416.25 in Billed Charges for Rev 278 = $295.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,303.86,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $416.25 in Billed Charges for Rev 278 = $303.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,202.30,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $416.25 in Billed Charges for Rev 278 = $202.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,353.81,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $416.25 in Billed Charges for Rev 278 = $353.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,HUMANA,HUMANA CHOICE CARE PPO,353.81,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $416.25 in Billed Charges for Rev 278 = $353.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,303.86,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $416.25 in Billed Charges for Rev 278 = $303.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,208.13,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $416.25 in Billed Charges for Rev 278 = $208.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,349.65,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $416.25 in Billed Charges for Rev 278 = $349.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,312.19,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $416.25 in Billed Charges for Rev 278 = $312.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,382.95,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $416.25 in Billed Charges for Rev 278 = $382.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,265.69,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $416.25 in Billed Charges for Rev 278 = $265.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,299.70,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $416.25 in Billed Charges for Rev 278 = $299.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,299.70,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $416.25 in Billed Charges for Rev 278 = $299.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,258.08,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $416.25 in Billed Charges for Rev 278 = $258.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,299.70,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $416.25 in Billed Charges for Rev 278 = $299.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,299.70,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $416.25 in Billed Charges for Rev 278 = $299.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 0.6GM,278,RC,10014810,CDM,,,,,,both,,,416.2500,274.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,249.75,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $416.25 in Billed Charges for Rev 278 = $249.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,AETNA,AETNA HSHS,395.84,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $612.75 in Billed Charges for Rev 278 = $395.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,AETNA,ALL COMMERCIAL AETNA,612.75,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.75 in Billed Charges for Rev 278 = $612.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,612.75,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.75 in Billed Charges for Rev 278 = $612.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,CENPATICO,ALL MEDICAID CENPATICO,612.75,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.75 in Billed Charges for Rev 278 = $612.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,520.84,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $612.75 in Billed Charges for Rev 278 = $520.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,CIGNA,ALL COMMERCIAL CIGNA,428.93,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $612.75 in Billed Charges for Rev 278 = $428.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,COFINITY,COFINITY,612.75,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.75 in Billed Charges for Rev 278 = $612.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,582.11,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $612.75 in Billed Charges for Rev 278 = $582.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,514.71,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $612.75 in Billed Charges for Rev 278 = $514.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,435.05,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $612.75 in Billed Charges for Rev 278 = $435.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,447.31,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $612.75 in Billed Charges for Rev 278 = $447.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,297.80,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $612.75 in Billed Charges for Rev 278 = $297.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,520.84,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $612.75 in Billed Charges for Rev 278 = $520.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,HUMANA,HUMANA CHOICE CARE PPO,520.84,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $612.75 in Billed Charges for Rev 278 = $520.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,447.31,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $612.75 in Billed Charges for Rev 278 = $447.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,612.75,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.75 in Billed Charges for Rev 278 = $612.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,306.38,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $612.75 in Billed Charges for Rev 278 = $306.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,514.71,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $612.75 in Billed Charges for Rev 278 = $514.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,459.56,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $612.75 in Billed Charges for Rev 278 = $459.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,563.73,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $612.75 in Billed Charges for Rev 278 = $563.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,391.12,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $612.75 in Billed Charges for Rev 278 = $391.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,441.18,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $612.75 in Billed Charges for Rev 278 = $441.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,441.18,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $612.75 in Billed Charges for Rev 278 = $441.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,379.91,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $612.75 in Billed Charges for Rev 278 = $379.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,441.18,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $612.75 in Billed Charges for Rev 278 = $441.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,441.18,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $612.75 in Billed Charges for Rev 278 = $441.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.4GM,278,RC,10022530,CDM,,,,,,both,,,612.7500,404.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,367.65,,,,,,,297.8000,612.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $612.75 in Billed Charges for Rev 278 = $367.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,AETNA,AETNA HSHS,333.34,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $516.00 in Billed Charges for Rev 278 = $333.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,AETNA,ALL COMMERCIAL AETNA,516.00,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $516.00 in Billed Charges for Rev 278 = $516.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,516.00,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $516.00 in Billed Charges for Rev 278 = $516.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,CENPATICO,ALL MEDICAID CENPATICO,516.00,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $516.00 in Billed Charges for Rev 278 = $516.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,438.60,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $516.00 in Billed Charges for Rev 278 = $438.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,CIGNA,ALL COMMERCIAL CIGNA,361.20,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $516.00 in Billed Charges for Rev 278 = $361.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,COFINITY,COFINITY,516.00,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $516.00 in Billed Charges for Rev 278 = $516.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,490.20,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $516.00 in Billed Charges for Rev 278 = $490.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,433.44,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $516.00 in Billed Charges for Rev 278 = $433.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,366.36,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $516.00 in Billed Charges for Rev 278 = $366.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,376.68,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $516.00 in Billed Charges for Rev 278 = $376.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,250.78,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $516.00 in Billed Charges for Rev 278 = $250.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,438.60,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $516.00 in Billed Charges for Rev 278 = $438.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,HUMANA,HUMANA CHOICE CARE PPO,438.60,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $516.00 in Billed Charges for Rev 278 = $438.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,376.68,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $516.00 in Billed Charges for Rev 278 = $376.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,516.00,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $516.00 in Billed Charges for Rev 278 = $516.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,258.00,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $516.00 in Billed Charges for Rev 278 = $258.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,433.44,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $516.00 in Billed Charges for Rev 278 = $433.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,387.00,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $516.00 in Billed Charges for Rev 278 = $387.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,474.72,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $516.00 in Billed Charges for Rev 278 = $474.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,329.36,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $516.00 in Billed Charges for Rev 278 = $329.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,371.52,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $516.00 in Billed Charges for Rev 278 = $371.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,371.52,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $516.00 in Billed Charges for Rev 278 = $371.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,319.92,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $516.00 in Billed Charges for Rev 278 = $319.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,371.52,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $516.00 in Billed Charges for Rev 278 = $371.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,371.52,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $516.00 in Billed Charges for Rev 278 = $371.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.8GM,278,RC,10014826,CDM,,,,,,both,,,516.0000,340.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,309.60,,,,,,,250.7800,516.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $516.00 in Billed Charges for Rev 278 = $309.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,AETNA,AETNA HSHS,627.78,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $971.80 in Billed Charges for Rev 278 = $627.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,AETNA,ALL COMMERCIAL AETNA,971.80,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $971.80 in Billed Charges for Rev 278 = $971.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,971.80,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $971.80 in Billed Charges for Rev 278 = $971.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,CENPATICO,ALL MEDICAID CENPATICO,971.80,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $971.80 in Billed Charges for Rev 278 = $971.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,826.03,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $971.80 in Billed Charges for Rev 278 = $826.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,CIGNA,ALL COMMERCIAL CIGNA,680.26,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $971.80 in Billed Charges for Rev 278 = $680.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,COFINITY,COFINITY,971.80,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $971.80 in Billed Charges for Rev 278 = $971.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,923.21,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $971.80 in Billed Charges for Rev 278 = $923.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,816.31,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $971.80 in Billed Charges for Rev 278 = $816.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,689.98,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $971.80 in Billed Charges for Rev 278 = $689.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,709.41,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $971.80 in Billed Charges for Rev 278 = $709.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,472.29,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $971.80 in Billed Charges for Rev 278 = $472.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,826.03,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $971.80 in Billed Charges for Rev 278 = $826.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,HUMANA,HUMANA CHOICE CARE PPO,826.03,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $971.80 in Billed Charges for Rev 278 = $826.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,709.41,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $971.80 in Billed Charges for Rev 278 = $709.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,971.80,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $971.80 in Billed Charges for Rev 278 = $971.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,485.90,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $971.80 in Billed Charges for Rev 278 = $485.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,816.31,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $971.80 in Billed Charges for Rev 278 = $816.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,728.85,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $971.80 in Billed Charges for Rev 278 = $728.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,894.06,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $971.80 in Billed Charges for Rev 278 = $894.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,620.30,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $971.80 in Billed Charges for Rev 278 = $620.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,699.70,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $971.80 in Billed Charges for Rev 278 = $699.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,699.70,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $971.80 in Billed Charges for Rev 278 = $699.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,602.52,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $971.80 in Billed Charges for Rev 278 = $602.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,699.70,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $971.80 in Billed Charges for Rev 278 = $699.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,699.70,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $971.80 in Billed Charges for Rev 278 = $699.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS KURZ PLESTER ANGULAR EAR .2 X 3.25 X .5MM,278,RC,10011902,CDM,,,,,,both,,,971.8000,641.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,583.08,,,,,,,472.2900,971.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $971.80 in Billed Charges for Rev 278 = $583.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,AETNA,AETNA HSHS,659.73,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,021.25 in Billed Charges for Rev 278 = $659.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,AETNA,ALL COMMERCIAL AETNA,1021.25,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.25 in Billed Charges for Rev 278 = $1,021.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,ANTHEM,ANTHEM POS/HMO,531.05,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,021.25 in Billed Charges for Rev 278 = $531.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,ANTHEM,ANTHEM PPO,531.05,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,021.25 in Billed Charges for Rev 278 = $531.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1021.25,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.25 in Billed Charges for Rev 278 = $1,021.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,CENPATICO,ALL MEDICAID CENPATICO,1021.25,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.25 in Billed Charges for Rev 278 = $1,021.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,868.06,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,021.25 in Billed Charges for Rev 278 = $868.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,CIGNA,ALL COMMERCIAL CIGNA,714.88,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,021.25 in Billed Charges for Rev 278 = $714.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,COFINITY,COFINITY,1021.25,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.25 in Billed Charges for Rev 278 = $1,021.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,970.19,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,021.25 in Billed Charges for Rev 278 = $970.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,HEALTH CARE ALLIANCE,THE ALLIANCE,857.85,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,021.25 in Billed Charges for Rev 278 = $857.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,725.09,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,021.25 in Billed Charges for Rev 278 = $725.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,745.51,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,021.25 in Billed Charges for Rev 278 = $745.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,HSHS EMPLOYEES,HSHS EMPLOYEES,496.33,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,021.25 in Billed Charges for Rev 278 = $496.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,868.06,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,021.25 in Billed Charges for Rev 278 = $868.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,HUMANA,HUMANA CHOICE CARE PPO,868.06,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,021.25 in Billed Charges for Rev 278 = $868.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,745.51,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,021.25 in Billed Charges for Rev 278 = $745.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1021.25,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.25 in Billed Charges for Rev 278 = $1,021.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,510.63,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,021.25 in Billed Charges for Rev 278 = $510.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,857.85,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,021.25 in Billed Charges for Rev 278 = $857.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,765.94,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,021.25 in Billed Charges for Rev 278 = $765.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,939.55,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,021.25 in Billed Charges for Rev 278 = $939.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,651.86,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,021.25 in Billed Charges for Rev 278 = $651.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,735.30,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,021.25 in Billed Charges for Rev 278 = $735.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,735.30,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,021.25 in Billed Charges for Rev 278 = $735.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,633.18,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,021.25 in Billed Charges for Rev 278 = $633.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,735.30,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,021.25 in Billed Charges for Rev 278 = $735.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,735.30,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,021.25 in Billed Charges for Rev 278 = $735.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.0MM,278,RC,10059547,CDM,,,,,,both,,,1021.2500,674.0300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,612.75,,,,,,,496.3300,1021.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,021.25 in Billed Charges for Rev 278 = $612.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,AETNA,AETNA HSHS,409.73,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $634.25 in Billed Charges for Rev 278 = $409.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,AETNA,ALL COMMERCIAL AETNA,634.25,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.25 in Billed Charges for Rev 278 = $634.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,634.25,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.25 in Billed Charges for Rev 278 = $634.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,CENPATICO,ALL MEDICAID CENPATICO,634.25,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.25 in Billed Charges for Rev 278 = $634.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,539.11,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $634.25 in Billed Charges for Rev 278 = $539.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,CIGNA,ALL COMMERCIAL CIGNA,443.98,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $634.25 in Billed Charges for Rev 278 = $443.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,COFINITY,COFINITY,634.25,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.25 in Billed Charges for Rev 278 = $634.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,602.54,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $634.25 in Billed Charges for Rev 278 = $602.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,532.77,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $634.25 in Billed Charges for Rev 278 = $532.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,450.32,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $634.25 in Billed Charges for Rev 278 = $450.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,463.00,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $634.25 in Billed Charges for Rev 278 = $463.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,308.25,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $634.25 in Billed Charges for Rev 278 = $308.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,539.11,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $634.25 in Billed Charges for Rev 278 = $539.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,HUMANA,HUMANA CHOICE CARE PPO,539.11,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $634.25 in Billed Charges for Rev 278 = $539.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,463.00,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $634.25 in Billed Charges for Rev 278 = $463.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,634.25,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.25 in Billed Charges for Rev 278 = $634.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,317.13,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $634.25 in Billed Charges for Rev 278 = $317.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,532.77,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $634.25 in Billed Charges for Rev 278 = $532.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,475.69,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $634.25 in Billed Charges for Rev 278 = $475.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,583.51,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $634.25 in Billed Charges for Rev 278 = $583.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,404.84,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $634.25 in Billed Charges for Rev 278 = $404.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,456.66,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $634.25 in Billed Charges for Rev 278 = $456.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,456.66,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $634.25 in Billed Charges for Rev 278 = $456.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,393.24,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $634.25 in Billed Charges for Rev 278 = $393.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,456.66,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $634.25 in Billed Charges for Rev 278 = $456.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,456.66,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $634.25 in Billed Charges for Rev 278 = $456.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR APPLEBAUM INCUS REPLACEMENT 2.5MM,278,RC,10015804,CDM,,,,,,both,,,634.2500,418.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,380.55,,,,,,,308.2500,634.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $634.25 in Billed Charges for Rev 278 = $380.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,AETNA,AETNA HSHS,229.06,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $354.58 in Billed Charges for Rev 278 = $229.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,AETNA,ALL COMMERCIAL AETNA,354.58,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.58 in Billed Charges for Rev 278 = $354.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,354.58,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.58 in Billed Charges for Rev 278 = $354.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,CENPATICO,ALL MEDICAID CENPATICO,354.58,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.58 in Billed Charges for Rev 278 = $354.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,301.39,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $354.58 in Billed Charges for Rev 278 = $301.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,CIGNA,ALL COMMERCIAL CIGNA,248.21,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $354.58 in Billed Charges for Rev 278 = $248.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,COFINITY,COFINITY,354.58,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.58 in Billed Charges for Rev 278 = $354.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,336.85,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $354.58 in Billed Charges for Rev 278 = $336.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,297.85,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $354.58 in Billed Charges for Rev 278 = $297.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,251.75,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $354.58 in Billed Charges for Rev 278 = $251.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,258.84,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $354.58 in Billed Charges for Rev 278 = $258.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,172.33,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $354.58 in Billed Charges for Rev 278 = $172.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,301.39,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $354.58 in Billed Charges for Rev 278 = $301.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,HUMANA,HUMANA CHOICE CARE PPO,301.39,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $354.58 in Billed Charges for Rev 278 = $301.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,258.84,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $354.58 in Billed Charges for Rev 278 = $258.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,354.58,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.58 in Billed Charges for Rev 278 = $354.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,177.29,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $354.58 in Billed Charges for Rev 278 = $177.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,297.85,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $354.58 in Billed Charges for Rev 278 = $297.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,265.94,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $354.58 in Billed Charges for Rev 278 = $265.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,326.21,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $354.58 in Billed Charges for Rev 278 = $326.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,226.33,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $354.58 in Billed Charges for Rev 278 = $226.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,255.30,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $354.58 in Billed Charges for Rev 278 = $255.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,255.30,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $354.58 in Billed Charges for Rev 278 = $255.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,219.84,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $354.58 in Billed Charges for Rev 278 = $219.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,255.30,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $354.58 in Billed Charges for Rev 278 = $255.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,255.30,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $354.58 in Billed Charges for Rev 278 = $255.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR DORNHOFFER TI FOOTPLATE,278,RC,10022807,CDM,,,,,,both,,,354.5800,234.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,212.75,,,,,,,172.3300,354.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $354.58 in Billed Charges for Rev 278 = $212.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,AETNA,AETNA HSHS,491.67,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $761.10 in Billed Charges for Rev 278 = $491.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,AETNA,ALL COMMERCIAL AETNA,761.10,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $761.10 in Billed Charges for Rev 278 = $761.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,761.10,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $761.10 in Billed Charges for Rev 278 = $761.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,CENPATICO,ALL MEDICAID CENPATICO,761.10,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $761.10 in Billed Charges for Rev 278 = $761.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,646.94,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $761.10 in Billed Charges for Rev 278 = $646.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,CIGNA,ALL COMMERCIAL CIGNA,532.77,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $761.10 in Billed Charges for Rev 278 = $532.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,COFINITY,COFINITY,761.10,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $761.10 in Billed Charges for Rev 278 = $761.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,723.05,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $761.10 in Billed Charges for Rev 278 = $723.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,639.32,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $761.10 in Billed Charges for Rev 278 = $639.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,540.38,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $761.10 in Billed Charges for Rev 278 = $540.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,555.60,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $761.10 in Billed Charges for Rev 278 = $555.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,369.89,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $761.10 in Billed Charges for Rev 278 = $369.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,646.94,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $761.10 in Billed Charges for Rev 278 = $646.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,HUMANA,HUMANA CHOICE CARE PPO,646.94,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $761.10 in Billed Charges for Rev 278 = $646.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,555.60,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $761.10 in Billed Charges for Rev 278 = $555.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,761.10,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $761.10 in Billed Charges for Rev 278 = $761.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,380.55,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $761.10 in Billed Charges for Rev 278 = $380.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,639.32,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $761.10 in Billed Charges for Rev 278 = $639.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,570.83,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $761.10 in Billed Charges for Rev 278 = $570.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,700.21,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $761.10 in Billed Charges for Rev 278 = $700.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,485.81,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $761.10 in Billed Charges for Rev 278 = $485.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,547.99,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $761.10 in Billed Charges for Rev 278 = $547.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,547.99,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $761.10 in Billed Charges for Rev 278 = $547.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,471.88,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $761.10 in Billed Charges for Rev 278 = $471.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,547.99,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $761.10 in Billed Charges for Rev 278 = $547.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,547.99,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $761.10 in Billed Charges for Rev 278 = $547.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS BUCKET HANDLE EAR .4MM X 4.0MM,278,RC,10033558,CDM,,,,,,both,,,761.1000,502.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,456.66,,,,,,,369.8900,761.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $761.10 in Billed Charges for Rev 278 = $456.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,AETNA,AETNA HSHS,481.95,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $746.05 in Billed Charges for Rev 278 = $481.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,AETNA,ALL COMMERCIAL AETNA,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,CENPATICO,ALL MEDICAID CENPATICO,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,634.14,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $746.05 in Billed Charges for Rev 278 = $634.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,CIGNA,ALL COMMERCIAL CIGNA,522.24,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $746.05 in Billed Charges for Rev 278 = $522.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,COFINITY,COFINITY,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,708.75,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $746.05 in Billed Charges for Rev 278 = $708.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,626.68,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $746.05 in Billed Charges for Rev 278 = $626.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,529.70,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $746.05 in Billed Charges for Rev 278 = $529.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,544.62,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $746.05 in Billed Charges for Rev 278 = $544.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,362.58,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $746.05 in Billed Charges for Rev 278 = $362.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,634.14,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $746.05 in Billed Charges for Rev 278 = $634.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,HUMANA,HUMANA CHOICE CARE PPO,634.14,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $746.05 in Billed Charges for Rev 278 = $634.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,544.62,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $746.05 in Billed Charges for Rev 278 = $544.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,373.03,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $746.05 in Billed Charges for Rev 278 = $373.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,626.68,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $746.05 in Billed Charges for Rev 278 = $626.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,559.54,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $746.05 in Billed Charges for Rev 278 = $559.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,686.37,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $746.05 in Billed Charges for Rev 278 = $686.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,476.20,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $746.05 in Billed Charges for Rev 278 = $476.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,537.16,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $746.05 in Billed Charges for Rev 278 = $537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,537.16,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $746.05 in Billed Charges for Rev 278 = $537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,462.55,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $746.05 in Billed Charges for Rev 278 = $462.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,537.16,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $746.05 in Billed Charges for Rev 278 = $537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,537.16,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $746.05 in Billed Charges for Rev 278 = $537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX INCUS-STAPES,278,RC,10000254,CDM,,,,,,both,,,746.0500,492.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,447.63,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $746.05 in Billed Charges for Rev 278 = $447.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,AETNA,AETNA HSHS,159.89,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $247.50 in Billed Charges for Rev 278 = $159.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,AETNA,ALL COMMERCIAL AETNA,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,CENPATICO,ALL MEDICAID CENPATICO,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,210.38,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.50 in Billed Charges for Rev 278 = $210.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,CIGNA,ALL COMMERCIAL CIGNA,173.25,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $247.50 in Billed Charges for Rev 278 = $173.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,COFINITY,COFINITY,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,235.13,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $247.50 in Billed Charges for Rev 278 = $235.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,207.90,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $247.50 in Billed Charges for Rev 278 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,175.73,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $247.50 in Billed Charges for Rev 278 = $175.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,180.68,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $247.50 in Billed Charges for Rev 278 = $180.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,120.29,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $247.50 in Billed Charges for Rev 278 = $120.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,210.38,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.50 in Billed Charges for Rev 278 = $210.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,HUMANA,HUMANA CHOICE CARE PPO,210.38,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.50 in Billed Charges for Rev 278 = $210.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,180.68,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $247.50 in Billed Charges for Rev 278 = $180.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,123.75,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $247.50 in Billed Charges for Rev 278 = $123.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,207.90,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $247.50 in Billed Charges for Rev 278 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,185.63,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $247.50 in Billed Charges for Rev 278 = $185.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,227.70,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $247.50 in Billed Charges for Rev 278 = $227.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,157.98,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $247.50 in Billed Charges for Rev 278 = $157.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,178.20,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.50 in Billed Charges for Rev 278 = $178.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,178.20,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.50 in Billed Charges for Rev 278 = $178.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,153.45,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $247.50 in Billed Charges for Rev 278 = $153.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,178.20,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.50 in Billed Charges for Rev 278 = $178.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,178.20,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.50 in Billed Charges for Rev 278 = $178.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 1ML,278,RC,10077273,CDM,,,,,,both,,,247.5000,163.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,148.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $247.50 in Billed Charges for Rev 278 = $148.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,AETNA,AETNA HSHS,990.58,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,533.40 in Billed Charges for Rev 278 = $990.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,AETNA,ALL COMMERCIAL AETNA,1533.40,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,533.40 in Billed Charges for Rev 278 = $1,533.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,ANTHEM,ANTHEM POS/HMO,797.37,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,533.40 in Billed Charges for Rev 278 = $797.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,ANTHEM,ANTHEM PPO,797.37,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,533.40 in Billed Charges for Rev 278 = $797.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1533.40,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,533.40 in Billed Charges for Rev 278 = $1,533.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,CENPATICO,ALL MEDICAID CENPATICO,1533.40,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,533.40 in Billed Charges for Rev 278 = $1,533.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1303.39,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,533.40 in Billed Charges for Rev 278 = $1,303.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,CIGNA,ALL COMMERCIAL CIGNA,1073.38,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,533.40 in Billed Charges for Rev 278 = $1,073.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,COFINITY,COFINITY,1533.40,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,533.40 in Billed Charges for Rev 278 = $1,533.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1456.73,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,533.40 in Billed Charges for Rev 278 = $1,456.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,1288.06,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,533.40 in Billed Charges for Rev 278 = $1,288.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1088.71,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,533.40 in Billed Charges for Rev 278 = $1,088.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1119.38,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,533.40 in Billed Charges for Rev 278 = $1,119.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,745.23,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,533.40 in Billed Charges for Rev 278 = $745.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1303.39,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,533.40 in Billed Charges for Rev 278 = $1,303.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,HUMANA,HUMANA CHOICE CARE PPO,1303.39,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,533.40 in Billed Charges for Rev 278 = $1,303.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1119.38,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,533.40 in Billed Charges for Rev 278 = $1,119.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1533.40,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,533.40 in Billed Charges for Rev 278 = $1,533.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,766.70,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,533.40 in Billed Charges for Rev 278 = $766.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1288.06,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,533.40 in Billed Charges for Rev 278 = $1,288.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1150.05,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,533.40 in Billed Charges for Rev 278 = $1,150.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1410.73,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,533.40 in Billed Charges for Rev 278 = $1,410.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,978.77,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,533.40 in Billed Charges for Rev 278 = $978.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1104.05,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,533.40 in Billed Charges for Rev 278 = $1,104.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1104.05,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,533.40 in Billed Charges for Rev 278 = $1,104.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,950.71,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,533.40 in Billed Charges for Rev 278 = $950.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1104.05,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,533.40 in Billed Charges for Rev 278 = $1,104.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1104.05,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,533.40 in Billed Charges for Rev 278 = $1,104.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 8ML,278,RC,10077274,CDM,,,,,,both,,,1533.4000,1012.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,920.04,,,,,,,745.2300,1533.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,533.40 in Billed Charges for Rev 278 = $920.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,AETNA,AETNA HSHS,829.01,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,283.30 in Billed Charges for Rev 278 = $829.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,AETNA,ALL COMMERCIAL AETNA,1283.30,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,283.30 in Billed Charges for Rev 278 = $1,283.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,ANTHEM,ANTHEM POS/HMO,667.32,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,283.30 in Billed Charges for Rev 278 = $667.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,ANTHEM,ANTHEM PPO,667.32,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,283.30 in Billed Charges for Rev 278 = $667.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1283.30,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,283.30 in Billed Charges for Rev 278 = $1,283.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,CENPATICO,ALL MEDICAID CENPATICO,1283.30,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,283.30 in Billed Charges for Rev 278 = $1,283.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1090.81,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,283.30 in Billed Charges for Rev 278 = $1,090.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,CIGNA,ALL COMMERCIAL CIGNA,898.31,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,283.30 in Billed Charges for Rev 278 = $898.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,COFINITY,COFINITY,1283.30,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,283.30 in Billed Charges for Rev 278 = $1,283.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1219.14,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,283.30 in Billed Charges for Rev 278 = $1,219.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,1077.97,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,283.30 in Billed Charges for Rev 278 = $1,077.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,911.14,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,283.30 in Billed Charges for Rev 278 = $911.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,936.81,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,283.30 in Billed Charges for Rev 278 = $936.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,623.68,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,283.30 in Billed Charges for Rev 278 = $623.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1090.81,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,283.30 in Billed Charges for Rev 278 = $1,090.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,HUMANA,HUMANA CHOICE CARE PPO,1090.81,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,283.30 in Billed Charges for Rev 278 = $1,090.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,936.81,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,283.30 in Billed Charges for Rev 278 = $936.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1283.30,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,283.30 in Billed Charges for Rev 278 = $1,283.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,641.65,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,283.30 in Billed Charges for Rev 278 = $641.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1077.97,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,283.30 in Billed Charges for Rev 278 = $1,077.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,962.48,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,283.30 in Billed Charges for Rev 278 = $962.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1180.64,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,283.30 in Billed Charges for Rev 278 = $1,180.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,819.13,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,283.30 in Billed Charges for Rev 278 = $819.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,923.98,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,283.30 in Billed Charges for Rev 278 = $923.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,923.98,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,283.30 in Billed Charges for Rev 278 = $923.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,795.65,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,283.30 in Billed Charges for Rev 278 = $795.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,923.98,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,283.30 in Billed Charges for Rev 278 = $923.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,923.98,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,283.30 in Billed Charges for Rev 278 = $923.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESERVOIR OMMAYA CONVERTIBLE (NL850-1213),278,RC,10018007,CDM,,,,,,both,,,1283.3000,846.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,769.98,,,,,,,623.6800,1283.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,283.30 in Billed Charges for Rev 278 = $769.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,AETNA,AETNA HSHS,3755.84,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,814.00 in Billed Charges for Rev 278 = $3,755.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,AETNA,ALL COMMERCIAL AETNA,5814.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,814.00 in Billed Charges for Rev 278 = $5,814.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,ANTHEM,ANTHEM POS/HMO,3023.28,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,814.00 in Billed Charges for Rev 278 = $3,023.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,ANTHEM,ANTHEM PPO,3023.28,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,814.00 in Billed Charges for Rev 278 = $3,023.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5814.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,814.00 in Billed Charges for Rev 278 = $5,814.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,CENPATICO,ALL MEDICAID CENPATICO,5814.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,814.00 in Billed Charges for Rev 278 = $5,814.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4941.90,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,814.00 in Billed Charges for Rev 278 = $4,941.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,CIGNA,ALL COMMERCIAL CIGNA,4069.80,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,814.00 in Billed Charges for Rev 278 = $4,069.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,COFINITY,COFINITY,5814.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,814.00 in Billed Charges for Rev 278 = $5,814.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5523.30,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,814.00 in Billed Charges for Rev 278 = $5,523.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,4883.76,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,814.00 in Billed Charges for Rev 278 = $4,883.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4127.94,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,814.00 in Billed Charges for Rev 278 = $4,127.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4244.22,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,814.00 in Billed Charges for Rev 278 = $4,244.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,2825.60,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,814.00 in Billed Charges for Rev 278 = $2,825.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4941.90,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,814.00 in Billed Charges for Rev 278 = $4,941.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,HUMANA,HUMANA CHOICE CARE HMO,2907.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,814.00 in Billed Charges for Rev 278 = $2,907.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,HUMANA,HUMANA CHOICE CARE PPO,4941.90,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,814.00 in Billed Charges for Rev 278 = $4,941.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,HUMANA,HUMANA NATIIONAL POS HMO,2907.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,814.00 in Billed Charges for Rev 278 = $2,907.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4244.22,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,814.00 in Billed Charges for Rev 278 = $4,244.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,5814.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,814.00 in Billed Charges for Rev 278 = $5,814.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2907.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,814.00 in Billed Charges for Rev 278 = $2,907.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4883.76,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,814.00 in Billed Charges for Rev 278 = $4,883.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4360.50,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,814.00 in Billed Charges for Rev 278 = $4,360.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5348.88,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,814.00 in Billed Charges for Rev 278 = $5,348.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2907.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,814.00 in Billed Charges for Rev 278 = $2,907.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2907.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,814.00 in Billed Charges for Rev 278 = $2,907.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,PREVEA HEALTH NETWORK,PREVEA360,2907.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,814.00 in Billed Charges for Rev 278 = $2,907.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2907.00,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,814.00 in Billed Charges for Rev 278 = $2,907.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3711.08,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,814.00 in Billed Charges for Rev 278 = $3,711.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4186.08,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,814.00 in Billed Charges for Rev 278 = $4,186.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4186.08,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,814.00 in Billed Charges for Rev 278 = $4,186.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3604.68,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,814.00 in Billed Charges for Rev 278 = $3,604.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4186.08,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,814.00 in Billed Charges for Rev 278 = $4,186.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4186.08,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,814.00 in Billed Charges for Rev 278 = $4,186.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 30MM MTRL FLEX TEMPLT EDWRD MYXO ETLOGIX TITAN,278,RC,10022470,CDM,,,,,,both,,,5814.0000,3837.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3488.40,,,,,,,2825.6000,5814.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,814.00 in Billed Charges for Rev 278 = $3,488.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,AETNA,AETNA HSHS,2025.21,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,135.00 in Billed Charges for Rev 278 = $2,025.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,AETNA,ALL COMMERCIAL AETNA,3135.00,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,135.00 in Billed Charges for Rev 278 = $3,135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,ANTHEM,ANTHEM POS/HMO,1630.20,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,135.00 in Billed Charges for Rev 278 = $1,630.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,ANTHEM,ANTHEM PPO,1630.20,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,135.00 in Billed Charges for Rev 278 = $1,630.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3135.00,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,135.00 in Billed Charges for Rev 278 = $3,135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,CENPATICO,ALL MEDICAID CENPATICO,3135.00,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,135.00 in Billed Charges for Rev 278 = $3,135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2664.75,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,135.00 in Billed Charges for Rev 278 = $2,664.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,CIGNA,ALL COMMERCIAL CIGNA,2194.50,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,135.00 in Billed Charges for Rev 278 = $2,194.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,COFINITY,COFINITY,3135.00,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,135.00 in Billed Charges for Rev 278 = $3,135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2978.25,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,135.00 in Billed Charges for Rev 278 = $2,978.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,2633.40,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,135.00 in Billed Charges for Rev 278 = $2,633.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2225.85,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,135.00 in Billed Charges for Rev 278 = $2,225.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2288.55,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,135.00 in Billed Charges for Rev 278 = $2,288.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,1523.61,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,135.00 in Billed Charges for Rev 278 = $1,523.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2664.75,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,135.00 in Billed Charges for Rev 278 = $2,664.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,HUMANA,HUMANA CHOICE CARE HMO,1567.50,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,135.00 in Billed Charges for Rev 278 = $1,567.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,HUMANA,HUMANA CHOICE CARE PPO,2664.75,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,135.00 in Billed Charges for Rev 278 = $2,664.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,HUMANA,HUMANA NATIIONAL POS HMO,1567.50,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,135.00 in Billed Charges for Rev 278 = $1,567.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2288.55,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,135.00 in Billed Charges for Rev 278 = $2,288.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3135.00,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,135.00 in Billed Charges for Rev 278 = $3,135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1567.50,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,135.00 in Billed Charges for Rev 278 = $1,567.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2633.40,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,135.00 in Billed Charges for Rev 278 = $2,633.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2351.25,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,135.00 in Billed Charges for Rev 278 = $2,351.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2884.20,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,135.00 in Billed Charges for Rev 278 = $2,884.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2001.07,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,135.00 in Billed Charges for Rev 278 = $2,001.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2257.20,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,135.00 in Billed Charges for Rev 278 = $2,257.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2257.20,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,135.00 in Billed Charges for Rev 278 = $2,257.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1943.70,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,135.00 in Billed Charges for Rev 278 = $1,943.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2257.20,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,135.00 in Billed Charges for Rev 278 = $2,257.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2257.20,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,135.00 in Billed Charges for Rev 278 = $2,257.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 36MM 43.6MM 35.9MM MTRL/TRCSPD 3D FLXBND TEMPLT,278,RC,10003953,CDM,,,,,,both,,,3135.0000,2069.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1881.00,,,,,,,1523.6100,3135.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,135.00 in Billed Charges for Rev 278 = $1,881.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,AETNA,AETNA HSHS,3255.84,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,040.00 in Billed Charges for Rev 278 = $3,255.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,AETNA,ALL COMMERCIAL AETNA,5040.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,040.00 in Billed Charges for Rev 278 = $5,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,ANTHEM,ANTHEM POS/HMO,2620.80,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,040.00 in Billed Charges for Rev 278 = $2,620.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,ANTHEM,ANTHEM PPO,2620.80,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,040.00 in Billed Charges for Rev 278 = $2,620.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5040.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,040.00 in Billed Charges for Rev 278 = $5,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,CENPATICO,ALL MEDICAID CENPATICO,5040.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,040.00 in Billed Charges for Rev 278 = $5,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4284.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,040.00 in Billed Charges for Rev 278 = $4,284.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,CIGNA,ALL COMMERCIAL CIGNA,3528.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,040.00 in Billed Charges for Rev 278 = $3,528.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,COFINITY,COFINITY,5040.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,040.00 in Billed Charges for Rev 278 = $5,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4788.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,040.00 in Billed Charges for Rev 278 = $4,788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,4233.60,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,040.00 in Billed Charges for Rev 278 = $4,233.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3578.40,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,040.00 in Billed Charges for Rev 278 = $3,578.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3679.20,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,040.00 in Billed Charges for Rev 278 = $3,679.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,2449.44,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,040.00 in Billed Charges for Rev 278 = $2,449.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4284.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,040.00 in Billed Charges for Rev 278 = $4,284.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,HUMANA,HUMANA CHOICE CARE HMO,2520.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,040.00 in Billed Charges for Rev 278 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,HUMANA,HUMANA CHOICE CARE PPO,4284.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,040.00 in Billed Charges for Rev 278 = $4,284.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,HUMANA,HUMANA NATIIONAL POS HMO,2520.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,040.00 in Billed Charges for Rev 278 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3679.20,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,040.00 in Billed Charges for Rev 278 = $3,679.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,5040.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,040.00 in Billed Charges for Rev 278 = $5,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2520.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,040.00 in Billed Charges for Rev 278 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4233.60,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,040.00 in Billed Charges for Rev 278 = $4,233.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3780.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,040.00 in Billed Charges for Rev 278 = $3,780.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4636.80,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,040.00 in Billed Charges for Rev 278 = $4,636.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2520.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,040.00 in Billed Charges for Rev 278 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2520.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,040.00 in Billed Charges for Rev 278 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,PREVEA HEALTH NETWORK,PREVEA360,2520.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,040.00 in Billed Charges for Rev 278 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2520.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,040.00 in Billed Charges for Rev 278 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3217.03,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,040.00 in Billed Charges for Rev 278 = $3,217.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3628.80,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,040.00 in Billed Charges for Rev 278 = $3,628.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3628.80,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,040.00 in Billed Charges for Rev 278 = $3,628.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3124.80,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,040.00 in Billed Charges for Rev 278 = $3,124.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3628.80,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,040.00 in Billed Charges for Rev 278 = $3,628.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3628.80,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,040.00 in Billed Charges for Rev 278 = $3,628.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS MITRAL 24MM,278,RC,10012520,CDM,,,,,,both,,,5040.0000,3326.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3024.00,,,,,,,2449.4400,5040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,040.00 in Billed Charges for Rev 278 = $3,024.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,AETNA,AETNA HSHS,3482.59,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,391.00 in Billed Charges for Rev 278 = $3,482.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,AETNA,ALL COMMERCIAL AETNA,5391.00,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,391.00 in Billed Charges for Rev 278 = $5,391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,ANTHEM,ANTHEM POS/HMO,2803.32,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,391.00 in Billed Charges for Rev 278 = $2,803.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,ANTHEM,ANTHEM PPO,2803.32,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,391.00 in Billed Charges for Rev 278 = $2,803.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5391.00,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,391.00 in Billed Charges for Rev 278 = $5,391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,CENPATICO,ALL MEDICAID CENPATICO,5391.00,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,391.00 in Billed Charges for Rev 278 = $5,391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4582.35,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,391.00 in Billed Charges for Rev 278 = $4,582.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,CIGNA,ALL COMMERCIAL CIGNA,3773.70,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,391.00 in Billed Charges for Rev 278 = $3,773.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,COFINITY,COFINITY,5391.00,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,391.00 in Billed Charges for Rev 278 = $5,391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5121.45,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,391.00 in Billed Charges for Rev 278 = $5,121.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,4528.44,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,391.00 in Billed Charges for Rev 278 = $4,528.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3827.61,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,391.00 in Billed Charges for Rev 278 = $3,827.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3935.43,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,391.00 in Billed Charges for Rev 278 = $3,935.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,2620.03,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,391.00 in Billed Charges for Rev 278 = $2,620.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4582.35,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,391.00 in Billed Charges for Rev 278 = $4,582.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,HUMANA,HUMANA CHOICE CARE HMO,2695.50,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,391.00 in Billed Charges for Rev 278 = $2,695.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,HUMANA,HUMANA CHOICE CARE PPO,4582.35,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,391.00 in Billed Charges for Rev 278 = $4,582.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,HUMANA,HUMANA NATIIONAL POS HMO,2695.50,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,391.00 in Billed Charges for Rev 278 = $2,695.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3935.43,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,391.00 in Billed Charges for Rev 278 = $3,935.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,5391.00,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,391.00 in Billed Charges for Rev 278 = $5,391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2695.50,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,391.00 in Billed Charges for Rev 278 = $2,695.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4528.44,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,391.00 in Billed Charges for Rev 278 = $4,528.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4043.25,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,391.00 in Billed Charges for Rev 278 = $4,043.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4959.72,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,391.00 in Billed Charges for Rev 278 = $4,959.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2695.50,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,391.00 in Billed Charges for Rev 278 = $2,695.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2695.50,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,391.00 in Billed Charges for Rev 278 = $2,695.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,PREVEA HEALTH NETWORK,PREVEA360,2695.50,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,391.00 in Billed Charges for Rev 278 = $2,695.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2695.50,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,391.00 in Billed Charges for Rev 278 = $2,695.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3441.08,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,391.00 in Billed Charges for Rev 278 = $3,441.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3881.52,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,391.00 in Billed Charges for Rev 278 = $3,881.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3881.52,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,391.00 in Billed Charges for Rev 278 = $3,881.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3342.42,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,391.00 in Billed Charges for Rev 278 = $3,342.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3881.52,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,391.00 in Billed Charges for Rev 278 = $3,881.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3881.52,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,391.00 in Billed Charges for Rev 278 = $3,881.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING PHYSIO TRICUSPID ANNULOPLASTY 24,278,RC,70200915,CDM,,,,,,both,,,5391.0000,3558.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3234.60,,,,,,,2620.0300,5391.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,391.00 in Billed Charges for Rev 278 = $3,234.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,AETNA,AETNA HSHS,454.17,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $703.05 in Billed Charges for Rev 278 = $454.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,AETNA,ALL COMMERCIAL AETNA,703.05,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.05 in Billed Charges for Rev 278 = $703.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,703.05,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.05 in Billed Charges for Rev 278 = $703.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,CENPATICO,ALL MEDICAID CENPATICO,703.05,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.05 in Billed Charges for Rev 278 = $703.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,597.59,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $703.05 in Billed Charges for Rev 278 = $597.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,CIGNA,ALL COMMERCIAL CIGNA,492.14,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $703.05 in Billed Charges for Rev 278 = $492.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,COFINITY,COFINITY,703.05,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.05 in Billed Charges for Rev 278 = $703.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,667.90,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $703.05 in Billed Charges for Rev 278 = $667.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,590.56,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $703.05 in Billed Charges for Rev 278 = $590.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,499.17,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $703.05 in Billed Charges for Rev 278 = $499.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,513.23,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $703.05 in Billed Charges for Rev 278 = $513.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,341.68,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $703.05 in Billed Charges for Rev 278 = $341.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,597.59,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $703.05 in Billed Charges for Rev 278 = $597.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,HUMANA,HUMANA CHOICE CARE PPO,597.59,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $703.05 in Billed Charges for Rev 278 = $597.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,513.23,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $703.05 in Billed Charges for Rev 278 = $513.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,703.05,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.05 in Billed Charges for Rev 278 = $703.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,351.53,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $703.05 in Billed Charges for Rev 278 = $351.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,590.56,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $703.05 in Billed Charges for Rev 278 = $590.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,527.29,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $703.05 in Billed Charges for Rev 278 = $527.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,646.81,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $703.05 in Billed Charges for Rev 278 = $646.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,448.76,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $703.05 in Billed Charges for Rev 278 = $448.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,506.20,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $703.05 in Billed Charges for Rev 278 = $506.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,506.20,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $703.05 in Billed Charges for Rev 278 = $506.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,435.89,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $703.05 in Billed Charges for Rev 278 = $435.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,506.20,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $703.05 in Billed Charges for Rev 278 = $506.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,506.20,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $703.05 in Billed Charges for Rev 278 = $506.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD MEDTRONIC 3.5 X 300MM,278,RC,10052203,CDM,,,,,,both,,,703.0500,464.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,421.83,,,,,,,341.6800,703.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $703.05 in Billed Charges for Rev 278 = $421.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,AETNA,AETNA HSHS,320.84,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $496.65 in Billed Charges for Rev 278 = $320.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,AETNA,ALL COMMERCIAL AETNA,496.65,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.65 in Billed Charges for Rev 278 = $496.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,496.65,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.65 in Billed Charges for Rev 278 = $496.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,CENPATICO,ALL MEDICAID CENPATICO,496.65,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.65 in Billed Charges for Rev 278 = $496.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,422.15,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.65 in Billed Charges for Rev 278 = $422.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,CIGNA,ALL COMMERCIAL CIGNA,347.66,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $496.65 in Billed Charges for Rev 278 = $347.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,COFINITY,COFINITY,496.65,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.65 in Billed Charges for Rev 278 = $496.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,471.82,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $496.65 in Billed Charges for Rev 278 = $471.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,417.19,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $496.65 in Billed Charges for Rev 278 = $417.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,352.62,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $496.65 in Billed Charges for Rev 278 = $352.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,362.55,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $496.65 in Billed Charges for Rev 278 = $362.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,241.37,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $496.65 in Billed Charges for Rev 278 = $241.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,422.15,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.65 in Billed Charges for Rev 278 = $422.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,HUMANA,HUMANA CHOICE CARE PPO,422.15,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.65 in Billed Charges for Rev 278 = $422.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,362.55,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $496.65 in Billed Charges for Rev 278 = $362.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,496.65,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.65 in Billed Charges for Rev 278 = $496.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,248.33,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $496.65 in Billed Charges for Rev 278 = $248.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,417.19,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $496.65 in Billed Charges for Rev 278 = $417.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,372.49,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $496.65 in Billed Charges for Rev 278 = $372.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,456.92,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $496.65 in Billed Charges for Rev 278 = $456.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,317.01,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $496.65 in Billed Charges for Rev 278 = $317.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,357.59,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.65 in Billed Charges for Rev 278 = $357.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,357.59,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.65 in Billed Charges for Rev 278 = $357.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,307.92,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $496.65 in Billed Charges for Rev 278 = $307.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,357.59,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.65 in Billed Charges for Rev 278 = $357.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,357.59,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.65 in Billed Charges for Rev 278 = $357.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SPNL 120MM 3.2MM VRTX MX TITAN RECON SYS NONSTRL,278,RC,10032625,CDM,,,,,,both,,,496.6500,327.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,297.99,,,,,,,241.3700,496.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $496.65 in Billed Charges for Rev 278 = $297.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,AETNA,AETNA HSHS,405.56,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $627.80 in Billed Charges for Rev 278 = $405.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,AETNA,ALL COMMERCIAL AETNA,627.80,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.80 in Billed Charges for Rev 278 = $627.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,627.80,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.80 in Billed Charges for Rev 278 = $627.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,CENPATICO,ALL MEDICAID CENPATICO,627.80,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.80 in Billed Charges for Rev 278 = $627.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,533.63,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $627.80 in Billed Charges for Rev 278 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,CIGNA,ALL COMMERCIAL CIGNA,439.46,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $627.80 in Billed Charges for Rev 278 = $439.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,COFINITY,COFINITY,627.80,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.80 in Billed Charges for Rev 278 = $627.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,596.41,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $627.80 in Billed Charges for Rev 278 = $596.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,527.35,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $627.80 in Billed Charges for Rev 278 = $527.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,445.74,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $627.80 in Billed Charges for Rev 278 = $445.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,458.29,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $627.80 in Billed Charges for Rev 278 = $458.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,305.11,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $627.80 in Billed Charges for Rev 278 = $305.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,533.63,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $627.80 in Billed Charges for Rev 278 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,HUMANA,HUMANA CHOICE CARE PPO,533.63,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $627.80 in Billed Charges for Rev 278 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,458.29,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $627.80 in Billed Charges for Rev 278 = $458.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,627.80,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.80 in Billed Charges for Rev 278 = $627.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,313.90,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $627.80 in Billed Charges for Rev 278 = $313.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,527.35,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $627.80 in Billed Charges for Rev 278 = $527.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,470.85,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $627.80 in Billed Charges for Rev 278 = $470.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,577.58,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $627.80 in Billed Charges for Rev 278 = $577.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,400.72,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $627.80 in Billed Charges for Rev 278 = $400.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,452.02,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $627.80 in Billed Charges for Rev 278 = $452.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,452.02,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $627.80 in Billed Charges for Rev 278 = $452.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,389.24,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $627.80 in Billed Charges for Rev 278 = $389.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,452.02,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $627.80 in Billed Charges for Rev 278 = $452.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,452.02,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $627.80 in Billed Charges for Rev 278 = $452.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 8X174,278,RC,10064532,CDM,,,,,,both,,,627.8000,414.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,376.68,,,,,,,305.1100,627.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $627.80 in Billed Charges for Rev 278 = $376.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,AETNA,AETNA HSHS,634.73,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $982.55 in Billed Charges for Rev 278 = $634.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,AETNA,ALL COMMERCIAL AETNA,982.55,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $982.55 in Billed Charges for Rev 278 = $982.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,982.55,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $982.55 in Billed Charges for Rev 278 = $982.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,CENPATICO,ALL MEDICAID CENPATICO,982.55,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $982.55 in Billed Charges for Rev 278 = $982.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,835.17,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $982.55 in Billed Charges for Rev 278 = $835.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,CIGNA,ALL COMMERCIAL CIGNA,687.79,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $982.55 in Billed Charges for Rev 278 = $687.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,COFINITY,COFINITY,982.55,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $982.55 in Billed Charges for Rev 278 = $982.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,933.42,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $982.55 in Billed Charges for Rev 278 = $933.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,825.34,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $982.55 in Billed Charges for Rev 278 = $825.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,697.61,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $982.55 in Billed Charges for Rev 278 = $697.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,717.26,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $982.55 in Billed Charges for Rev 278 = $717.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,477.52,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $982.55 in Billed Charges for Rev 278 = $477.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,835.17,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $982.55 in Billed Charges for Rev 278 = $835.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,HUMANA,HUMANA CHOICE CARE PPO,835.17,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $982.55 in Billed Charges for Rev 278 = $835.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,717.26,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $982.55 in Billed Charges for Rev 278 = $717.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,982.55,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $982.55 in Billed Charges for Rev 278 = $982.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,491.28,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $982.55 in Billed Charges for Rev 278 = $491.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,825.34,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $982.55 in Billed Charges for Rev 278 = $825.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,736.91,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $982.55 in Billed Charges for Rev 278 = $736.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,903.95,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $982.55 in Billed Charges for Rev 278 = $903.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,627.16,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $982.55 in Billed Charges for Rev 278 = $627.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,707.44,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $982.55 in Billed Charges for Rev 278 = $707.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,707.44,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $982.55 in Billed Charges for Rev 278 = $707.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,609.18,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $982.55 in Billed Charges for Rev 278 = $609.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,707.44,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $982.55 in Billed Charges for Rev 278 = $707.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,707.44,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $982.55 in Billed Charges for Rev 278 = $707.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 150MM,278,RC,10071106,CDM,,,,,,both,,,982.5500,648.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,589.53,,,,,,,477.5200,982.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $982.55 in Billed Charges for Rev 278 = $589.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,AETNA,AETNA HSHS,651.39,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,008.35 in Billed Charges for Rev 278 = $651.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,AETNA,ALL COMMERCIAL AETNA,1008.35,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,008.35 in Billed Charges for Rev 278 = $1,008.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,ANTHEM,ANTHEM POS/HMO,524.34,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,008.35 in Billed Charges for Rev 278 = $524.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,ANTHEM,ANTHEM PPO,524.34,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,008.35 in Billed Charges for Rev 278 = $524.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1008.35,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,008.35 in Billed Charges for Rev 278 = $1,008.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,CENPATICO,ALL MEDICAID CENPATICO,1008.35,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,008.35 in Billed Charges for Rev 278 = $1,008.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,857.10,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,008.35 in Billed Charges for Rev 278 = $857.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,CIGNA,ALL COMMERCIAL CIGNA,705.85,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,008.35 in Billed Charges for Rev 278 = $705.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,COFINITY,COFINITY,1008.35,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,008.35 in Billed Charges for Rev 278 = $1,008.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,957.93,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,008.35 in Billed Charges for Rev 278 = $957.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,847.01,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,008.35 in Billed Charges for Rev 278 = $847.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,715.93,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,008.35 in Billed Charges for Rev 278 = $715.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,736.10,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,008.35 in Billed Charges for Rev 278 = $736.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,490.06,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,008.35 in Billed Charges for Rev 278 = $490.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,857.10,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,008.35 in Billed Charges for Rev 278 = $857.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,HUMANA,HUMANA CHOICE CARE PPO,857.10,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,008.35 in Billed Charges for Rev 278 = $857.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,736.10,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,008.35 in Billed Charges for Rev 278 = $736.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1008.35,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,008.35 in Billed Charges for Rev 278 = $1,008.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,504.18,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,008.35 in Billed Charges for Rev 278 = $504.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,847.01,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,008.35 in Billed Charges for Rev 278 = $847.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,756.26,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,008.35 in Billed Charges for Rev 278 = $756.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,927.68,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,008.35 in Billed Charges for Rev 278 = $927.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,643.63,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,008.35 in Billed Charges for Rev 278 = $643.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,726.01,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,008.35 in Billed Charges for Rev 278 = $726.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,726.01,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,008.35 in Billed Charges for Rev 278 = $726.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,625.18,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,008.35 in Billed Charges for Rev 278 = $625.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,726.01,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,008.35 in Billed Charges for Rev 278 = $726.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,726.01,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,008.35 in Billed Charges for Rev 278 = $726.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 250MM,278,RC,10071107,CDM,,,,,,both,,,1008.3500,665.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,605.01,,,,,,,490.0600,1008.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,008.35 in Billed Charges for Rev 278 = $605.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,AETNA,AETNA HSHS,668.06,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,034.15 in Billed Charges for Rev 278 = $668.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,AETNA,ALL COMMERCIAL AETNA,1034.15,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,034.15 in Billed Charges for Rev 278 = $1,034.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,ANTHEM,ANTHEM POS/HMO,537.76,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,034.15 in Billed Charges for Rev 278 = $537.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,ANTHEM,ANTHEM PPO,537.76,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,034.15 in Billed Charges for Rev 278 = $537.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1034.15,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,034.15 in Billed Charges for Rev 278 = $1,034.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,CENPATICO,ALL MEDICAID CENPATICO,1034.15,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,034.15 in Billed Charges for Rev 278 = $1,034.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,879.03,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,034.15 in Billed Charges for Rev 278 = $879.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,CIGNA,ALL COMMERCIAL CIGNA,723.91,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,034.15 in Billed Charges for Rev 278 = $723.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,COFINITY,COFINITY,1034.15,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,034.15 in Billed Charges for Rev 278 = $1,034.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,982.44,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,034.15 in Billed Charges for Rev 278 = $982.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,868.69,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,034.15 in Billed Charges for Rev 278 = $868.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,734.25,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,034.15 in Billed Charges for Rev 278 = $734.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,754.93,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,034.15 in Billed Charges for Rev 278 = $754.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,502.60,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,034.15 in Billed Charges for Rev 278 = $502.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,879.03,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,034.15 in Billed Charges for Rev 278 = $879.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,HUMANA,HUMANA CHOICE CARE PPO,879.03,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,034.15 in Billed Charges for Rev 278 = $879.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,754.93,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,034.15 in Billed Charges for Rev 278 = $754.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1034.15,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,034.15 in Billed Charges for Rev 278 = $1,034.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,517.08,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,034.15 in Billed Charges for Rev 278 = $517.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,868.69,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,034.15 in Billed Charges for Rev 278 = $868.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,775.61,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,034.15 in Billed Charges for Rev 278 = $775.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,951.42,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,034.15 in Billed Charges for Rev 278 = $951.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,660.10,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,034.15 in Billed Charges for Rev 278 = $660.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,744.59,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,034.15 in Billed Charges for Rev 278 = $744.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,744.59,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,034.15 in Billed Charges for Rev 278 = $744.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,641.17,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,034.15 in Billed Charges for Rev 278 = $641.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,744.59,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,034.15 in Billed Charges for Rev 278 = $744.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,744.59,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,034.15 in Billed Charges for Rev 278 = $744.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 300MM,278,RC,10071108,CDM,,,,,,both,,,1034.1500,682.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,620.49,,,,,,,502.6000,1034.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,034.15 in Billed Charges for Rev 278 = $620.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,AETNA,AETNA HSHS,296.95,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $459.67 in Billed Charges for Rev 278 = $296.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,AETNA,ALL COMMERCIAL AETNA,459.67,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $459.67 in Billed Charges for Rev 278 = $459.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,459.67,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $459.67 in Billed Charges for Rev 278 = $459.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,CENPATICO,ALL MEDICAID CENPATICO,459.67,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $459.67 in Billed Charges for Rev 278 = $459.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,390.72,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $459.67 in Billed Charges for Rev 278 = $390.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,CIGNA,ALL COMMERCIAL CIGNA,321.77,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $459.67 in Billed Charges for Rev 278 = $321.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,COFINITY,COFINITY,459.67,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $459.67 in Billed Charges for Rev 278 = $459.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,436.69,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $459.67 in Billed Charges for Rev 278 = $436.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,386.12,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $459.67 in Billed Charges for Rev 278 = $386.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,326.37,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $459.67 in Billed Charges for Rev 278 = $326.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,335.56,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $459.67 in Billed Charges for Rev 278 = $335.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,223.40,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $459.67 in Billed Charges for Rev 278 = $223.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,390.72,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $459.67 in Billed Charges for Rev 278 = $390.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,HUMANA,HUMANA CHOICE CARE PPO,390.72,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $459.67 in Billed Charges for Rev 278 = $390.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,335.56,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $459.67 in Billed Charges for Rev 278 = $335.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,459.67,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $459.67 in Billed Charges for Rev 278 = $459.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,229.84,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $459.67 in Billed Charges for Rev 278 = $229.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,386.12,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $459.67 in Billed Charges for Rev 278 = $386.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,344.75,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $459.67 in Billed Charges for Rev 278 = $344.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,422.90,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $459.67 in Billed Charges for Rev 278 = $422.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,293.41,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $459.67 in Billed Charges for Rev 278 = $293.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,330.96,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $459.67 in Billed Charges for Rev 278 = $330.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,330.96,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $459.67 in Billed Charges for Rev 278 = $330.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,285.00,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $459.67 in Billed Charges for Rev 278 = $285.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,330.96,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $459.67 in Billed Charges for Rev 278 = $330.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,330.96,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $459.67 in Billed Charges for Rev 278 = $330.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 100MM,278,RC,10001441,CDM,,,,,,both,,,459.6700,303.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,275.80,,,,,,,223.4000,459.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $459.67 in Billed Charges for Rev 278 = $275.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,AETNA,AETNA HSHS,350.14,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $542.02 in Billed Charges for Rev 278 = $350.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,AETNA,ALL COMMERCIAL AETNA,542.02,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.02 in Billed Charges for Rev 278 = $542.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,542.02,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.02 in Billed Charges for Rev 278 = $542.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,CENPATICO,ALL MEDICAID CENPATICO,542.02,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.02 in Billed Charges for Rev 278 = $542.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,460.72,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.02 in Billed Charges for Rev 278 = $460.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,CIGNA,ALL COMMERCIAL CIGNA,379.41,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $542.02 in Billed Charges for Rev 278 = $379.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,COFINITY,COFINITY,542.02,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.02 in Billed Charges for Rev 278 = $542.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,514.92,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $542.02 in Billed Charges for Rev 278 = $514.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,455.30,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $542.02 in Billed Charges for Rev 278 = $455.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,384.83,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $542.02 in Billed Charges for Rev 278 = $384.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,395.67,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $542.02 in Billed Charges for Rev 278 = $395.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,263.42,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $542.02 in Billed Charges for Rev 278 = $263.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,460.72,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.02 in Billed Charges for Rev 278 = $460.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,HUMANA,HUMANA CHOICE CARE PPO,460.72,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.02 in Billed Charges for Rev 278 = $460.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,395.67,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $542.02 in Billed Charges for Rev 278 = $395.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,542.02,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.02 in Billed Charges for Rev 278 = $542.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,271.01,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $542.02 in Billed Charges for Rev 278 = $271.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,455.30,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $542.02 in Billed Charges for Rev 278 = $455.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,406.52,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $542.02 in Billed Charges for Rev 278 = $406.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,498.66,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $542.02 in Billed Charges for Rev 278 = $498.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,345.97,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $542.02 in Billed Charges for Rev 278 = $345.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,390.25,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.02 in Billed Charges for Rev 278 = $390.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,390.25,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.02 in Billed Charges for Rev 278 = $390.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,336.05,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $542.02 in Billed Charges for Rev 278 = $336.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,390.25,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.02 in Billed Charges for Rev 278 = $390.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,390.25,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.02 in Billed Charges for Rev 278 = $390.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 400MM,278,RC,10041999,CDM,,,,,,both,,,542.0200,357.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,325.21,,,,,,,263.4200,542.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $542.02 in Billed Charges for Rev 278 = $325.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,AETNA,AETNA HSHS,54.04,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $83.66 in Billed Charges for Rev 278 = $54.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,AETNA,ALL COMMERCIAL AETNA,83.66,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.66 in Billed Charges for Rev 278 = $83.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,83.66,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.66 in Billed Charges for Rev 278 = $83.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,CENPATICO,ALL MEDICAID CENPATICO,83.66,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.66 in Billed Charges for Rev 278 = $83.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,71.11,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.66 in Billed Charges for Rev 278 = $71.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,CIGNA,ALL COMMERCIAL CIGNA,58.56,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $83.66 in Billed Charges for Rev 278 = $58.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,COFINITY,COFINITY,83.66,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.66 in Billed Charges for Rev 278 = $83.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,79.48,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $83.66 in Billed Charges for Rev 278 = $79.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,70.27,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $83.66 in Billed Charges for Rev 278 = $70.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,59.40,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $83.66 in Billed Charges for Rev 278 = $59.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,61.07,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $83.66 in Billed Charges for Rev 278 = $61.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,40.66,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $83.66 in Billed Charges for Rev 278 = $40.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,71.11,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.66 in Billed Charges for Rev 278 = $71.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,HUMANA,HUMANA CHOICE CARE PPO,71.11,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.66 in Billed Charges for Rev 278 = $71.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,61.07,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $83.66 in Billed Charges for Rev 278 = $61.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,83.66,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.66 in Billed Charges for Rev 278 = $83.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,41.83,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $83.66 in Billed Charges for Rev 278 = $41.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,70.27,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $83.66 in Billed Charges for Rev 278 = $70.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,62.75,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $83.66 in Billed Charges for Rev 278 = $62.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,76.97,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $83.66 in Billed Charges for Rev 278 = $76.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,53.40,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $83.66 in Billed Charges for Rev 278 = $53.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,60.24,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.66 in Billed Charges for Rev 278 = $60.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,60.24,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.66 in Billed Charges for Rev 278 = $60.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,51.87,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $83.66 in Billed Charges for Rev 278 = $51.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,60.24,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.66 in Billed Charges for Rev 278 = $60.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,60.24,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.66 in Billed Charges for Rev 278 = $60.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X  60MM,278,RC,10001435,CDM,,,,,,both,,,83.6600,55.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,50.20,,,,,,,40.6600,83.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $83.66 in Billed Charges for Rev 278 = $50.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,AETNA,AETNA HSHS,217.75,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $337.07 in Billed Charges for Rev 278 = $217.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,AETNA,ALL COMMERCIAL AETNA,337.07,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.07 in Billed Charges for Rev 278 = $337.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,337.07,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.07 in Billed Charges for Rev 278 = $337.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,CENPATICO,ALL MEDICAID CENPATICO,337.07,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.07 in Billed Charges for Rev 278 = $337.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,286.51,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $337.07 in Billed Charges for Rev 278 = $286.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,CIGNA,ALL COMMERCIAL CIGNA,235.95,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $337.07 in Billed Charges for Rev 278 = $235.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,COFINITY,COFINITY,337.07,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.07 in Billed Charges for Rev 278 = $337.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,320.22,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $337.07 in Billed Charges for Rev 278 = $320.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,283.14,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $337.07 in Billed Charges for Rev 278 = $283.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,239.32,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $337.07 in Billed Charges for Rev 278 = $239.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,246.06,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $337.07 in Billed Charges for Rev 278 = $246.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,163.82,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $337.07 in Billed Charges for Rev 278 = $163.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,286.51,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $337.07 in Billed Charges for Rev 278 = $286.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,HUMANA,HUMANA CHOICE CARE PPO,286.51,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $337.07 in Billed Charges for Rev 278 = $286.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,246.06,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $337.07 in Billed Charges for Rev 278 = $246.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,337.07,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.07 in Billed Charges for Rev 278 = $337.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,168.54,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $337.07 in Billed Charges for Rev 278 = $168.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,283.14,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $337.07 in Billed Charges for Rev 278 = $283.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,252.80,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $337.07 in Billed Charges for Rev 278 = $252.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,310.10,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $337.07 in Billed Charges for Rev 278 = $310.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,215.15,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $337.07 in Billed Charges for Rev 278 = $215.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,242.69,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $337.07 in Billed Charges for Rev 278 = $242.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,242.69,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $337.07 in Billed Charges for Rev 278 = $242.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,208.98,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $337.07 in Billed Charges for Rev 278 = $208.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,242.69,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $337.07 in Billed Charges for Rev 278 = $242.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,242.69,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $337.07 in Billed Charges for Rev 278 = $242.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 8.0 X 200MM,278,RC,10045942,CDM,,,,,,both,,,337.0700,222.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,202.24,,,,,,,163.8200,337.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $337.07 in Billed Charges for Rev 278 = $202.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,AETNA,AETNA HSHS,602.45,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $932.58 in Billed Charges for Rev 278 = $602.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,AETNA,ALL COMMERCIAL AETNA,932.58,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.58 in Billed Charges for Rev 278 = $932.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,932.58,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.58 in Billed Charges for Rev 278 = $932.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,CENPATICO,ALL MEDICAID CENPATICO,932.58,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.58 in Billed Charges for Rev 278 = $932.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,792.69,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $932.58 in Billed Charges for Rev 278 = $792.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,CIGNA,ALL COMMERCIAL CIGNA,652.81,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $932.58 in Billed Charges for Rev 278 = $652.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,COFINITY,COFINITY,932.58,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.58 in Billed Charges for Rev 278 = $932.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,885.95,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $932.58 in Billed Charges for Rev 278 = $885.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,783.37,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $932.58 in Billed Charges for Rev 278 = $783.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,662.13,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $932.58 in Billed Charges for Rev 278 = $662.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,680.78,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $932.58 in Billed Charges for Rev 278 = $680.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,453.23,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $932.58 in Billed Charges for Rev 278 = $453.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,792.69,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $932.58 in Billed Charges for Rev 278 = $792.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,HUMANA,HUMANA CHOICE CARE PPO,792.69,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $932.58 in Billed Charges for Rev 278 = $792.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,680.78,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $932.58 in Billed Charges for Rev 278 = $680.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,932.58,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.58 in Billed Charges for Rev 278 = $932.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,466.29,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $932.58 in Billed Charges for Rev 278 = $466.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,783.37,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $932.58 in Billed Charges for Rev 278 = $783.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,699.44,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $932.58 in Billed Charges for Rev 278 = $699.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,857.97,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $932.58 in Billed Charges for Rev 278 = $857.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,595.27,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $932.58 in Billed Charges for Rev 278 = $595.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,671.46,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $932.58 in Billed Charges for Rev 278 = $671.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,671.46,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $932.58 in Billed Charges for Rev 278 = $671.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,578.20,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $932.58 in Billed Charges for Rev 278 = $578.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,671.46,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $932.58 in Billed Charges for Rev 278 = $671.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,671.46,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $932.58 in Billed Charges for Rev 278 = $671.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS 3.6MM 3.5MM LMBPRTNL 1 PIECE SLT VLV CDMN HLTR HFMN,278,RC,10028466,CDM,,,,,,both,,,932.5800,615.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,559.55,,,,,,,453.2300,932.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $932.58 in Billed Charges for Rev 278 = $559.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,AETNA,AETNA HSHS,1058.12,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,637.95 in Billed Charges for Rev 278 = $1,058.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,AETNA,ALL COMMERCIAL AETNA,1637.95,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.95 in Billed Charges for Rev 278 = $1,637.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,ANTHEM,ANTHEM POS/HMO,851.73,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,637.95 in Billed Charges for Rev 278 = $851.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,ANTHEM,ANTHEM PPO,851.73,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,637.95 in Billed Charges for Rev 278 = $851.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1637.95,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.95 in Billed Charges for Rev 278 = $1,637.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,CENPATICO,ALL MEDICAID CENPATICO,1637.95,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.95 in Billed Charges for Rev 278 = $1,637.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1392.26,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.95 in Billed Charges for Rev 278 = $1,392.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,CIGNA,ALL COMMERCIAL CIGNA,1146.57,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,637.95 in Billed Charges for Rev 278 = $1,146.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,COFINITY,COFINITY,1637.95,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.95 in Billed Charges for Rev 278 = $1,637.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1556.05,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,637.95 in Billed Charges for Rev 278 = $1,556.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,1375.88,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,637.95 in Billed Charges for Rev 278 = $1,375.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1162.94,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,637.95 in Billed Charges for Rev 278 = $1,162.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1195.70,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,637.95 in Billed Charges for Rev 278 = $1,195.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,796.04,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,637.95 in Billed Charges for Rev 278 = $796.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1392.26,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.95 in Billed Charges for Rev 278 = $1,392.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,HUMANA,HUMANA CHOICE CARE PPO,1392.26,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.95 in Billed Charges for Rev 278 = $1,392.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1195.70,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,637.95 in Billed Charges for Rev 278 = $1,195.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1637.95,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.95 in Billed Charges for Rev 278 = $1,637.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,818.98,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,637.95 in Billed Charges for Rev 278 = $818.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1375.88,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,637.95 in Billed Charges for Rev 278 = $1,375.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1228.46,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,637.95 in Billed Charges for Rev 278 = $1,228.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1506.91,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,637.95 in Billed Charges for Rev 278 = $1,506.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1045.50,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,637.95 in Billed Charges for Rev 278 = $1,045.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1179.32,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.95 in Billed Charges for Rev 278 = $1,179.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1179.32,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.95 in Billed Charges for Rev 278 = $1,179.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1015.53,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,637.95 in Billed Charges for Rev 278 = $1,015.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1179.32,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.95 in Billed Charges for Rev 278 = $1,179.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1179.32,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.95 in Billed Charges for Rev 278 = $1,179.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT NS PRUITT F3-S CRTD 15CM T PORT INLYING POLYURE 9FR,278,RC,10071488,CDM,,,,,,both,,,1637.9500,1081.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,982.77,,,,,,,796.0400,1637.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,637.95 in Billed Charges for Rev 278 = $982.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,AETNA,AETNA HSHS,532.14,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $823.75 in Billed Charges for Rev 278 = $532.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,AETNA,ALL COMMERCIAL AETNA,823.75,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.75 in Billed Charges for Rev 278 = $823.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,823.75,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.75 in Billed Charges for Rev 278 = $823.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,CENPATICO,ALL MEDICAID CENPATICO,823.75,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.75 in Billed Charges for Rev 278 = $823.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,700.19,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.75 in Billed Charges for Rev 278 = $700.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,CIGNA,ALL COMMERCIAL CIGNA,576.63,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $823.75 in Billed Charges for Rev 278 = $576.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,COFINITY,COFINITY,823.75,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.75 in Billed Charges for Rev 278 = $823.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,782.56,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $823.75 in Billed Charges for Rev 278 = $782.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,691.95,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $823.75 in Billed Charges for Rev 278 = $691.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,584.86,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $823.75 in Billed Charges for Rev 278 = $584.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,601.34,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $823.75 in Billed Charges for Rev 278 = $601.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,400.34,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $823.75 in Billed Charges for Rev 278 = $400.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,700.19,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.75 in Billed Charges for Rev 278 = $700.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,HUMANA,HUMANA CHOICE CARE PPO,700.19,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.75 in Billed Charges for Rev 278 = $700.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,601.34,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $823.75 in Billed Charges for Rev 278 = $601.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,823.75,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.75 in Billed Charges for Rev 278 = $823.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,411.88,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $823.75 in Billed Charges for Rev 278 = $411.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,691.95,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $823.75 in Billed Charges for Rev 278 = $691.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,617.81,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $823.75 in Billed Charges for Rev 278 = $617.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,757.85,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $823.75 in Billed Charges for Rev 278 = $757.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,525.80,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $823.75 in Billed Charges for Rev 278 = $525.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,593.10,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.75 in Billed Charges for Rev 278 = $593.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,593.10,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.75 in Billed Charges for Rev 278 = $593.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,510.73,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $823.75 in Billed Charges for Rev 278 = $510.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,593.10,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.75 in Billed Charges for Rev 278 = $593.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,593.10,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.75 in Billed Charges for Rev 278 = $593.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PERM STD FORWARD ANGLED 11.8MM,278,RC,10069272,CDM,,,,,,both,,,823.7500,543.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,494.25,,,,,,,400.3400,823.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $823.75 in Billed Charges for Rev 278 = $494.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,AETNA,AETNA HSHS,511.67,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $792.06 in Billed Charges for Rev 278 = $511.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,AETNA,ALL COMMERCIAL AETNA,792.06,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.06 in Billed Charges for Rev 278 = $792.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,792.06,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.06 in Billed Charges for Rev 278 = $792.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,CENPATICO,ALL MEDICAID CENPATICO,792.06,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.06 in Billed Charges for Rev 278 = $792.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,673.25,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $792.06 in Billed Charges for Rev 278 = $673.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,CIGNA,ALL COMMERCIAL CIGNA,554.44,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $792.06 in Billed Charges for Rev 278 = $554.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,COFINITY,COFINITY,792.06,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.06 in Billed Charges for Rev 278 = $792.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,752.46,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $792.06 in Billed Charges for Rev 278 = $752.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,665.33,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $792.06 in Billed Charges for Rev 278 = $665.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,562.36,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $792.06 in Billed Charges for Rev 278 = $562.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,578.20,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $792.06 in Billed Charges for Rev 278 = $578.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,384.94,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $792.06 in Billed Charges for Rev 278 = $384.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,673.25,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $792.06 in Billed Charges for Rev 278 = $673.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,HUMANA,HUMANA CHOICE CARE PPO,673.25,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $792.06 in Billed Charges for Rev 278 = $673.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,578.20,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $792.06 in Billed Charges for Rev 278 = $578.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,792.06,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.06 in Billed Charges for Rev 278 = $792.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,396.03,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $792.06 in Billed Charges for Rev 278 = $396.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,665.33,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $792.06 in Billed Charges for Rev 278 = $665.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,594.05,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $792.06 in Billed Charges for Rev 278 = $594.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,728.70,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $792.06 in Billed Charges for Rev 278 = $728.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,505.57,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $792.06 in Billed Charges for Rev 278 = $505.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,570.28,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $792.06 in Billed Charges for Rev 278 = $570.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,570.28,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $792.06 in Billed Charges for Rev 278 = $570.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,491.08,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $792.06 in Billed Charges for Rev 278 = $491.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,570.28,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $792.06 in Billed Charges for Rev 278 = $570.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,570.28,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $792.06 in Billed Charges for Rev 278 = $570.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLIP YASARGIL ANEURYSM PREM STD SLIGHT CURVED 8.3MM,278,RC,10001229,CDM,,,,,,both,,,792.0600,522.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,475.24,,,,,,,384.9400,792.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $792.06 in Billed Charges for Rev 278 = $475.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,AETNA,AETNA HSHS,802.69,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,242.55 in Billed Charges for Rev 278 = $802.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,AETNA,ALL COMMERCIAL AETNA,1242.55,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,242.55 in Billed Charges for Rev 278 = $1,242.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,ANTHEM,ANTHEM POS/HMO,646.13,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,242.55 in Billed Charges for Rev 278 = $646.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,ANTHEM,ANTHEM PPO,646.13,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,242.55 in Billed Charges for Rev 278 = $646.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1242.55,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,242.55 in Billed Charges for Rev 278 = $1,242.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,CENPATICO,ALL MEDICAID CENPATICO,1242.55,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,242.55 in Billed Charges for Rev 278 = $1,242.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1056.17,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,242.55 in Billed Charges for Rev 278 = $1,056.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,CIGNA,ALL COMMERCIAL CIGNA,869.79,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,242.55 in Billed Charges for Rev 278 = $869.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,COFINITY,COFINITY,1242.55,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,242.55 in Billed Charges for Rev 278 = $1,242.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1180.42,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,242.55 in Billed Charges for Rev 278 = $1,180.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,1043.74,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,242.55 in Billed Charges for Rev 278 = $1,043.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,882.21,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,242.55 in Billed Charges for Rev 278 = $882.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,907.06,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,242.55 in Billed Charges for Rev 278 = $907.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,603.88,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,242.55 in Billed Charges for Rev 278 = $603.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1056.17,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,242.55 in Billed Charges for Rev 278 = $1,056.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,HUMANA,HUMANA CHOICE CARE PPO,1056.17,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,242.55 in Billed Charges for Rev 278 = $1,056.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,907.06,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,242.55 in Billed Charges for Rev 278 = $907.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1242.55,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,242.55 in Billed Charges for Rev 278 = $1,242.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,621.28,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,242.55 in Billed Charges for Rev 278 = $621.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1043.74,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,242.55 in Billed Charges for Rev 278 = $1,043.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,931.91,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,242.55 in Billed Charges for Rev 278 = $931.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1143.15,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,242.55 in Billed Charges for Rev 278 = $1,143.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,793.12,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,242.55 in Billed Charges for Rev 278 = $793.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,894.64,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,242.55 in Billed Charges for Rev 278 = $894.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,894.64,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,242.55 in Billed Charges for Rev 278 = $894.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,770.38,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,242.55 in Billed Charges for Rev 278 = $770.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,894.64,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,242.55 in Billed Charges for Rev 278 = $894.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,894.64,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,242.55 in Billed Charges for Rev 278 = $894.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT EXTERNAL CAR END 3 X 4 MM,278,RC,10028939,CDM,,,,,,both,,,1242.5500,820.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,745.53,,,,,,,603.8800,1242.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,242.55 in Billed Charges for Rev 278 = $745.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,AETNA,AETNA HSHS,57.20,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $88.54 in Billed Charges for Rev 278 = $57.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,AETNA,ALL COMMERCIAL AETNA,88.54,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.54 in Billed Charges for Rev 278 = $88.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,88.54,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.54 in Billed Charges for Rev 278 = $88.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,CENPATICO,ALL MEDICAID CENPATICO,88.54,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.54 in Billed Charges for Rev 278 = $88.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,75.26,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.54 in Billed Charges for Rev 278 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,CIGNA,ALL COMMERCIAL CIGNA,61.98,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $88.54 in Billed Charges for Rev 278 = $61.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,COFINITY,COFINITY,88.54,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.54 in Billed Charges for Rev 278 = $88.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,84.11,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $88.54 in Billed Charges for Rev 278 = $84.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,74.37,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $88.54 in Billed Charges for Rev 278 = $74.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,62.86,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $88.54 in Billed Charges for Rev 278 = $62.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,64.63,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $88.54 in Billed Charges for Rev 278 = $64.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,43.03,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $88.54 in Billed Charges for Rev 278 = $43.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,75.26,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.54 in Billed Charges for Rev 278 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,HUMANA,HUMANA CHOICE CARE PPO,75.26,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.54 in Billed Charges for Rev 278 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,64.63,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $88.54 in Billed Charges for Rev 278 = $64.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,88.54,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.54 in Billed Charges for Rev 278 = $88.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,44.27,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $88.54 in Billed Charges for Rev 278 = $44.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,74.37,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $88.54 in Billed Charges for Rev 278 = $74.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,66.41,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $88.54 in Billed Charges for Rev 278 = $66.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,81.46,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $88.54 in Billed Charges for Rev 278 = $81.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,56.52,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $88.54 in Billed Charges for Rev 278 = $56.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,63.75,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.54 in Billed Charges for Rev 278 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,63.75,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.54 in Billed Charges for Rev 278 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,54.89,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $88.54 in Billed Charges for Rev 278 = $54.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,63.75,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.54 in Billed Charges for Rev 278 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,63.75,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.54 in Billed Charges for Rev 278 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE SILICONE 16MM,278,RC,10003997,CDM,,,,,,both,,,88.5400,58.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,53.12,,,,,,,43.0300,88.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $88.54 in Billed Charges for Rev 278 = $53.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,AETNA,AETNA HSHS,8837.28,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $13,680.00 in Billed Charges for Rev 278 = $8,837.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,AETNA,ALL COMMERCIAL AETNA,13680.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,680.00 in Billed Charges for Rev 278 = $13,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,ANTHEM,ANTHEM POS/HMO,7113.60,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $13,680.00 in Billed Charges for Rev 278 = $7,113.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,ANTHEM,ANTHEM PPO,7113.60,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $13,680.00 in Billed Charges for Rev 278 = $7,113.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13680.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,680.00 in Billed Charges for Rev 278 = $13,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,CENPATICO,ALL MEDICAID CENPATICO,13680.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,680.00 in Billed Charges for Rev 278 = $13,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11628.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,680.00 in Billed Charges for Rev 278 = $11,628.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,CIGNA,ALL COMMERCIAL CIGNA,9576.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $13,680.00 in Billed Charges for Rev 278 = $9,576.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,COFINITY,COFINITY,13680.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,680.00 in Billed Charges for Rev 278 = $13,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12996.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $13,680.00 in Billed Charges for Rev 278 = $12,996.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,11491.20,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $13,680.00 in Billed Charges for Rev 278 = $11,491.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9712.80,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $13,680.00 in Billed Charges for Rev 278 = $9,712.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9986.40,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $13,680.00 in Billed Charges for Rev 278 = $9,986.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,6648.48,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $13,680.00 in Billed Charges for Rev 278 = $6,648.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11628.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,680.00 in Billed Charges for Rev 278 = $11,628.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,HUMANA,HUMANA CHOICE CARE HMO,6840.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,680.00 in Billed Charges for Rev 278 = $6,840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,HUMANA,HUMANA CHOICE CARE PPO,11628.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,680.00 in Billed Charges for Rev 278 = $11,628.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,HUMANA,HUMANA NATIIONAL POS HMO,6840.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,680.00 in Billed Charges for Rev 278 = $6,840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9986.40,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $13,680.00 in Billed Charges for Rev 278 = $9,986.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,13680.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,680.00 in Billed Charges for Rev 278 = $13,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6840.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,680.00 in Billed Charges for Rev 278 = $6,840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11491.20,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $13,680.00 in Billed Charges for Rev 278 = $11,491.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10260.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $13,680.00 in Billed Charges for Rev 278 = $10,260.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12585.60,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $13,680.00 in Billed Charges for Rev 278 = $12,585.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6840.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,680.00 in Billed Charges for Rev 278 = $6,840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6840.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,680.00 in Billed Charges for Rev 278 = $6,840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,PREVEA HEALTH NETWORK,PREVEA360,6840.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,680.00 in Billed Charges for Rev 278 = $6,840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6840.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,680.00 in Billed Charges for Rev 278 = $6,840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8731.94,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $13,680.00 in Billed Charges for Rev 278 = $8,731.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9849.60,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,680.00 in Billed Charges for Rev 278 = $9,849.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6374.88,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $13,680.00 in Billed Charges for Rev 278 = $6,374.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,6374.88,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $13,680.00 in Billed Charges for Rev 278 = $6,374.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,6374.88,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $13,680.00 in Billed Charges for Rev 278 = $6,374.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9849.60,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,680.00 in Billed Charges for Rev 278 = $9,849.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8481.60,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $13,680.00 in Billed Charges for Rev 278 = $8,481.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9849.60,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,680.00 in Billed Charges for Rev 278 = $9,849.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9849.60,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,680.00 in Billed Charges for Rev 278 = $9,849.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  3.0MMX21MM,278,RC,10075026,CDM,,,,,,both,,,13680.0000,9028.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8208.00,,,,,,,6374.8800,13680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $13,680.00 in Billed Charges for Rev 278 = $8,208.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,AETNA,AETNA HSHS,1644.13,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,545.09 in Billed Charges for Rev 278 = $1,644.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,AETNA,ALL COMMERCIAL AETNA,2545.09,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,545.09 in Billed Charges for Rev 278 = $2,545.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,ANTHEM,ANTHEM POS/HMO,1323.45,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,545.09 in Billed Charges for Rev 278 = $1,323.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,ANTHEM,ANTHEM PPO,1323.45,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,545.09 in Billed Charges for Rev 278 = $1,323.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2545.09,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,545.09 in Billed Charges for Rev 278 = $2,545.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,CENPATICO,ALL MEDICAID CENPATICO,2545.09,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,545.09 in Billed Charges for Rev 278 = $2,545.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2163.33,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,545.09 in Billed Charges for Rev 278 = $2,163.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,CIGNA,ALL COMMERCIAL CIGNA,1781.56,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,545.09 in Billed Charges for Rev 278 = $1,781.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,COFINITY,COFINITY,2545.09,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,545.09 in Billed Charges for Rev 278 = $2,545.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2417.84,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,545.09 in Billed Charges for Rev 278 = $2,417.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,2137.88,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,545.09 in Billed Charges for Rev 278 = $2,137.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1807.01,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,545.09 in Billed Charges for Rev 278 = $1,807.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1857.92,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,545.09 in Billed Charges for Rev 278 = $1,857.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,1236.91,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,545.09 in Billed Charges for Rev 278 = $1,236.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2163.33,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,545.09 in Billed Charges for Rev 278 = $2,163.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,HUMANA,HUMANA CHOICE CARE HMO,1272.55,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,545.09 in Billed Charges for Rev 278 = $1,272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,HUMANA,HUMANA CHOICE CARE PPO,2163.33,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,545.09 in Billed Charges for Rev 278 = $2,163.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,HUMANA,HUMANA NATIIONAL POS HMO,1272.55,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,545.09 in Billed Charges for Rev 278 = $1,272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1857.92,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,545.09 in Billed Charges for Rev 278 = $1,857.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2545.09,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,545.09 in Billed Charges for Rev 278 = $2,545.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1272.55,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,545.09 in Billed Charges for Rev 278 = $1,272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2137.88,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,545.09 in Billed Charges for Rev 278 = $2,137.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1908.82,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,545.09 in Billed Charges for Rev 278 = $1,908.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2341.48,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,545.09 in Billed Charges for Rev 278 = $2,341.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1624.53,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,545.09 in Billed Charges for Rev 278 = $1,624.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1832.46,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,545.09 in Billed Charges for Rev 278 = $1,832.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1832.46,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,545.09 in Billed Charges for Rev 278 = $1,832.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1577.96,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,545.09 in Billed Charges for Rev 278 = $1,577.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1832.46,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,545.09 in Billed Charges for Rev 278 = $1,832.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1832.46,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,545.09 in Billed Charges for Rev 278 = $1,832.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 50 (002350),278,RC,10031931,CDM,,,,,,both,,,2545.0900,1679.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1527.05,,,,,,,1236.9100,2545.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,545.09 in Billed Charges for Rev 278 = $1,527.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,AETNA,AETNA HSHS,787.96,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,219.75 in Billed Charges for Rev 278 = $787.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,AETNA,ALL COMMERCIAL AETNA,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,ANTHEM,ANTHEM POS/HMO,634.27,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,219.75 in Billed Charges for Rev 278 = $634.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,ANTHEM,ANTHEM PPO,634.27,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,219.75 in Billed Charges for Rev 278 = $634.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,CENPATICO,ALL MEDICAID CENPATICO,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1036.79,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,219.75 in Billed Charges for Rev 278 = $1,036.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,CIGNA,ALL COMMERCIAL CIGNA,853.83,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,219.75 in Billed Charges for Rev 278 = $853.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,COFINITY,COFINITY,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1158.76,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,219.75 in Billed Charges for Rev 278 = $1,158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,1024.59,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,219.75 in Billed Charges for Rev 278 = $1,024.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,866.02,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,219.75 in Billed Charges for Rev 278 = $866.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,890.42,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,219.75 in Billed Charges for Rev 278 = $890.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,592.80,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,219.75 in Billed Charges for Rev 278 = $592.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1036.79,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,219.75 in Billed Charges for Rev 278 = $1,036.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,HUMANA,HUMANA CHOICE CARE PPO,1036.79,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,219.75 in Billed Charges for Rev 278 = $1,036.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,890.42,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,219.75 in Billed Charges for Rev 278 = $890.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,609.88,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,219.75 in Billed Charges for Rev 278 = $609.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1024.59,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,219.75 in Billed Charges for Rev 278 = $1,024.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,914.81,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,219.75 in Billed Charges for Rev 278 = $914.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1122.17,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,219.75 in Billed Charges for Rev 278 = $1,122.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,778.57,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,219.75 in Billed Charges for Rev 278 = $778.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,878.22,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,219.75 in Billed Charges for Rev 278 = $878.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,878.22,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,219.75 in Billed Charges for Rev 278 = $878.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,756.25,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,219.75 in Billed Charges for Rev 278 = $756.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,878.22,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,219.75 in Billed Charges for Rev 278 = $878.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,878.22,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,219.75 in Billed Charges for Rev 278 = $878.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE AMBIODRY AMNOITIC MEM 2 X 3,278,RC,10041369,CDM,,,,,,both,,,1219.7500,805.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,731.85,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,219.75 in Billed Charges for Rev 278 = $731.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,AETNA,AETNA HSHS,16.09,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.90 in Billed Charges for Rev 278 = $16.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,AETNA,ALL COMMERCIAL AETNA,24.90,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.90 in Billed Charges for Rev 278 = $24.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.90,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.90 in Billed Charges for Rev 278 = $24.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,CENPATICO,ALL MEDICAID CENPATICO,24.90,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.90 in Billed Charges for Rev 278 = $24.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,21.17,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.90 in Billed Charges for Rev 278 = $21.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,CIGNA,ALL COMMERCIAL CIGNA,17.43,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.90 in Billed Charges for Rev 278 = $17.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,COFINITY,COFINITY,24.90,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.90 in Billed Charges for Rev 278 = $24.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.66,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.90 in Billed Charges for Rev 278 = $23.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,20.92,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.90 in Billed Charges for Rev 278 = $20.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.68,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.90 in Billed Charges for Rev 278 = $17.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.18,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.90 in Billed Charges for Rev 278 = $18.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,12.10,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.90 in Billed Charges for Rev 278 = $12.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,21.17,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.90 in Billed Charges for Rev 278 = $21.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,HUMANA,HUMANA CHOICE CARE PPO,21.17,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.90 in Billed Charges for Rev 278 = $21.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.18,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.90 in Billed Charges for Rev 278 = $18.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.90,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.90 in Billed Charges for Rev 278 = $24.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.45,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.90 in Billed Charges for Rev 278 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.92,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.90 in Billed Charges for Rev 278 = $20.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.68,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.90 in Billed Charges for Rev 278 = $18.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.91,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.90 in Billed Charges for Rev 278 = $22.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.89,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.90 in Billed Charges for Rev 278 = $15.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.93,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.90 in Billed Charges for Rev 278 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.93,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.90 in Billed Charges for Rev 278 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.44,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.90 in Billed Charges for Rev 278 = $15.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.93,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.90 in Billed Charges for Rev 278 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.93,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.90 in Billed Charges for Rev 278 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR COLLAR BUTTON,278,RC,70905136,CDM,,,,,,both,,,24.9000,16.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.94,,,,,,,12.1000,24.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.90 in Billed Charges for Rev 278 = $14.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,AETNA,AETNA HSHS,8.91,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $13.79 in Billed Charges for Rev 278 = $8.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,AETNA,ALL COMMERCIAL AETNA,13.79,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.79 in Billed Charges for Rev 278 = $13.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13.79,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.79 in Billed Charges for Rev 278 = $13.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,CENPATICO,ALL MEDICAID CENPATICO,13.79,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.79 in Billed Charges for Rev 278 = $13.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11.72,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.79 in Billed Charges for Rev 278 = $11.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,CIGNA,ALL COMMERCIAL CIGNA,9.65,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $13.79 in Billed Charges for Rev 278 = $9.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,COFINITY,COFINITY,13.79,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.79 in Billed Charges for Rev 278 = $13.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13.10,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $13.79 in Billed Charges for Rev 278 = $13.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,11.58,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.79 in Billed Charges for Rev 278 = $11.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9.79,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $13.79 in Billed Charges for Rev 278 = $9.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.07,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.79 in Billed Charges for Rev 278 = $10.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,6.70,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $13.79 in Billed Charges for Rev 278 = $6.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11.72,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.79 in Billed Charges for Rev 278 = $11.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,HUMANA,HUMANA CHOICE CARE PPO,11.72,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.79 in Billed Charges for Rev 278 = $11.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.07,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.79 in Billed Charges for Rev 278 = $10.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,13.79,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.79 in Billed Charges for Rev 278 = $13.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.90,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $13.79 in Billed Charges for Rev 278 = $6.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11.58,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.79 in Billed Charges for Rev 278 = $11.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.34,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $13.79 in Billed Charges for Rev 278 = $10.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12.69,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $13.79 in Billed Charges for Rev 278 = $12.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.80,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $13.79 in Billed Charges for Rev 278 = $8.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.93,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.79 in Billed Charges for Rev 278 = $9.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.93,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.79 in Billed Charges for Rev 278 = $9.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.55,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $13.79 in Billed Charges for Rev 278 = $8.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.93,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.79 in Billed Charges for Rev 278 = $9.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.93,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.79 in Billed Charges for Rev 278 = $9.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR DONALDSON,278,RC,10005432,CDM,,,,,,both,,,13.7900,9.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.27,,,,,,,6.7000,13.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.79 in Billed Charges for Rev 278 = $8.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,AETNA,AETNA HSHS,21.27,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $32.93 in Billed Charges for Rev 278 = $21.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,AETNA,ALL COMMERCIAL AETNA,32.93,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.93 in Billed Charges for Rev 278 = $32.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,32.93,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.93 in Billed Charges for Rev 278 = $32.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,CENPATICO,ALL MEDICAID CENPATICO,32.93,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.93 in Billed Charges for Rev 278 = $32.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,27.99,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.93 in Billed Charges for Rev 278 = $27.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,CIGNA,ALL COMMERCIAL CIGNA,23.05,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $32.93 in Billed Charges for Rev 278 = $23.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,COFINITY,COFINITY,32.93,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.93 in Billed Charges for Rev 278 = $32.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,31.28,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $32.93 in Billed Charges for Rev 278 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,27.66,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.93 in Billed Charges for Rev 278 = $27.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,23.38,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $32.93 in Billed Charges for Rev 278 = $23.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,24.04,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.93 in Billed Charges for Rev 278 = $24.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,16.00,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $32.93 in Billed Charges for Rev 278 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,27.99,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.93 in Billed Charges for Rev 278 = $27.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,HUMANA,HUMANA CHOICE CARE PPO,27.99,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.93 in Billed Charges for Rev 278 = $27.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,24.04,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.93 in Billed Charges for Rev 278 = $24.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,32.93,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.93 in Billed Charges for Rev 278 = $32.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.47,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $32.93 in Billed Charges for Rev 278 = $16.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,27.66,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.93 in Billed Charges for Rev 278 = $27.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,24.70,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $32.93 in Billed Charges for Rev 278 = $24.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,30.30,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $32.93 in Billed Charges for Rev 278 = $30.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,21.02,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $32.93 in Billed Charges for Rev 278 = $21.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,23.71,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.93 in Billed Charges for Rev 278 = $23.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,23.71,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.93 in Billed Charges for Rev 278 = $23.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,20.42,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $32.93 in Billed Charges for Rev 278 = $20.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,23.71,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.93 in Billed Charges for Rev 278 = $23.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,23.71,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.93 in Billed Charges for Rev 278 = $23.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHEEHY COLLAR BUTTON,278,RC,10033544,CDM,,,,,,both,,,32.9300,21.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,19.76,,,,,,,16.0000,32.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.93 in Billed Charges for Rev 278 = $19.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,AETNA,AETNA HSHS,14.61,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $22.62 in Billed Charges for Rev 278 = $14.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,AETNA,ALL COMMERCIAL AETNA,22.62,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.62 in Billed Charges for Rev 278 = $22.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,22.62,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.62 in Billed Charges for Rev 278 = $22.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,CENPATICO,ALL MEDICAID CENPATICO,22.62,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.62 in Billed Charges for Rev 278 = $22.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,19.23,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.62 in Billed Charges for Rev 278 = $19.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,CIGNA,ALL COMMERCIAL CIGNA,15.83,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $22.62 in Billed Charges for Rev 278 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,COFINITY,COFINITY,22.62,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.62 in Billed Charges for Rev 278 = $22.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,21.49,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $22.62 in Billed Charges for Rev 278 = $21.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,19.00,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.62 in Billed Charges for Rev 278 = $19.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,16.06,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $22.62 in Billed Charges for Rev 278 = $16.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16.51,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.62 in Billed Charges for Rev 278 = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,10.99,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $22.62 in Billed Charges for Rev 278 = $10.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,19.23,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.62 in Billed Charges for Rev 278 = $19.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,HUMANA,HUMANA CHOICE CARE PPO,19.23,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.62 in Billed Charges for Rev 278 = $19.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16.51,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.62 in Billed Charges for Rev 278 = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,22.62,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.62 in Billed Charges for Rev 278 = $22.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.31,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $22.62 in Billed Charges for Rev 278 = $11.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,19.00,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.62 in Billed Charges for Rev 278 = $19.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16.97,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $22.62 in Billed Charges for Rev 278 = $16.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,20.81,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $22.62 in Billed Charges for Rev 278 = $20.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14.44,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $22.62 in Billed Charges for Rev 278 = $14.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,16.29,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.62 in Billed Charges for Rev 278 = $16.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,16.29,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.62 in Billed Charges for Rev 278 = $16.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.02,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $22.62 in Billed Charges for Rev 278 = $14.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,16.29,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.62 in Billed Charges for Rev 278 = $16.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,16.29,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.62 in Billed Charges for Rev 278 = $16.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENT, 1.14MM, BLUE, FLUOROPLASTIC",278,RC,ASC272,CDM,,,,,,both,,,22.6200,14.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.57,,,,,,,10.9900,22.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.62 in Billed Charges for Rev 278 = $13.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,AETNA,AETNA HSHS,18.08,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $27.98 in Billed Charges for Rev 278 = $18.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,AETNA,ALL COMMERCIAL AETNA,27.98,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.98 in Billed Charges for Rev 278 = $27.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,27.98,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.98 in Billed Charges for Rev 278 = $27.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,CENPATICO,ALL MEDICAID CENPATICO,27.98,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.98 in Billed Charges for Rev 278 = $27.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,23.78,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.98 in Billed Charges for Rev 278 = $23.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,CIGNA,ALL COMMERCIAL CIGNA,19.59,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $27.98 in Billed Charges for Rev 278 = $19.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,COFINITY,COFINITY,27.98,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.98 in Billed Charges for Rev 278 = $27.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,26.58,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $27.98 in Billed Charges for Rev 278 = $26.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,23.50,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.98 in Billed Charges for Rev 278 = $23.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19.87,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $27.98 in Billed Charges for Rev 278 = $19.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,20.43,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.98 in Billed Charges for Rev 278 = $20.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,13.60,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $27.98 in Billed Charges for Rev 278 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,23.78,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.98 in Billed Charges for Rev 278 = $23.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,HUMANA,HUMANA CHOICE CARE PPO,23.78,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.98 in Billed Charges for Rev 278 = $23.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,20.43,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.98 in Billed Charges for Rev 278 = $20.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,27.98,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.98 in Billed Charges for Rev 278 = $27.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.99,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $27.98 in Billed Charges for Rev 278 = $13.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,23.50,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.98 in Billed Charges for Rev 278 = $23.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20.99,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $27.98 in Billed Charges for Rev 278 = $20.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,25.74,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $27.98 in Billed Charges for Rev 278 = $25.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.86,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $27.98 in Billed Charges for Rev 278 = $17.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,20.15,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.98 in Billed Charges for Rev 278 = $20.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,20.15,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.98 in Billed Charges for Rev 278 = $20.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.35,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $27.98 in Billed Charges for Rev 278 = $17.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,20.15,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.98 in Billed Charges for Rev 278 = $20.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,20.15,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.98 in Billed Charges for Rev 278 = $20.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"TUBE POPE VENTED, 1.14MM, BLUE FLUOROPLASTIC, 2PK",278,RC,ASC273,CDM,,,,,,both,,,27.9800,18.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16.79,,,,,,,13.6000,27.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.98 in Billed Charges for Rev 278 = $16.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,AETNA,AETNA HSHS,104.98,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $162.50 in Billed Charges for Rev 278 = $104.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,AETNA,ALL COMMERCIAL AETNA,162.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $162.50 in Billed Charges for Rev 278 = $162.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,162.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $162.50 in Billed Charges for Rev 278 = $162.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,CENPATICO,ALL MEDICAID CENPATICO,162.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $162.50 in Billed Charges for Rev 278 = $162.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,138.13,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $162.50 in Billed Charges for Rev 278 = $138.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,CIGNA,ALL COMMERCIAL CIGNA,113.75,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $162.50 in Billed Charges for Rev 278 = $113.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,COFINITY,COFINITY,162.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $162.50 in Billed Charges for Rev 278 = $162.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,154.38,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $162.50 in Billed Charges for Rev 278 = $154.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,HEALTH CARE ALLIANCE,THE ALLIANCE,136.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $162.50 in Billed Charges for Rev 278 = $136.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,115.38,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $162.50 in Billed Charges for Rev 278 = $115.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,118.63,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $162.50 in Billed Charges for Rev 278 = $118.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,HSHS EMPLOYEES,HSHS EMPLOYEES,78.98,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $162.50 in Billed Charges for Rev 278 = $78.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,138.13,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $162.50 in Billed Charges for Rev 278 = $138.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,HUMANA,HUMANA CHOICE CARE PPO,138.13,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $162.50 in Billed Charges for Rev 278 = $138.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,118.63,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $162.50 in Billed Charges for Rev 278 = $118.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,LIVE360,LIVE360 HSHS HEALTHY PLAN,162.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $162.50 in Billed Charges for Rev 278 = $162.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,81.25,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $162.50 in Billed Charges for Rev 278 = $81.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,136.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $162.50 in Billed Charges for Rev 278 = $136.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,121.88,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $162.50 in Billed Charges for Rev 278 = $121.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,149.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $162.50 in Billed Charges for Rev 278 = $149.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,103.72,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $162.50 in Billed Charges for Rev 278 = $103.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,117.00,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $162.50 in Billed Charges for Rev 278 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,117.00,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $162.50 in Billed Charges for Rev 278 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,100.75,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $162.50 in Billed Charges for Rev 278 = $100.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,117.00,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $162.50 in Billed Charges for Rev 278 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,117.00,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $162.50 in Billed Charges for Rev 278 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY CUFFLESS SILICONE BIVONA 5.0,278,RC,10020836,CDM,,,,,,both,,,162.5000,107.2500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,97.50,,,,,,,78.9800,162.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $162.50 in Billed Charges for Rev 278 = $97.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,AETNA,AETNA HSHS,15.96,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.71 in Billed Charges for Rev 278 = $15.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,AETNA,ALL COMMERCIAL AETNA,24.71,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.71 in Billed Charges for Rev 278 = $24.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.71,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.71 in Billed Charges for Rev 278 = $24.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,CENPATICO,ALL MEDICAID CENPATICO,24.71,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.71 in Billed Charges for Rev 278 = $24.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,21.00,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.71 in Billed Charges for Rev 278 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,CIGNA,ALL COMMERCIAL CIGNA,17.30,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.71 in Billed Charges for Rev 278 = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,COFINITY,COFINITY,24.71,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.71 in Billed Charges for Rev 278 = $24.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.47,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.71 in Billed Charges for Rev 278 = $23.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,HEALTH CARE ALLIANCE,THE ALLIANCE,20.76,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.71 in Billed Charges for Rev 278 = $20.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.54,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.71 in Billed Charges for Rev 278 = $17.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.04,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.71 in Billed Charges for Rev 278 = $18.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,HSHS EMPLOYEES,HSHS EMPLOYEES,12.01,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.71 in Billed Charges for Rev 278 = $12.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,21.00,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.71 in Billed Charges for Rev 278 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,HUMANA,HUMANA CHOICE CARE PPO,21.00,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.71 in Billed Charges for Rev 278 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.04,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.71 in Billed Charges for Rev 278 = $18.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.71,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.71 in Billed Charges for Rev 278 = $24.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.36,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.71 in Billed Charges for Rev 278 = $12.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.76,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.71 in Billed Charges for Rev 278 = $20.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.53,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.71 in Billed Charges for Rev 278 = $18.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.73,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.71 in Billed Charges for Rev 278 = $22.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.77,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.71 in Billed Charges for Rev 278 = $15.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.79,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.71 in Billed Charges for Rev 278 = $17.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.79,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.71 in Billed Charges for Rev 278 = $17.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.32,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.71 in Billed Charges for Rev 278 = $15.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.79,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.71 in Billed Charges for Rev 278 = $17.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.79,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.71 in Billed Charges for Rev 278 = $17.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 1.14MM SHRRD FLRPLAS GRMT MYRNGTM LTXFR,278,RC,10000218,CDM,,,,,,both,,,24.7100,16.3100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.83,,,,,,,12.0100,24.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.71 in Billed Charges for Rev 278 = $14.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,AETNA,AETNA HSHS,386.11,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $597.70 in Billed Charges for Rev 278 = $386.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,AETNA,ALL COMMERCIAL AETNA,597.70,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $597.70 in Billed Charges for Rev 278 = $597.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,597.70,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $597.70 in Billed Charges for Rev 278 = $597.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,CENPATICO,ALL MEDICAID CENPATICO,597.70,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $597.70 in Billed Charges for Rev 278 = $597.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,508.05,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $597.70 in Billed Charges for Rev 278 = $508.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,CIGNA,ALL COMMERCIAL CIGNA,418.39,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $597.70 in Billed Charges for Rev 278 = $418.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,COFINITY,COFINITY,597.70,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $597.70 in Billed Charges for Rev 278 = $597.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,567.82,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $597.70 in Billed Charges for Rev 278 = $567.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,502.07,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $597.70 in Billed Charges for Rev 278 = $502.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,424.37,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $597.70 in Billed Charges for Rev 278 = $424.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,436.32,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $597.70 in Billed Charges for Rev 278 = $436.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,290.48,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $597.70 in Billed Charges for Rev 278 = $290.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,508.05,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $597.70 in Billed Charges for Rev 278 = $508.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,HUMANA,HUMANA CHOICE CARE PPO,508.05,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $597.70 in Billed Charges for Rev 278 = $508.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,436.32,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $597.70 in Billed Charges for Rev 278 = $436.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,597.70,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $597.70 in Billed Charges for Rev 278 = $597.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,298.85,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $597.70 in Billed Charges for Rev 278 = $298.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,502.07,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $597.70 in Billed Charges for Rev 278 = $502.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,448.28,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $597.70 in Billed Charges for Rev 278 = $448.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,549.88,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $597.70 in Billed Charges for Rev 278 = $549.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,381.51,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $597.70 in Billed Charges for Rev 278 = $381.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,430.34,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $597.70 in Billed Charges for Rev 278 = $430.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,430.34,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $597.70 in Billed Charges for Rev 278 = $430.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,370.57,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $597.70 in Billed Charges for Rev 278 = $370.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,430.34,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $597.70 in Billed Charges for Rev 278 = $430.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,430.34,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $597.70 in Billed Charges for Rev 278 = $430.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
V,278,RC,10043811,CDM,,,,,,both,,,597.7000,394.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,358.62,,,,,,,290.4800,597.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $597.70 in Billed Charges for Rev 278 = $358.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,AETNA,AETNA HSHS,4767.48,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,380.00 in Billed Charges for Rev 278 = $4,767.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,AETNA,ALL COMMERCIAL AETNA,7380.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,380.00 in Billed Charges for Rev 278 = $7,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,ANTHEM,ANTHEM POS/HMO,3837.60,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,380.00 in Billed Charges for Rev 278 = $3,837.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,ANTHEM,ANTHEM PPO,3837.60,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,380.00 in Billed Charges for Rev 278 = $3,837.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7380.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,380.00 in Billed Charges for Rev 278 = $7,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,CENPATICO,ALL MEDICAID CENPATICO,7380.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,380.00 in Billed Charges for Rev 278 = $7,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6273.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,380.00 in Billed Charges for Rev 278 = $6,273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,CIGNA,ALL COMMERCIAL CIGNA,5166.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,380.00 in Billed Charges for Rev 278 = $5,166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,COFINITY,COFINITY,7380.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,380.00 in Billed Charges for Rev 278 = $7,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7011.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,380.00 in Billed Charges for Rev 278 = $7,011.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,6199.20,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,380.00 in Billed Charges for Rev 278 = $6,199.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5239.80,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,380.00 in Billed Charges for Rev 278 = $5,239.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5387.40,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,380.00 in Billed Charges for Rev 278 = $5,387.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,3586.68,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,380.00 in Billed Charges for Rev 278 = $3,586.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6273.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,380.00 in Billed Charges for Rev 278 = $6,273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,HUMANA,HUMANA CHOICE CARE HMO,3690.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,380.00 in Billed Charges for Rev 278 = $3,690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,HUMANA,HUMANA CHOICE CARE PPO,6273.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,380.00 in Billed Charges for Rev 278 = $6,273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,HUMANA,HUMANA NATIIONAL POS HMO,3690.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,380.00 in Billed Charges for Rev 278 = $3,690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5387.40,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,380.00 in Billed Charges for Rev 278 = $5,387.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,7380.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,380.00 in Billed Charges for Rev 278 = $7,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3690.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,380.00 in Billed Charges for Rev 278 = $3,690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6199.20,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,380.00 in Billed Charges for Rev 278 = $6,199.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5535.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,380.00 in Billed Charges for Rev 278 = $5,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6789.60,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,380.00 in Billed Charges for Rev 278 = $6,789.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3690.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,380.00 in Billed Charges for Rev 278 = $3,690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3690.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,380.00 in Billed Charges for Rev 278 = $3,690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,PREVEA HEALTH NETWORK,PREVEA360,3690.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,380.00 in Billed Charges for Rev 278 = $3,690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3690.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,380.00 in Billed Charges for Rev 278 = $3,690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4710.65,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,380.00 in Billed Charges for Rev 278 = $4,710.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5313.60,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,380.00 in Billed Charges for Rev 278 = $5,313.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3439.08,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,380.00 in Billed Charges for Rev 278 = $3,439.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,3439.08,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,380.00 in Billed Charges for Rev 278 = $3,439.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,3439.08,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,380.00 in Billed Charges for Rev 278 = $3,439.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5313.60,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,380.00 in Billed Charges for Rev 278 = $5,313.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4575.60,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,380.00 in Billed Charges for Rev 278 = $4,575.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5313.60,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,380.00 in Billed Charges for Rev 278 = $5,313.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5313.60,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,380.00 in Billed Charges for Rev 278 = $5,313.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AOR 17MM 14.8MM MSTR HP 85D SUP ANNL XPD CUFF MECH ROT,278,RC,10027531,CDM,,,,,,both,,,7380.0000,4870.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4428.00,,,,,,,3439.0800,7380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,380.00 in Billed Charges for Rev 278 = $4,428.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,AETNA,AETNA HSHS,8381.46,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $12,974.40 in Billed Charges for Rev 278 = $8,381.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,AETNA,ALL COMMERCIAL AETNA,12974.40,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,974.40 in Billed Charges for Rev 278 = $12,974.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,ANTHEM,ANTHEM POS/HMO,6746.69,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,974.40 in Billed Charges for Rev 278 = $6,746.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,ANTHEM,ANTHEM PPO,6746.69,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,974.40 in Billed Charges for Rev 278 = $6,746.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12974.40,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,974.40 in Billed Charges for Rev 278 = $12,974.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,CENPATICO,ALL MEDICAID CENPATICO,12974.40,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,974.40 in Billed Charges for Rev 278 = $12,974.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11028.24,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,974.40 in Billed Charges for Rev 278 = $11,028.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,CIGNA,ALL COMMERCIAL CIGNA,9082.08,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $12,974.40 in Billed Charges for Rev 278 = $9,082.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,COFINITY,COFINITY,12974.40,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,974.40 in Billed Charges for Rev 278 = $12,974.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12325.68,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $12,974.40 in Billed Charges for Rev 278 = $12,325.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,10898.50,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,974.40 in Billed Charges for Rev 278 = $10,898.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9211.82,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $12,974.40 in Billed Charges for Rev 278 = $9,211.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9471.31,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,974.40 in Billed Charges for Rev 278 = $9,471.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,6305.56,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $12,974.40 in Billed Charges for Rev 278 = $6,305.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11028.24,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,974.40 in Billed Charges for Rev 278 = $11,028.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,HUMANA,HUMANA CHOICE CARE HMO,6487.20,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,974.40 in Billed Charges for Rev 278 = $6,487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,HUMANA,HUMANA CHOICE CARE PPO,11028.24,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,974.40 in Billed Charges for Rev 278 = $11,028.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,HUMANA,HUMANA NATIIONAL POS HMO,6487.20,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,974.40 in Billed Charges for Rev 278 = $6,487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9471.31,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,974.40 in Billed Charges for Rev 278 = $9,471.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,12974.40,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,974.40 in Billed Charges for Rev 278 = $12,974.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6487.20,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,974.40 in Billed Charges for Rev 278 = $6,487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10898.50,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,974.40 in Billed Charges for Rev 278 = $10,898.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9730.80,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $12,974.40 in Billed Charges for Rev 278 = $9,730.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11936.45,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $12,974.40 in Billed Charges for Rev 278 = $11,936.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6487.20,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,974.40 in Billed Charges for Rev 278 = $6,487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6487.20,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,974.40 in Billed Charges for Rev 278 = $6,487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,PREVEA HEALTH NETWORK,PREVEA360,6487.20,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,974.40 in Billed Charges for Rev 278 = $6,487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6487.20,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,974.40 in Billed Charges for Rev 278 = $6,487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8281.56,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $12,974.40 in Billed Charges for Rev 278 = $8,281.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9341.57,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,974.40 in Billed Charges for Rev 278 = $9,341.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6046.07,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,974.40 in Billed Charges for Rev 278 = $6,046.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,6046.07,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,974.40 in Billed Charges for Rev 278 = $6,046.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,6046.07,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,974.40 in Billed Charges for Rev 278 = $6,046.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9341.57,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,974.40 in Billed Charges for Rev 278 = $9,341.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8044.13,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $12,974.40 in Billed Charges for Rev 278 = $8,044.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9341.57,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,974.40 in Billed Charges for Rev 278 = $9,341.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9341.57,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,974.40 in Billed Charges for Rev 278 = $9,341.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MAGNA PERICARDIAL 19MM,278,RC,10028352,CDM,,,,,,both,,,12974.4000,8563.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7784.64,,,,,,,6046.0700,12974.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $12,974.40 in Billed Charges for Rev 278 = $7,784.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,AETNA,AETNA HSHS,5540.74,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,577.00 in Billed Charges for Rev 278 = $5,540.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,AETNA,ALL COMMERCIAL AETNA,8577.00,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,577.00 in Billed Charges for Rev 278 = $8,577.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,ANTHEM,ANTHEM POS/HMO,4460.04,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,577.00 in Billed Charges for Rev 278 = $4,460.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,ANTHEM,ANTHEM PPO,4460.04,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,577.00 in Billed Charges for Rev 278 = $4,460.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8577.00,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,577.00 in Billed Charges for Rev 278 = $8,577.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,CENPATICO,ALL MEDICAID CENPATICO,8577.00,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,577.00 in Billed Charges for Rev 278 = $8,577.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7290.45,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,577.00 in Billed Charges for Rev 278 = $7,290.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,CIGNA,ALL COMMERCIAL CIGNA,6003.90,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,577.00 in Billed Charges for Rev 278 = $6,003.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,COFINITY,COFINITY,8577.00,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,577.00 in Billed Charges for Rev 278 = $8,577.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8148.15,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,577.00 in Billed Charges for Rev 278 = $8,148.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,7204.68,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,577.00 in Billed Charges for Rev 278 = $7,204.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6089.67,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,577.00 in Billed Charges for Rev 278 = $6,089.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6261.21,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,577.00 in Billed Charges for Rev 278 = $6,261.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,4168.42,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,577.00 in Billed Charges for Rev 278 = $4,168.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7290.45,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,577.00 in Billed Charges for Rev 278 = $7,290.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,HUMANA,HUMANA CHOICE CARE HMO,4288.50,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,577.00 in Billed Charges for Rev 278 = $4,288.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,HUMANA,HUMANA CHOICE CARE PPO,7290.45,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,577.00 in Billed Charges for Rev 278 = $7,290.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,HUMANA,HUMANA NATIIONAL POS HMO,4288.50,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,577.00 in Billed Charges for Rev 278 = $4,288.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6261.21,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,577.00 in Billed Charges for Rev 278 = $6,261.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,8577.00,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,577.00 in Billed Charges for Rev 278 = $8,577.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4288.50,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,577.00 in Billed Charges for Rev 278 = $4,288.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7204.68,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,577.00 in Billed Charges for Rev 278 = $7,204.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6432.75,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,577.00 in Billed Charges for Rev 278 = $6,432.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7890.84,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,577.00 in Billed Charges for Rev 278 = $7,890.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4288.50,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,577.00 in Billed Charges for Rev 278 = $4,288.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4288.50,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,577.00 in Billed Charges for Rev 278 = $4,288.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,PREVEA HEALTH NETWORK,PREVEA360,4288.50,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,577.00 in Billed Charges for Rev 278 = $4,288.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4288.50,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,577.00 in Billed Charges for Rev 278 = $4,288.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5474.70,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,577.00 in Billed Charges for Rev 278 = $5,474.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6175.44,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,577.00 in Billed Charges for Rev 278 = $6,175.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3996.88,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,577.00 in Billed Charges for Rev 278 = $3,996.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,3996.88,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,577.00 in Billed Charges for Rev 278 = $3,996.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,3996.88,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,577.00 in Billed Charges for Rev 278 = $3,996.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6175.44,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,577.00 in Billed Charges for Rev 278 = $6,175.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5317.74,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,577.00 in Billed Charges for Rev 278 = $5,317.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6175.44,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,577.00 in Billed Charges for Rev 278 = $6,175.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6175.44,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,577.00 in Billed Charges for Rev 278 = $6,175.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC MOSAIC ULTRA 19MM,278,RC,10013015,CDM,,,,,,both,,,8577.0000,5660.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5146.20,,,,,,,3996.8800,8577.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,577.00 in Billed Charges for Rev 278 = $5,146.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,AETNA,AETNA HSHS,6593.08,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $10,206.00 in Billed Charges for Rev 278 = $6,593.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,AETNA,ALL COMMERCIAL AETNA,10206.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,206.00 in Billed Charges for Rev 278 = $10,206.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,ANTHEM,ANTHEM POS/HMO,5307.12,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,206.00 in Billed Charges for Rev 278 = $5,307.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,ANTHEM,ANTHEM PPO,5307.12,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,206.00 in Billed Charges for Rev 278 = $5,307.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10206.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,206.00 in Billed Charges for Rev 278 = $10,206.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,CENPATICO,ALL MEDICAID CENPATICO,10206.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,206.00 in Billed Charges for Rev 278 = $10,206.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8675.10,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,206.00 in Billed Charges for Rev 278 = $8,675.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,CIGNA,ALL COMMERCIAL CIGNA,7144.20,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $10,206.00 in Billed Charges for Rev 278 = $7,144.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,COFINITY,COFINITY,10206.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,206.00 in Billed Charges for Rev 278 = $10,206.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9695.70,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $10,206.00 in Billed Charges for Rev 278 = $9,695.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,8573.04,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,206.00 in Billed Charges for Rev 278 = $8,573.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7246.26,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $10,206.00 in Billed Charges for Rev 278 = $7,246.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7450.38,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,206.00 in Billed Charges for Rev 278 = $7,450.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,4960.12,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $10,206.00 in Billed Charges for Rev 278 = $4,960.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8675.10,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,206.00 in Billed Charges for Rev 278 = $8,675.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,HUMANA,HUMANA CHOICE CARE HMO,5103.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,206.00 in Billed Charges for Rev 278 = $5,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,HUMANA,HUMANA CHOICE CARE PPO,8675.10,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,206.00 in Billed Charges for Rev 278 = $8,675.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,HUMANA,HUMANA NATIIONAL POS HMO,5103.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,206.00 in Billed Charges for Rev 278 = $5,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7450.38,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,206.00 in Billed Charges for Rev 278 = $7,450.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,10206.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,206.00 in Billed Charges for Rev 278 = $10,206.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5103.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,206.00 in Billed Charges for Rev 278 = $5,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8573.04,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,206.00 in Billed Charges for Rev 278 = $8,573.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7654.50,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $10,206.00 in Billed Charges for Rev 278 = $7,654.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9389.52,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $10,206.00 in Billed Charges for Rev 278 = $9,389.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5103.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,206.00 in Billed Charges for Rev 278 = $5,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5103.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,206.00 in Billed Charges for Rev 278 = $5,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,PREVEA HEALTH NETWORK,PREVEA360,5103.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,206.00 in Billed Charges for Rev 278 = $5,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5103.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,206.00 in Billed Charges for Rev 278 = $5,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6514.49,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $10,206.00 in Billed Charges for Rev 278 = $6,514.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7348.32,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,206.00 in Billed Charges for Rev 278 = $7,348.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4756.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,206.00 in Billed Charges for Rev 278 = $4,756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,4756.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,206.00 in Billed Charges for Rev 278 = $4,756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,4756.00,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,206.00 in Billed Charges for Rev 278 = $4,756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7348.32,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,206.00 in Billed Charges for Rev 278 = $7,348.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6327.72,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $10,206.00 in Billed Charges for Rev 278 = $6,327.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7348.32,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,206.00 in Billed Charges for Rev 278 = $7,348.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7348.32,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,206.00 in Billed Charges for Rev 278 = $7,348.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE AORTIC ON-X,278,RC,10053836,CDM,,,,,,both,,,10206.0000,6735.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6123.60,,,,,,,4756.0000,10206.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $10,206.00 in Billed Charges for Rev 278 = $6,123.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,AETNA,AETNA HSHS,1778.50,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,753.10 in Billed Charges for Rev 278 = $1,778.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,AETNA,ALL COMMERCIAL AETNA,2753.10,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,753.10 in Billed Charges for Rev 278 = $2,753.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,ANTHEM,ANTHEM POS/HMO,1431.61,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,753.10 in Billed Charges for Rev 278 = $1,431.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,ANTHEM,ANTHEM PPO,1431.61,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,753.10 in Billed Charges for Rev 278 = $1,431.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2753.10,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,753.10 in Billed Charges for Rev 278 = $2,753.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,CENPATICO,ALL MEDICAID CENPATICO,2753.10,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,753.10 in Billed Charges for Rev 278 = $2,753.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2340.14,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,753.10 in Billed Charges for Rev 278 = $2,340.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,CIGNA,ALL COMMERCIAL CIGNA,1927.17,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,753.10 in Billed Charges for Rev 278 = $1,927.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,COFINITY,COFINITY,2753.10,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,753.10 in Billed Charges for Rev 278 = $2,753.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2615.45,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,753.10 in Billed Charges for Rev 278 = $2,615.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,2312.60,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,753.10 in Billed Charges for Rev 278 = $2,312.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1954.70,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,753.10 in Billed Charges for Rev 278 = $1,954.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2009.76,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,753.10 in Billed Charges for Rev 278 = $2,009.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,1338.01,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,753.10 in Billed Charges for Rev 278 = $1,338.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2340.14,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,753.10 in Billed Charges for Rev 278 = $2,340.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,HUMANA,HUMANA CHOICE CARE HMO,1376.55,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,753.10 in Billed Charges for Rev 278 = $1,376.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,HUMANA,HUMANA CHOICE CARE PPO,2340.14,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,753.10 in Billed Charges for Rev 278 = $2,340.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,HUMANA,HUMANA NATIIONAL POS HMO,1376.55,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,753.10 in Billed Charges for Rev 278 = $1,376.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2009.76,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,753.10 in Billed Charges for Rev 278 = $2,009.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,2753.10,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,753.10 in Billed Charges for Rev 278 = $2,753.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1376.55,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,753.10 in Billed Charges for Rev 278 = $1,376.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2312.60,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,753.10 in Billed Charges for Rev 278 = $2,312.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2064.83,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,753.10 in Billed Charges for Rev 278 = $2,064.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2532.85,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,753.10 in Billed Charges for Rev 278 = $2,532.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1757.30,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,753.10 in Billed Charges for Rev 278 = $1,757.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1982.23,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,753.10 in Billed Charges for Rev 278 = $1,982.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1982.23,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,753.10 in Billed Charges for Rev 278 = $1,982.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1706.92,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,753.10 in Billed Charges for Rev 278 = $1,706.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1982.23,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,753.10 in Billed Charges for Rev 278 = $1,982.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1982.23,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,753.10 in Billed Charges for Rev 278 = $1,982.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE DURAN ANCORE BAND  25MM,278,RC,10034560,CDM,,,,,,both,,,2753.1000,1817.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1651.86,,,,,,,1338.0100,2753.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,753.10 in Billed Charges for Rev 278 = $1,651.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,AETNA,AETNA HSHS,34884.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $54,000.00 in Billed Charges for Rev 278 = $34,884.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,AETNA,ALL COMMERCIAL AETNA,54000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,000.00 in Billed Charges for Rev 278 = $54,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,ANTHEM,ANTHEM POS/HMO,28080.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $54,000.00 in Billed Charges for Rev 278 = $28,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,ANTHEM,ANTHEM PPO,28080.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $54,000.00 in Billed Charges for Rev 278 = $28,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,54000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,000.00 in Billed Charges for Rev 278 = $54,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,CENPATICO,ALL MEDICAID CENPATICO,54000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,000.00 in Billed Charges for Rev 278 = $54,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,45900.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $54,000.00 in Billed Charges for Rev 278 = $45,900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,CIGNA,ALL COMMERCIAL CIGNA,37800.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $54,000.00 in Billed Charges for Rev 278 = $37,800.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,COFINITY,COFINITY,54000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,000.00 in Billed Charges for Rev 278 = $54,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,51300.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $54,000.00 in Billed Charges for Rev 278 = $51,300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,45360.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $54,000.00 in Billed Charges for Rev 278 = $45,360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,38340.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $54,000.00 in Billed Charges for Rev 278 = $38,340.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,39420.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $54,000.00 in Billed Charges for Rev 278 = $39,420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,26244.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $54,000.00 in Billed Charges for Rev 278 = $26,244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,45900.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $54,000.00 in Billed Charges for Rev 278 = $45,900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,HUMANA,HUMANA CHOICE CARE HMO,27000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $54,000.00 in Billed Charges for Rev 278 = $27,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,HUMANA,HUMANA CHOICE CARE PPO,45900.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $54,000.00 in Billed Charges for Rev 278 = $45,900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,HUMANA,HUMANA NATIIONAL POS HMO,27000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $54,000.00 in Billed Charges for Rev 278 = $27,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,39420.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $54,000.00 in Billed Charges for Rev 278 = $39,420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,54000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,000.00 in Billed Charges for Rev 278 = $54,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $54,000.00 in Billed Charges for Rev 278 = $27,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,45360.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $54,000.00 in Billed Charges for Rev 278 = $45,360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,40500.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $54,000.00 in Billed Charges for Rev 278 = $40,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,49680.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $54,000.00 in Billed Charges for Rev 278 = $49,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,27000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $54,000.00 in Billed Charges for Rev 278 = $27,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,27000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $54,000.00 in Billed Charges for Rev 278 = $27,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,PREVEA HEALTH NETWORK,PREVEA360,27000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $54,000.00 in Billed Charges for Rev 278 = $27,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,27000.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $54,000.00 in Billed Charges for Rev 278 = $27,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,34468.20,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $54,000.00 in Billed Charges for Rev 278 = $34,468.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,38880.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $54,000.00 in Billed Charges for Rev 278 = $38,880.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,25164.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $54,000.00 in Billed Charges for Rev 278 = $25,164.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,25164.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $54,000.00 in Billed Charges for Rev 278 = $25,164.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,25164.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $54,000.00 in Billed Charges for Rev 278 = $25,164.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,38880.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $54,000.00 in Billed Charges for Rev 278 = $38,880.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,33480.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $54,000.00 in Billed Charges for Rev 278 = $33,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,38880.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $54,000.00 in Billed Charges for Rev 278 = $38,880.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,38880.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $54,000.00 in Billed Charges for Rev 278 = $38,880.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE EVOLUT PRO TAVR  29MM,278,RC,10073972,CDM,,,,,,both,,,54000.0000,35640.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,32400.00,,,,,,,25164.0000,54000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $54,000.00 in Billed Charges for Rev 278 = $32,400.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,AETNA,AETNA HSHS,8023.32,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $12,420.00 in Billed Charges for Rev 278 = $8,023.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,AETNA,ALL COMMERCIAL AETNA,12420.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,420.00 in Billed Charges for Rev 278 = $12,420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,ANTHEM,ANTHEM POS/HMO,6458.40,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,420.00 in Billed Charges for Rev 278 = $6,458.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,ANTHEM,ANTHEM PPO,6458.40,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,420.00 in Billed Charges for Rev 278 = $6,458.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12420.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,420.00 in Billed Charges for Rev 278 = $12,420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,CENPATICO,ALL MEDICAID CENPATICO,12420.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,420.00 in Billed Charges for Rev 278 = $12,420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10557.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,420.00 in Billed Charges for Rev 278 = $10,557.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,CIGNA,ALL COMMERCIAL CIGNA,8694.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $12,420.00 in Billed Charges for Rev 278 = $8,694.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,COFINITY,COFINITY,12420.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,420.00 in Billed Charges for Rev 278 = $12,420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11799.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $12,420.00 in Billed Charges for Rev 278 = $11,799.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,10432.80,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,420.00 in Billed Charges for Rev 278 = $10,432.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8818.20,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $12,420.00 in Billed Charges for Rev 278 = $8,818.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9066.60,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,420.00 in Billed Charges for Rev 278 = $9,066.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,6036.12,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $12,420.00 in Billed Charges for Rev 278 = $6,036.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10557.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,420.00 in Billed Charges for Rev 278 = $10,557.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,HUMANA,HUMANA CHOICE CARE HMO,6210.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,420.00 in Billed Charges for Rev 278 = $6,210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,HUMANA,HUMANA CHOICE CARE PPO,10557.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,420.00 in Billed Charges for Rev 278 = $10,557.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,HUMANA,HUMANA NATIIONAL POS HMO,6210.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,420.00 in Billed Charges for Rev 278 = $6,210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9066.60,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,420.00 in Billed Charges for Rev 278 = $9,066.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,12420.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,420.00 in Billed Charges for Rev 278 = $12,420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6210.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,420.00 in Billed Charges for Rev 278 = $6,210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10432.80,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,420.00 in Billed Charges for Rev 278 = $10,432.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9315.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $12,420.00 in Billed Charges for Rev 278 = $9,315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11426.40,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $12,420.00 in Billed Charges for Rev 278 = $11,426.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6210.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,420.00 in Billed Charges for Rev 278 = $6,210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6210.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,420.00 in Billed Charges for Rev 278 = $6,210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,PREVEA HEALTH NETWORK,PREVEA360,6210.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,420.00 in Billed Charges for Rev 278 = $6,210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6210.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,420.00 in Billed Charges for Rev 278 = $6,210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7927.69,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $12,420.00 in Billed Charges for Rev 278 = $7,927.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8942.40,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,420.00 in Billed Charges for Rev 278 = $8,942.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5787.72,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,420.00 in Billed Charges for Rev 278 = $5,787.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,5787.72,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,420.00 in Billed Charges for Rev 278 = $5,787.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,5787.72,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,420.00 in Billed Charges for Rev 278 = $5,787.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8942.40,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,420.00 in Billed Charges for Rev 278 = $8,942.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7700.40,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $12,420.00 in Billed Charges for Rev 278 = $7,700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8942.40,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,420.00 in Billed Charges for Rev 278 = $8,942.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8942.40,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,420.00 in Billed Charges for Rev 278 = $8,942.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE FREESTYLE AORTIC ROOT 19MM,278,RC,10031921,CDM,,,,,,both,,,12420.0000,8197.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7452.00,,,,,,,5787.7200,12420.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $12,420.00 in Billed Charges for Rev 278 = $7,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,AETNA,AETNA HSHS,5092.48,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,883.10 in Billed Charges for Rev 278 = $5,092.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,AETNA,ALL COMMERCIAL AETNA,7883.10,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,883.10 in Billed Charges for Rev 278 = $7,883.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,ANTHEM,ANTHEM POS/HMO,4099.21,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,883.10 in Billed Charges for Rev 278 = $4,099.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,ANTHEM,ANTHEM PPO,4099.21,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,883.10 in Billed Charges for Rev 278 = $4,099.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7883.10,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,883.10 in Billed Charges for Rev 278 = $7,883.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,CENPATICO,ALL MEDICAID CENPATICO,7883.10,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,883.10 in Billed Charges for Rev 278 = $7,883.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6700.64,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,883.10 in Billed Charges for Rev 278 = $6,700.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,CIGNA,ALL COMMERCIAL CIGNA,5518.17,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,883.10 in Billed Charges for Rev 278 = $5,518.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,COFINITY,COFINITY,7883.10,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,883.10 in Billed Charges for Rev 278 = $7,883.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7488.95,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,883.10 in Billed Charges for Rev 278 = $7,488.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,HEALTH CARE ALLIANCE,THE ALLIANCE,6621.80,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,883.10 in Billed Charges for Rev 278 = $6,621.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5597.00,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,883.10 in Billed Charges for Rev 278 = $5,597.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5754.66,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,883.10 in Billed Charges for Rev 278 = $5,754.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,HSHS EMPLOYEES,HSHS EMPLOYEES,3831.19,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,883.10 in Billed Charges for Rev 278 = $3,831.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6700.64,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,883.10 in Billed Charges for Rev 278 = $6,700.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,HUMANA,HUMANA CHOICE CARE HMO,3941.55,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,883.10 in Billed Charges for Rev 278 = $3,941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,HUMANA,HUMANA CHOICE CARE PPO,6700.64,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,883.10 in Billed Charges for Rev 278 = $6,700.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,HUMANA,HUMANA NATIIONAL POS HMO,3941.55,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,883.10 in Billed Charges for Rev 278 = $3,941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5754.66,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,883.10 in Billed Charges for Rev 278 = $5,754.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,LIVE360,LIVE360 HSHS HEALTHY PLAN,7883.10,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,883.10 in Billed Charges for Rev 278 = $7,883.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3941.55,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,883.10 in Billed Charges for Rev 278 = $3,941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6621.80,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,883.10 in Billed Charges for Rev 278 = $6,621.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5912.33,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,883.10 in Billed Charges for Rev 278 = $5,912.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7252.45,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,883.10 in Billed Charges for Rev 278 = $7,252.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3941.55,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,883.10 in Billed Charges for Rev 278 = $3,941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3941.55,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,883.10 in Billed Charges for Rev 278 = $3,941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,PREVEA HEALTH NETWORK,PREVEA360,3941.55,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,883.10 in Billed Charges for Rev 278 = $3,941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3941.55,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,883.10 in Billed Charges for Rev 278 = $3,941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5031.78,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,883.10 in Billed Charges for Rev 278 = $5,031.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5675.83,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,883.10 in Billed Charges for Rev 278 = $5,675.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3673.52,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,883.10 in Billed Charges for Rev 278 = $3,673.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,UNITED HEALTHCARE,UHC ONEIDA NATION,3673.52,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,883.10 in Billed Charges for Rev 278 = $3,673.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,UNITED HEALTHCARE,UNITED HEALTHCARE,3673.52,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,883.10 in Billed Charges for Rev 278 = $3,673.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5675.83,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,883.10 in Billed Charges for Rev 278 = $5,675.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4887.52,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,883.10 in Billed Charges for Rev 278 = $4,887.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5675.83,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,883.10 in Billed Charges for Rev 278 = $5,675.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5675.83,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,883.10 in Billed Charges for Rev 278 = $5,675.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE HAKIM PROGRAMMABLE MICRO HOUSING (PEDS),278,RC,70408131,CDM,,,,,,both,,,7883.1000,5202.8500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4729.86,,,,,,,3673.5200,7883.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,883.10 in Billed Charges for Rev 278 = $4,729.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,AETNA,AETNA HSHS,4651.20,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,200.00 in Billed Charges for Rev 278 = $4,651.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,AETNA,ALL COMMERCIAL AETNA,7200.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,200.00 in Billed Charges for Rev 278 = $7,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,ANTHEM,ANTHEM POS/HMO,3744.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,200.00 in Billed Charges for Rev 278 = $3,744.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,ANTHEM,ANTHEM PPO,3744.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,200.00 in Billed Charges for Rev 278 = $3,744.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7200.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,200.00 in Billed Charges for Rev 278 = $7,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,CENPATICO,ALL MEDICAID CENPATICO,7200.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,200.00 in Billed Charges for Rev 278 = $7,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6120.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,200.00 in Billed Charges for Rev 278 = $6,120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,CIGNA,ALL COMMERCIAL CIGNA,5040.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,200.00 in Billed Charges for Rev 278 = $5,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,COFINITY,COFINITY,7200.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,200.00 in Billed Charges for Rev 278 = $7,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6840.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,200.00 in Billed Charges for Rev 278 = $6,840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,6048.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,200.00 in Billed Charges for Rev 278 = $6,048.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5112.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,200.00 in Billed Charges for Rev 278 = $5,112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5256.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,200.00 in Billed Charges for Rev 278 = $5,256.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,3499.20,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,200.00 in Billed Charges for Rev 278 = $3,499.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6120.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,200.00 in Billed Charges for Rev 278 = $6,120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,HUMANA,HUMANA CHOICE CARE HMO,3600.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,200.00 in Billed Charges for Rev 278 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,HUMANA,HUMANA CHOICE CARE PPO,6120.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,200.00 in Billed Charges for Rev 278 = $6,120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,HUMANA,HUMANA NATIIONAL POS HMO,3600.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,200.00 in Billed Charges for Rev 278 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5256.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,200.00 in Billed Charges for Rev 278 = $5,256.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,7200.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,200.00 in Billed Charges for Rev 278 = $7,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3600.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,200.00 in Billed Charges for Rev 278 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6048.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,200.00 in Billed Charges for Rev 278 = $6,048.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5400.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,200.00 in Billed Charges for Rev 278 = $5,400.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6624.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,200.00 in Billed Charges for Rev 278 = $6,624.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3600.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,200.00 in Billed Charges for Rev 278 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3600.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,200.00 in Billed Charges for Rev 278 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,PREVEA HEALTH NETWORK,PREVEA360,3600.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,200.00 in Billed Charges for Rev 278 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3600.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,200.00 in Billed Charges for Rev 278 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4595.76,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,200.00 in Billed Charges for Rev 278 = $4,595.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5184.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,200.00 in Billed Charges for Rev 278 = $5,184.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3355.20,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,200.00 in Billed Charges for Rev 278 = $3,355.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,3355.20,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,200.00 in Billed Charges for Rev 278 = $3,355.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,3355.20,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,200.00 in Billed Charges for Rev 278 = $3,355.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5184.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,200.00 in Billed Charges for Rev 278 = $5,184.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4464.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,200.00 in Billed Charges for Rev 278 = $4,464.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5184.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,200.00 in Billed Charges for Rev 278 = $5,184.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5184.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,200.00 in Billed Charges for Rev 278 = $5,184.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL EPIC 25MM,278,RC,10051968,CDM,,,,,,both,,,7200.0000,4752.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4320.00,,,,,,,3355.2000,7200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,200.00 in Billed Charges for Rev 278 = $4,320.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,AETNA,AETNA HSHS,7247.73,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $11,219.40 in Billed Charges for Rev 278 = $7,247.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,AETNA,ALL COMMERCIAL AETNA,11219.40,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,219.40 in Billed Charges for Rev 278 = $11,219.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,ANTHEM,ANTHEM POS/HMO,5834.09,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $11,219.40 in Billed Charges for Rev 278 = $5,834.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,ANTHEM,ANTHEM PPO,5834.09,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $11,219.40 in Billed Charges for Rev 278 = $5,834.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11219.40,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,219.40 in Billed Charges for Rev 278 = $11,219.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,CENPATICO,ALL MEDICAID CENPATICO,11219.40,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,219.40 in Billed Charges for Rev 278 = $11,219.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9536.49,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,219.40 in Billed Charges for Rev 278 = $9,536.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,CIGNA,ALL COMMERCIAL CIGNA,7853.58,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $11,219.40 in Billed Charges for Rev 278 = $7,853.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,COFINITY,COFINITY,11219.40,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,219.40 in Billed Charges for Rev 278 = $11,219.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10658.43,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $11,219.40 in Billed Charges for Rev 278 = $10,658.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,9424.30,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $11,219.40 in Billed Charges for Rev 278 = $9,424.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7965.77,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $11,219.40 in Billed Charges for Rev 278 = $7,965.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8190.16,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $11,219.40 in Billed Charges for Rev 278 = $8,190.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,5452.63,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $11,219.40 in Billed Charges for Rev 278 = $5,452.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9536.49,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,219.40 in Billed Charges for Rev 278 = $9,536.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,HUMANA,HUMANA CHOICE CARE HMO,5609.70,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,219.40 in Billed Charges for Rev 278 = $5,609.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,HUMANA,HUMANA CHOICE CARE PPO,9536.49,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,219.40 in Billed Charges for Rev 278 = $9,536.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,HUMANA,HUMANA NATIIONAL POS HMO,5609.70,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,219.40 in Billed Charges for Rev 278 = $5,609.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8190.16,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $11,219.40 in Billed Charges for Rev 278 = $8,190.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,11219.40,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,219.40 in Billed Charges for Rev 278 = $11,219.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5609.70,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,219.40 in Billed Charges for Rev 278 = $5,609.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9424.30,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $11,219.40 in Billed Charges for Rev 278 = $9,424.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8414.55,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $11,219.40 in Billed Charges for Rev 278 = $8,414.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10321.85,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $11,219.40 in Billed Charges for Rev 278 = $10,321.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5609.70,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,219.40 in Billed Charges for Rev 278 = $5,609.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5609.70,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,219.40 in Billed Charges for Rev 278 = $5,609.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,PREVEA HEALTH NETWORK,PREVEA360,5609.70,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,219.40 in Billed Charges for Rev 278 = $5,609.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5609.70,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,219.40 in Billed Charges for Rev 278 = $5,609.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7161.34,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $11,219.40 in Billed Charges for Rev 278 = $7,161.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8077.97,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,219.40 in Billed Charges for Rev 278 = $8,077.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5228.24,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $11,219.40 in Billed Charges for Rev 278 = $5,228.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,5228.24,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $11,219.40 in Billed Charges for Rev 278 = $5,228.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,5228.24,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $11,219.40 in Billed Charges for Rev 278 = $5,228.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8077.97,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,219.40 in Billed Charges for Rev 278 = $8,077.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6956.03,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $11,219.40 in Billed Charges for Rev 278 = $6,956.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8077.97,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,219.40 in Billed Charges for Rev 278 = $8,077.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8077.97,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,219.40 in Billed Charges for Rev 278 = $8,077.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MTRL 25MM CRP-ED PRIMNT + THERMAFIX COCR BOVN PRICRD,278,RC,10031856,CDM,,,,,,both,,,11219.4000,7404.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6731.64,,,,,,,5228.2400,11219.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $11,219.40 in Billed Charges for Rev 278 = $6,731.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,AETNA,AETNA HSHS,4854.69,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,515.00 in Billed Charges for Rev 278 = $4,854.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,AETNA,ALL COMMERCIAL AETNA,7515.00,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,515.00 in Billed Charges for Rev 278 = $7,515.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,ANTHEM,ANTHEM POS/HMO,3907.80,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,515.00 in Billed Charges for Rev 278 = $3,907.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,ANTHEM,ANTHEM PPO,3907.80,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,515.00 in Billed Charges for Rev 278 = $3,907.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7515.00,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,515.00 in Billed Charges for Rev 278 = $7,515.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,CENPATICO,ALL MEDICAID CENPATICO,7515.00,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,515.00 in Billed Charges for Rev 278 = $7,515.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6387.75,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,515.00 in Billed Charges for Rev 278 = $6,387.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,CIGNA,ALL COMMERCIAL CIGNA,5260.50,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,515.00 in Billed Charges for Rev 278 = $5,260.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,COFINITY,COFINITY,7515.00,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,515.00 in Billed Charges for Rev 278 = $7,515.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7139.25,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,515.00 in Billed Charges for Rev 278 = $7,139.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,6312.60,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,515.00 in Billed Charges for Rev 278 = $6,312.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5335.65,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,515.00 in Billed Charges for Rev 278 = $5,335.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5485.95,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,515.00 in Billed Charges for Rev 278 = $5,485.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,3652.29,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,515.00 in Billed Charges for Rev 278 = $3,652.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6387.75,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,515.00 in Billed Charges for Rev 278 = $6,387.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,HUMANA,HUMANA CHOICE CARE HMO,3757.50,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,515.00 in Billed Charges for Rev 278 = $3,757.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,HUMANA,HUMANA CHOICE CARE PPO,6387.75,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,515.00 in Billed Charges for Rev 278 = $6,387.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,HUMANA,HUMANA NATIIONAL POS HMO,3757.50,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,515.00 in Billed Charges for Rev 278 = $3,757.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5485.95,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,515.00 in Billed Charges for Rev 278 = $5,485.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,7515.00,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,515.00 in Billed Charges for Rev 278 = $7,515.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3757.50,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,515.00 in Billed Charges for Rev 278 = $3,757.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6312.60,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,515.00 in Billed Charges for Rev 278 = $6,312.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5636.25,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,515.00 in Billed Charges for Rev 278 = $5,636.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6913.80,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,515.00 in Billed Charges for Rev 278 = $6,913.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3757.50,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,515.00 in Billed Charges for Rev 278 = $3,757.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3757.50,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,515.00 in Billed Charges for Rev 278 = $3,757.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,PREVEA HEALTH NETWORK,PREVEA360,3757.50,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,515.00 in Billed Charges for Rev 278 = $3,757.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3757.50,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,515.00 in Billed Charges for Rev 278 = $3,757.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4796.82,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,515.00 in Billed Charges for Rev 278 = $4,796.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5410.80,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,515.00 in Billed Charges for Rev 278 = $5,410.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3501.99,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,515.00 in Billed Charges for Rev 278 = $3,501.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,3501.99,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,515.00 in Billed Charges for Rev 278 = $3,501.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,3501.99,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,515.00 in Billed Charges for Rev 278 = $3,501.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5410.80,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,515.00 in Billed Charges for Rev 278 = $5,410.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4659.30,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,515.00 in Billed Charges for Rev 278 = $4,659.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5410.80,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,515.00 in Billed Charges for Rev 278 = $5,410.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5410.80,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,515.00 in Billed Charges for Rev 278 = $5,410.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE REGENT AORTIC 19MM,278,RC,10018903,CDM,,,,,,both,,,7515.0000,4959.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4509.00,,,,,,,3501.9900,7515.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,515.00 in Billed Charges for Rev 278 = $4,509.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,AETNA,AETNA HSHS,5188.04,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,031.02 in Billed Charges for Rev 278 = $5,188.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,AETNA,ALL COMMERCIAL AETNA,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,ANTHEM,ANTHEM POS/HMO,4176.13,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,031.02 in Billed Charges for Rev 278 = $4,176.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,ANTHEM,ANTHEM PPO,4176.13,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,031.02 in Billed Charges for Rev 278 = $4,176.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,CENPATICO,ALL MEDICAID CENPATICO,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6826.37,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,031.02 in Billed Charges for Rev 278 = $6,826.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,CIGNA,ALL COMMERCIAL CIGNA,5621.71,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,031.02 in Billed Charges for Rev 278 = $5,621.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,COFINITY,COFINITY,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7629.47,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,031.02 in Billed Charges for Rev 278 = $7,629.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,6746.06,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,031.02 in Billed Charges for Rev 278 = $6,746.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5702.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,031.02 in Billed Charges for Rev 278 = $5,702.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5862.64,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,031.02 in Billed Charges for Rev 278 = $5,862.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,3903.08,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,031.02 in Billed Charges for Rev 278 = $3,903.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6826.37,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,031.02 in Billed Charges for Rev 278 = $6,826.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,HUMANA,HUMANA CHOICE CARE HMO,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,HUMANA,HUMANA CHOICE CARE PPO,6826.37,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,031.02 in Billed Charges for Rev 278 = $6,826.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,HUMANA,HUMANA NATIIONAL POS HMO,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5862.64,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,031.02 in Billed Charges for Rev 278 = $5,862.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6746.06,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,031.02 in Billed Charges for Rev 278 = $6,746.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6023.27,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,031.02 in Billed Charges for Rev 278 = $6,023.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7388.54,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,031.02 in Billed Charges for Rev 278 = $7,388.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,PREVEA HEALTH NETWORK,PREVEA360,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5126.20,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,031.02 in Billed Charges for Rev 278 = $5,126.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5782.33,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,031.02 in Billed Charges for Rev 278 = $5,782.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3742.46,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,031.02 in Billed Charges for Rev 278 = $3,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,3742.46,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,031.02 in Billed Charges for Rev 278 = $3,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,3742.46,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,031.02 in Billed Charges for Rev 278 = $3,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5782.33,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,031.02 in Billed Charges for Rev 278 = $5,782.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4979.23,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,031.02 in Billed Charges for Rev 278 = $4,979.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5782.33,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,031.02 in Billed Charges for Rev 278 = $5,782.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5782.33,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,031.02 in Billed Charges for Rev 278 = $5,782.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT SM INLN CDMN CERTAS + SPHGRD,278,RC,10085908,CDM,,,,,,both,,,8031.0200,5300.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4818.61,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,031.02 in Billed Charges for Rev 278 = $4,818.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,AETNA,AETNA HSHS,5128.28,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,938.52 in Billed Charges for Rev 278 = $5,128.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,AETNA,ALL COMMERCIAL AETNA,7938.52,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,938.52 in Billed Charges for Rev 278 = $7,938.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,ANTHEM,ANTHEM POS/HMO,4128.03,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,938.52 in Billed Charges for Rev 278 = $4,128.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,ANTHEM,ANTHEM PPO,4128.03,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,938.52 in Billed Charges for Rev 278 = $4,128.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7938.52,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,938.52 in Billed Charges for Rev 278 = $7,938.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,CENPATICO,ALL MEDICAID CENPATICO,7938.52,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,938.52 in Billed Charges for Rev 278 = $7,938.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6747.74,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,938.52 in Billed Charges for Rev 278 = $6,747.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,CIGNA,ALL COMMERCIAL CIGNA,5556.96,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,938.52 in Billed Charges for Rev 278 = $5,556.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,COFINITY,COFINITY,7938.52,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,938.52 in Billed Charges for Rev 278 = $7,938.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7541.59,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,938.52 in Billed Charges for Rev 278 = $7,541.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,6668.36,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,938.52 in Billed Charges for Rev 278 = $6,668.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5636.35,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,938.52 in Billed Charges for Rev 278 = $5,636.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5795.12,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,938.52 in Billed Charges for Rev 278 = $5,795.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,3858.12,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,938.52 in Billed Charges for Rev 278 = $3,858.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6747.74,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,938.52 in Billed Charges for Rev 278 = $6,747.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,HUMANA,HUMANA CHOICE CARE HMO,3969.26,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,938.52 in Billed Charges for Rev 278 = $3,969.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,HUMANA,HUMANA CHOICE CARE PPO,6747.74,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,938.52 in Billed Charges for Rev 278 = $6,747.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,HUMANA,HUMANA NATIIONAL POS HMO,3969.26,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,938.52 in Billed Charges for Rev 278 = $3,969.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5795.12,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,938.52 in Billed Charges for Rev 278 = $5,795.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,7938.52,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,938.52 in Billed Charges for Rev 278 = $7,938.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3969.26,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,938.52 in Billed Charges for Rev 278 = $3,969.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6668.36,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,938.52 in Billed Charges for Rev 278 = $6,668.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5953.89,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,938.52 in Billed Charges for Rev 278 = $5,953.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7303.44,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,938.52 in Billed Charges for Rev 278 = $7,303.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3969.26,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,938.52 in Billed Charges for Rev 278 = $3,969.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3969.26,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,938.52 in Billed Charges for Rev 278 = $3,969.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,PREVEA HEALTH NETWORK,PREVEA360,3969.26,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,938.52 in Billed Charges for Rev 278 = $3,969.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3969.26,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,938.52 in Billed Charges for Rev 278 = $3,969.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5067.16,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,938.52 in Billed Charges for Rev 278 = $5,067.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5715.73,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,938.52 in Billed Charges for Rev 278 = $5,715.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3699.35,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,938.52 in Billed Charges for Rev 278 = $3,699.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,3699.35,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,938.52 in Billed Charges for Rev 278 = $3,699.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,3699.35,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,938.52 in Billed Charges for Rev 278 = $3,699.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5715.73,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,938.52 in Billed Charges for Rev 278 = $5,715.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4921.88,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,938.52 in Billed Charges for Rev 278 = $4,921.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5715.73,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,938.52 in Billed Charges for Rev 278 = $5,715.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5715.73,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,938.52 in Billed Charges for Rev 278 = $5,715.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHUNT PROGRAMMABLE STYLET CODMAN HAKIM SIPHONGUARD IN-LINE STAINLESS STEEL STERILE,278,RC,10017019,CDM,,,,,,both,,,7938.5200,5239.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4763.11,,,,,,,3699.3500,7938.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,938.52 in Billed Charges for Rev 278 = $4,763.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,AETNA,AETNA HSHS,6302.38,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $9,756.00 in Billed Charges for Rev 278 = $6,302.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,AETNA,ALL COMMERCIAL AETNA,9756.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,756.00 in Billed Charges for Rev 278 = $9,756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,ANTHEM,ANTHEM POS/HMO,5073.12,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,756.00 in Billed Charges for Rev 278 = $5,073.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,ANTHEM,ANTHEM PPO,5073.12,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,756.00 in Billed Charges for Rev 278 = $5,073.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9756.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,756.00 in Billed Charges for Rev 278 = $9,756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,CENPATICO,ALL MEDICAID CENPATICO,9756.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,756.00 in Billed Charges for Rev 278 = $9,756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8292.60,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,756.00 in Billed Charges for Rev 278 = $8,292.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,CIGNA,ALL COMMERCIAL CIGNA,6829.20,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $9,756.00 in Billed Charges for Rev 278 = $6,829.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,COFINITY,COFINITY,9756.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,756.00 in Billed Charges for Rev 278 = $9,756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9268.20,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $9,756.00 in Billed Charges for Rev 278 = $9,268.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,8195.04,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,756.00 in Billed Charges for Rev 278 = $8,195.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6926.76,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $9,756.00 in Billed Charges for Rev 278 = $6,926.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7121.88,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,756.00 in Billed Charges for Rev 278 = $7,121.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,4741.42,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $9,756.00 in Billed Charges for Rev 278 = $4,741.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8292.60,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,756.00 in Billed Charges for Rev 278 = $8,292.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,HUMANA,HUMANA CHOICE CARE HMO,4878.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,756.00 in Billed Charges for Rev 278 = $4,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,HUMANA,HUMANA CHOICE CARE PPO,8292.60,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,756.00 in Billed Charges for Rev 278 = $8,292.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,HUMANA,HUMANA NATIIONAL POS HMO,4878.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,756.00 in Billed Charges for Rev 278 = $4,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7121.88,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,756.00 in Billed Charges for Rev 278 = $7,121.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,9756.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,756.00 in Billed Charges for Rev 278 = $9,756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4878.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,756.00 in Billed Charges for Rev 278 = $4,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8195.04,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,756.00 in Billed Charges for Rev 278 = $8,195.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7317.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $9,756.00 in Billed Charges for Rev 278 = $7,317.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8975.52,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $9,756.00 in Billed Charges for Rev 278 = $8,975.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4878.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,756.00 in Billed Charges for Rev 278 = $4,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4878.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,756.00 in Billed Charges for Rev 278 = $4,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,PREVEA HEALTH NETWORK,PREVEA360,4878.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,756.00 in Billed Charges for Rev 278 = $4,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4878.00,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,756.00 in Billed Charges for Rev 278 = $4,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6227.25,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $9,756.00 in Billed Charges for Rev 278 = $6,227.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7024.32,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,756.00 in Billed Charges for Rev 278 = $7,024.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4546.30,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,756.00 in Billed Charges for Rev 278 = $4,546.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,4546.30,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,756.00 in Billed Charges for Rev 278 = $4,546.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,4546.30,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,756.00 in Billed Charges for Rev 278 = $4,546.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7024.32,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,756.00 in Billed Charges for Rev 278 = $7,024.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6048.72,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $9,756.00 in Billed Charges for Rev 278 = $6,048.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7024.32,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,756.00 in Billed Charges for Rev 278 = $7,024.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7024.32,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,756.00 in Billed Charges for Rev 278 = $7,024.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SJM MECH AORTIC W/CONDUIT 21MM,278,RC,10016232,CDM,,,,,,both,,,9756.0000,6438.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5853.60,,,,,,,4546.3000,9756.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,756.00 in Billed Charges for Rev 278 = $5,853.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,AETNA,AETNA HSHS,7093.08,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $10,980.00 in Billed Charges for Rev 278 = $7,093.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,AETNA,ALL COMMERCIAL AETNA,10980.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,980.00 in Billed Charges for Rev 278 = $10,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,ANTHEM,ANTHEM POS/HMO,5709.60,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,980.00 in Billed Charges for Rev 278 = $5,709.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,ANTHEM,ANTHEM PPO,5709.60,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,980.00 in Billed Charges for Rev 278 = $5,709.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10980.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,980.00 in Billed Charges for Rev 278 = $10,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,CENPATICO,ALL MEDICAID CENPATICO,10980.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,980.00 in Billed Charges for Rev 278 = $10,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9333.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,980.00 in Billed Charges for Rev 278 = $9,333.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,CIGNA,ALL COMMERCIAL CIGNA,7686.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $10,980.00 in Billed Charges for Rev 278 = $7,686.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,COFINITY,COFINITY,10980.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,980.00 in Billed Charges for Rev 278 = $10,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10431.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $10,980.00 in Billed Charges for Rev 278 = $10,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,9223.20,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,980.00 in Billed Charges for Rev 278 = $9,223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7795.80,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $10,980.00 in Billed Charges for Rev 278 = $7,795.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8015.40,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,980.00 in Billed Charges for Rev 278 = $8,015.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,5336.28,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $10,980.00 in Billed Charges for Rev 278 = $5,336.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9333.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,980.00 in Billed Charges for Rev 278 = $9,333.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,HUMANA,HUMANA CHOICE CARE HMO,5490.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,980.00 in Billed Charges for Rev 278 = $5,490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,HUMANA,HUMANA CHOICE CARE PPO,9333.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,980.00 in Billed Charges for Rev 278 = $9,333.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,HUMANA,HUMANA NATIIONAL POS HMO,5490.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,980.00 in Billed Charges for Rev 278 = $5,490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8015.40,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,980.00 in Billed Charges for Rev 278 = $8,015.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,10980.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,980.00 in Billed Charges for Rev 278 = $10,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5490.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,980.00 in Billed Charges for Rev 278 = $5,490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9223.20,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,980.00 in Billed Charges for Rev 278 = $9,223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8235.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $10,980.00 in Billed Charges for Rev 278 = $8,235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10101.60,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $10,980.00 in Billed Charges for Rev 278 = $10,101.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5490.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,980.00 in Billed Charges for Rev 278 = $5,490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5490.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,980.00 in Billed Charges for Rev 278 = $5,490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,PREVEA HEALTH NETWORK,PREVEA360,5490.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,980.00 in Billed Charges for Rev 278 = $5,490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5490.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,980.00 in Billed Charges for Rev 278 = $5,490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7008.53,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $10,980.00 in Billed Charges for Rev 278 = $7,008.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7905.60,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,980.00 in Billed Charges for Rev 278 = $7,905.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5116.68,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,980.00 in Billed Charges for Rev 278 = $5,116.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,5116.68,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,980.00 in Billed Charges for Rev 278 = $5,116.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,5116.68,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,980.00 in Billed Charges for Rev 278 = $5,116.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7905.60,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,980.00 in Billed Charges for Rev 278 = $7,905.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6807.60,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $10,980.00 in Billed Charges for Rev 278 = $6,807.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7905.60,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,980.00 in Billed Charges for Rev 278 = $7,905.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7905.60,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,980.00 in Billed Charges for Rev 278 = $7,905.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA W/GLIDE 19MM,278,RC,10070482,CDM,,,,,,both,,,10980.0000,7246.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6588.00,,,,,,,5116.6800,10980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $10,980.00 in Billed Charges for Rev 278 = $6,588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,AETNA,AETNA HSHS,1184.93,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,184.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,AETNA,ALL COMMERCIAL AETNA,1834.26,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,834.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,ANTHEM,ANTHEM POS/HMO,953.82,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $953.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,ANTHEM,ANTHEM PPO,953.82,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $953.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1834.26,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,834.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,CENPATICO,ALL MEDICAID CENPATICO,1834.26,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,834.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1559.12,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,559.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,CIGNA,ALL COMMERCIAL CIGNA,1283.98,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,283.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,COFINITY,COFINITY,1834.26,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,834.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1742.55,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,742.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,1540.78,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,540.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1302.32,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,302.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1339.01,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,339.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,891.45,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $891.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1559.12,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,559.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,HUMANA,HUMANA CHOICE CARE PPO,1559.12,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,559.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1339.01,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,339.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1834.26,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,834.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,917.13,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $917.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1540.78,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,540.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1375.70,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,375.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1687.52,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,687.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1170.81,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,170.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1320.67,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,320.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1320.67,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,320.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1137.24,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,137.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1320.67,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,320.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1320.67,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,320.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040514,CDM,,,,both,,,1834.2600,1210.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1100.56,,,,,,,891.4500,1834.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,834.26 in Billed Charges for Rev 278 Proc C1713 = $1,100.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,AETNA,AETNA HSHS,1274.45,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,274.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,AETNA,ALL COMMERCIAL AETNA,1972.84,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,972.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,ANTHEM,ANTHEM POS/HMO,1025.88,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,025.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,ANTHEM,ANTHEM PPO,1025.88,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,025.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1972.84,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,972.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,CENPATICO,ALL MEDICAID CENPATICO,1972.84,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,972.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1676.91,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,676.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,CIGNA,ALL COMMERCIAL CIGNA,1380.99,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,380.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,COFINITY,COFINITY,1972.84,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,972.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1874.20,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,874.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,1657.19,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,657.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1400.72,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,400.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1440.17,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,440.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,958.80,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $958.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1676.91,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,676.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,HUMANA,HUMANA CHOICE CARE PPO,1676.91,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,676.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1440.17,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,440.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1972.84,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,972.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,986.42,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $986.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1657.19,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,657.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1479.63,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,479.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1815.01,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,815.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1259.26,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,259.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1420.44,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,420.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1420.44,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,420.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1223.16,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,223.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1420.44,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,420.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1420.44,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,420.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10071484,CDM,,,,both,,,1972.8400,1302.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1183.70,,,,,,,958.8000,1972.8400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,972.84 in Billed Charges for Rev 278 Proc C1713 = $1,183.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,AETNA,AETNA HSHS,1083.97,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,083.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,AETNA,ALL COMMERCIAL AETNA,1677.97,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,677.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,ANTHEM,ANTHEM POS/HMO,872.54,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $872.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,ANTHEM,ANTHEM PPO,872.54,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $872.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1677.97,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,677.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,CENPATICO,ALL MEDICAID CENPATICO,1677.97,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,677.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1426.27,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,426.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,CIGNA,ALL COMMERCIAL CIGNA,1174.58,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,174.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,COFINITY,COFINITY,1677.97,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,677.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1594.07,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,594.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,1409.49,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,409.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1191.36,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,191.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1224.92,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,224.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,815.49,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $815.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1426.27,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,426.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,HUMANA,HUMANA CHOICE CARE PPO,1426.27,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,426.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1224.92,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,224.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1677.97,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,677.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,838.99,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $838.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1409.49,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,409.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1258.48,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,258.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1543.73,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,543.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1071.05,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,071.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1208.14,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,208.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1208.14,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,208.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1040.34,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,040.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1208.14,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,208.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1208.14,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,208.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10068975,CDM,,,,both,,,1677.9700,1107.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1006.78,,,,,,,815.4900,1677.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,677.97 in Billed Charges for Rev 278 Proc C1713 = $1,006.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,AETNA,AETNA HSHS,1030.62,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,030.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,AETNA,ALL COMMERCIAL AETNA,1595.39,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,595.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,ANTHEM,ANTHEM POS/HMO,829.60,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $829.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,ANTHEM,ANTHEM PPO,829.60,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $829.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1595.39,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,595.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,CENPATICO,ALL MEDICAID CENPATICO,1595.39,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,595.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1356.08,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,356.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,CIGNA,ALL COMMERCIAL CIGNA,1116.77,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,116.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,COFINITY,COFINITY,1595.39,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,595.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1515.62,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,515.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,1340.13,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,340.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1132.73,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,132.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1164.63,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,164.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,775.36,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $775.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1356.08,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,356.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,HUMANA,HUMANA CHOICE CARE PPO,1356.08,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,356.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1164.63,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,164.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1595.39,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,595.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,797.70,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $797.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1340.13,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,340.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1196.54,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,196.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1467.76,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,467.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1018.34,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,018.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1148.68,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,148.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1148.68,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,148.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,989.14,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $989.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1148.68,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,148.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1148.68,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $1,148.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084066,CDM,,,,both,,,1595.3900,1052.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,957.23,,,,,,,775.3600,1595.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,595.39 in Billed Charges for Rev 278 Proc C1713 = $957.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,AETNA,AETNA HSHS,1057.73,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,057.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,AETNA,ALL COMMERCIAL AETNA,1637.36,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,637.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,ANTHEM,ANTHEM POS/HMO,851.43,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $851.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,ANTHEM,ANTHEM PPO,851.43,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $851.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1637.36,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,637.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,CENPATICO,ALL MEDICAID CENPATICO,1637.36,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,637.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1391.76,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,391.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,CIGNA,ALL COMMERCIAL CIGNA,1146.15,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,146.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,COFINITY,COFINITY,1637.36,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,637.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1555.49,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,555.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,1375.38,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,375.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1162.53,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,162.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1195.27,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,195.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,795.76,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $795.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1391.76,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,391.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,HUMANA,HUMANA CHOICE CARE PPO,1391.76,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,391.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1195.27,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,195.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1637.36,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,637.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,818.68,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $818.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1375.38,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,375.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1228.02,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,228.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1506.37,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,506.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1045.13,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,045.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1178.90,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,178.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1178.90,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,178.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1015.16,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,015.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1178.90,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,178.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1178.90,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $1,178.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063137,CDM,,,,both,,,1637.3600,1080.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,982.42,,,,,,,795.7600,1637.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,637.36 in Billed Charges for Rev 278 Proc C1713 = $982.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,AETNA,AETNA HSHS,1256.61,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,256.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,AETNA,ALL COMMERCIAL AETNA,1945.22,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,945.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,ANTHEM,ANTHEM POS/HMO,1011.51,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,011.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,ANTHEM,ANTHEM PPO,1011.51,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,011.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1945.22,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,945.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,CENPATICO,ALL MEDICAID CENPATICO,1945.22,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,945.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1653.44,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,653.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,CIGNA,ALL COMMERCIAL CIGNA,1361.65,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,361.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,COFINITY,COFINITY,1945.22,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,945.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1847.96,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,847.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,HEALTH CARE ALLIANCE,THE ALLIANCE,1633.98,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,633.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1381.11,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,381.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1420.01,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,420.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,HSHS EMPLOYEES,HSHS EMPLOYEES,945.38,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $945.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1653.44,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,653.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,HUMANA,HUMANA CHOICE CARE PPO,1653.44,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,653.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1420.01,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,420.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1945.22,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,945.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,972.61,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $972.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1633.98,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,633.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1458.92,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,458.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1789.60,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,789.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1241.63,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,241.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1400.56,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,400.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1400.56,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,400.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1206.04,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,206.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1400.56,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,400.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1400.56,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,400.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049266,CDM,,,,both,,,1945.2200,1283.8500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1167.13,,,,,,,945.3800,1945.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,945.22 in Billed Charges for Rev 278 Proc C1713 = $1,167.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,AETNA,AETNA HSHS,1114.62,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,114.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,AETNA,ALL COMMERCIAL AETNA,1725.42,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,725.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,ANTHEM,ANTHEM POS/HMO,897.22,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $897.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,ANTHEM,ANTHEM PPO,897.22,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $897.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1725.42,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,725.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,CENPATICO,ALL MEDICAID CENPATICO,1725.42,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,725.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1466.61,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,466.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,CIGNA,ALL COMMERCIAL CIGNA,1207.79,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,207.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,COFINITY,COFINITY,1725.42,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,725.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1639.15,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,639.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,1449.35,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,449.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1225.05,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,225.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1259.56,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,259.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,838.55,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $838.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1466.61,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,466.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,HUMANA,HUMANA CHOICE CARE PPO,1466.61,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,466.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1259.56,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,259.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1725.42,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,725.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,862.71,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $862.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1449.35,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,449.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1294.07,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,294.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1587.39,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,587.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1101.34,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,101.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1242.30,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,242.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1242.30,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,242.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1069.76,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,069.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1242.30,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,242.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1242.30,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,242.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084074,CDM,,,,both,,,1725.4200,1138.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1035.25,,,,,,,838.5500,1725.4200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,725.42 in Billed Charges for Rev 278 Proc C1713 = $1,035.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,AETNA,AETNA HSHS,2423.28,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,751.20 in Billed Charges for Rev 278 = $2,423.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,AETNA,ALL COMMERCIAL AETNA,3751.20,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,751.20 in Billed Charges for Rev 278 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,ANTHEM,ANTHEM POS/HMO,1950.62,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,751.20 in Billed Charges for Rev 278 = $1,950.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,ANTHEM,ANTHEM PPO,1950.62,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,751.20 in Billed Charges for Rev 278 = $1,950.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3751.20,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,751.20 in Billed Charges for Rev 278 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,CENPATICO,ALL MEDICAID CENPATICO,3751.20,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,751.20 in Billed Charges for Rev 278 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3188.52,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,751.20 in Billed Charges for Rev 278 = $3,188.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,CIGNA,ALL COMMERCIAL CIGNA,2625.84,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,751.20 in Billed Charges for Rev 278 = $2,625.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,COFINITY,COFINITY,3751.20,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,751.20 in Billed Charges for Rev 278 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3563.64,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,751.20 in Billed Charges for Rev 278 = $3,563.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,3151.01,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,751.20 in Billed Charges for Rev 278 = $3,151.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2663.35,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,751.20 in Billed Charges for Rev 278 = $2,663.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2738.38,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,751.20 in Billed Charges for Rev 278 = $2,738.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,1823.08,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,751.20 in Billed Charges for Rev 278 = $1,823.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3188.52,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,751.20 in Billed Charges for Rev 278 = $3,188.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,HUMANA,HUMANA CHOICE CARE HMO,1875.60,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,751.20 in Billed Charges for Rev 278 = $1,875.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,HUMANA,HUMANA CHOICE CARE PPO,3188.52,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,751.20 in Billed Charges for Rev 278 = $3,188.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,HUMANA,HUMANA NATIIONAL POS HMO,1875.60,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,751.20 in Billed Charges for Rev 278 = $1,875.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2738.38,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,751.20 in Billed Charges for Rev 278 = $2,738.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,3751.20,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,751.20 in Billed Charges for Rev 278 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1875.60,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,751.20 in Billed Charges for Rev 278 = $1,875.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3151.01,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,751.20 in Billed Charges for Rev 278 = $3,151.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2813.40,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,751.20 in Billed Charges for Rev 278 = $2,813.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3451.10,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,751.20 in Billed Charges for Rev 278 = $3,451.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2394.39,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,751.20 in Billed Charges for Rev 278 = $2,394.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2700.86,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,751.20 in Billed Charges for Rev 278 = $2,700.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2700.86,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,751.20 in Billed Charges for Rev 278 = $2,700.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2325.74,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,751.20 in Billed Charges for Rev 278 = $2,325.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2700.86,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,751.20 in Billed Charges for Rev 278 = $2,700.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2700.86,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,751.20 in Billed Charges for Rev 278 = $2,700.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING WOUND PURAPLY PORCINE COLLAGEN MATRIX STERILE,278,RC,10093901,CDM,,,,,,both,,,3751.2000,2475.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2250.72,,,,,,,1823.0800,3751.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,751.20 in Billed Charges for Rev 278 = $2,250.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,AETNA,AETNA HSHS,1446.81,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,239.64 in Billed Charges for Rev 278 = $1,446.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,AETNA,ALL COMMERCIAL AETNA,2239.64,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,239.64 in Billed Charges for Rev 278 = $2,239.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,ANTHEM,ANTHEM POS/HMO,1164.61,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,239.64 in Billed Charges for Rev 278 = $1,164.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,ANTHEM,ANTHEM PPO,1164.61,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,239.64 in Billed Charges for Rev 278 = $1,164.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2239.64,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,239.64 in Billed Charges for Rev 278 = $2,239.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,CENPATICO,ALL MEDICAID CENPATICO,2239.64,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,239.64 in Billed Charges for Rev 278 = $2,239.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1903.69,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,239.64 in Billed Charges for Rev 278 = $1,903.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,CIGNA,ALL COMMERCIAL CIGNA,1567.75,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,239.64 in Billed Charges for Rev 278 = $1,567.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,COFINITY,COFINITY,2239.64,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,239.64 in Billed Charges for Rev 278 = $2,239.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2127.66,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,239.64 in Billed Charges for Rev 278 = $2,127.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,1881.30,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,239.64 in Billed Charges for Rev 278 = $1,881.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1590.14,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,239.64 in Billed Charges for Rev 278 = $1,590.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1634.94,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,239.64 in Billed Charges for Rev 278 = $1,634.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,1088.47,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,239.64 in Billed Charges for Rev 278 = $1,088.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1903.69,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,239.64 in Billed Charges for Rev 278 = $1,903.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,HUMANA,HUMANA CHOICE CARE PPO,1903.69,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,239.64 in Billed Charges for Rev 278 = $1,903.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1634.94,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,239.64 in Billed Charges for Rev 278 = $1,634.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2239.64,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,239.64 in Billed Charges for Rev 278 = $2,239.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1119.82,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,239.64 in Billed Charges for Rev 278 = $1,119.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1881.30,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,239.64 in Billed Charges for Rev 278 = $1,881.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1679.73,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,239.64 in Billed Charges for Rev 278 = $1,679.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2060.47,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,239.64 in Billed Charges for Rev 278 = $2,060.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1429.56,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,239.64 in Billed Charges for Rev 278 = $1,429.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1612.54,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,239.64 in Billed Charges for Rev 278 = $1,612.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1612.54,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,239.64 in Billed Charges for Rev 278 = $1,612.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1388.58,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,239.64 in Billed Charges for Rev 278 = $1,388.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1612.54,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,239.64 in Billed Charges for Rev 278 = $1,612.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1612.54,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,239.64 in Billed Charges for Rev 278 = $1,612.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY  4 X 5  (CDSLM45),278,RC,10033207,CDM,,,,,,both,,,2239.6400,1478.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1343.78,,,,,,,1088.4700,2239.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,239.64 in Billed Charges for Rev 278 = $1,343.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,AETNA,AETNA HSHS,581.95,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $900.85 in Billed Charges for Rev 278 = $581.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,AETNA,ALL COMMERCIAL AETNA,900.85,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $900.85 in Billed Charges for Rev 278 = $900.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,900.85,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $900.85 in Billed Charges for Rev 278 = $900.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,CENPATICO,ALL MEDICAID CENPATICO,900.85,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $900.85 in Billed Charges for Rev 278 = $900.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,765.72,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $900.85 in Billed Charges for Rev 278 = $765.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,CIGNA,ALL COMMERCIAL CIGNA,630.60,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $900.85 in Billed Charges for Rev 278 = $630.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,COFINITY,COFINITY,900.85,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $900.85 in Billed Charges for Rev 278 = $900.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,855.81,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $900.85 in Billed Charges for Rev 278 = $855.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,756.71,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $900.85 in Billed Charges for Rev 278 = $756.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,639.60,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $900.85 in Billed Charges for Rev 278 = $639.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,657.62,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $900.85 in Billed Charges for Rev 278 = $657.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,437.81,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $900.85 in Billed Charges for Rev 278 = $437.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,765.72,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $900.85 in Billed Charges for Rev 278 = $765.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,HUMANA,HUMANA CHOICE CARE PPO,765.72,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $900.85 in Billed Charges for Rev 278 = $765.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,657.62,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $900.85 in Billed Charges for Rev 278 = $657.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,900.85,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $900.85 in Billed Charges for Rev 278 = $900.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,450.43,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $900.85 in Billed Charges for Rev 278 = $450.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,756.71,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $900.85 in Billed Charges for Rev 278 = $756.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,675.64,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $900.85 in Billed Charges for Rev 278 = $675.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,828.78,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $900.85 in Billed Charges for Rev 278 = $828.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,575.01,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $900.85 in Billed Charges for Rev 278 = $575.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,648.61,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $900.85 in Billed Charges for Rev 278 = $648.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,648.61,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $900.85 in Billed Charges for Rev 278 = $648.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,558.53,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $900.85 in Billed Charges for Rev 278 = $558.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,648.61,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $900.85 in Billed Charges for Rev 278 = $648.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,648.61,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $900.85 in Billed Charges for Rev 278 = $648.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURAMATRIX ONLAY PLUS 2X2,278,RC,10072935,CDM,,,,,,both,,,900.8500,594.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,540.51,,,,,,,437.8100,900.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $900.85 in Billed Charges for Rev 278 = $540.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,AETNA,AETNA HSHS,1251.74,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,937.68 in Billed Charges for Rev 278 = $1,251.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,AETNA,ALL COMMERCIAL AETNA,1937.68,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.68 in Billed Charges for Rev 278 = $1,937.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,ANTHEM,ANTHEM POS/HMO,1007.59,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,937.68 in Billed Charges for Rev 278 = $1,007.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,ANTHEM,ANTHEM PPO,1007.59,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,937.68 in Billed Charges for Rev 278 = $1,007.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1937.68,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.68 in Billed Charges for Rev 278 = $1,937.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,CENPATICO,ALL MEDICAID CENPATICO,1937.68,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.68 in Billed Charges for Rev 278 = $1,937.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1647.03,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,937.68 in Billed Charges for Rev 278 = $1,647.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,CIGNA,ALL COMMERCIAL CIGNA,1356.38,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,937.68 in Billed Charges for Rev 278 = $1,356.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,COFINITY,COFINITY,1937.68,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.68 in Billed Charges for Rev 278 = $1,937.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1840.80,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,937.68 in Billed Charges for Rev 278 = $1,840.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,1627.65,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,937.68 in Billed Charges for Rev 278 = $1,627.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1375.75,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,937.68 in Billed Charges for Rev 278 = $1,375.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1414.51,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,937.68 in Billed Charges for Rev 278 = $1,414.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,941.71,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,937.68 in Billed Charges for Rev 278 = $941.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1647.03,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,937.68 in Billed Charges for Rev 278 = $1,647.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,HUMANA,HUMANA CHOICE CARE PPO,1647.03,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,937.68 in Billed Charges for Rev 278 = $1,647.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1414.51,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,937.68 in Billed Charges for Rev 278 = $1,414.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1937.68,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.68 in Billed Charges for Rev 278 = $1,937.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,968.84,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,937.68 in Billed Charges for Rev 278 = $968.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1627.65,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,937.68 in Billed Charges for Rev 278 = $1,627.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1453.26,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,937.68 in Billed Charges for Rev 278 = $1,453.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1782.67,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,937.68 in Billed Charges for Rev 278 = $1,782.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1236.82,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,937.68 in Billed Charges for Rev 278 = $1,236.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1395.13,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,937.68 in Billed Charges for Rev 278 = $1,395.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1395.13,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,937.68 in Billed Charges for Rev 278 = $1,395.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1201.36,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,937.68 in Billed Charges for Rev 278 = $1,201.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1395.13,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,937.68 in Billed Charges for Rev 278 = $1,395.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1395.13,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,937.68 in Billed Charges for Rev 278 = $1,395.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DURASEAL 5ML,278,RC,10055047,CDM,,,,,,both,,,1937.6800,1278.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1162.61,,,,,,,941.7100,1937.6800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,937.68 in Billed Charges for Rev 278 = $1,162.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,AETNA,AETNA HSHS,1330.46,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,059.54 in Billed Charges for Rev 278 = $1,330.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,AETNA,ALL COMMERCIAL AETNA,2059.54,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,059.54 in Billed Charges for Rev 278 = $2,059.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,ANTHEM,ANTHEM POS/HMO,1070.96,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,059.54 in Billed Charges for Rev 278 = $1,070.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,ANTHEM,ANTHEM PPO,1070.96,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,059.54 in Billed Charges for Rev 278 = $1,070.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2059.54,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,059.54 in Billed Charges for Rev 278 = $2,059.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,CENPATICO,ALL MEDICAID CENPATICO,2059.54,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,059.54 in Billed Charges for Rev 278 = $2,059.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1750.61,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,059.54 in Billed Charges for Rev 278 = $1,750.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,CIGNA,ALL COMMERCIAL CIGNA,1441.68,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,059.54 in Billed Charges for Rev 278 = $1,441.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,COFINITY,COFINITY,2059.54,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,059.54 in Billed Charges for Rev 278 = $2,059.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1956.56,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,059.54 in Billed Charges for Rev 278 = $1,956.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,1730.01,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,059.54 in Billed Charges for Rev 278 = $1,730.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1462.27,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,059.54 in Billed Charges for Rev 278 = $1,462.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1503.46,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,059.54 in Billed Charges for Rev 278 = $1,503.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,1000.94,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,059.54 in Billed Charges for Rev 278 = $1,000.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1750.61,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,059.54 in Billed Charges for Rev 278 = $1,750.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,HUMANA,HUMANA CHOICE CARE PPO,1750.61,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,059.54 in Billed Charges for Rev 278 = $1,750.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1503.46,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,059.54 in Billed Charges for Rev 278 = $1,503.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2059.54,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,059.54 in Billed Charges for Rev 278 = $2,059.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1029.77,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,059.54 in Billed Charges for Rev 278 = $1,029.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1730.01,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,059.54 in Billed Charges for Rev 278 = $1,730.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1544.66,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,059.54 in Billed Charges for Rev 278 = $1,544.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1894.78,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,059.54 in Billed Charges for Rev 278 = $1,894.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1314.60,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,059.54 in Billed Charges for Rev 278 = $1,314.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1482.87,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,059.54 in Billed Charges for Rev 278 = $1,482.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1482.87,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,059.54 in Billed Charges for Rev 278 = $1,482.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1276.91,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,059.54 in Billed Charges for Rev 278 = $1,276.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1482.87,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,059.54 in Billed Charges for Rev 278 = $1,482.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1482.87,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,059.54 in Billed Charges for Rev 278 = $1,482.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FILLER BONE VOID 10CC DBX ALOGRFT FRZDR MX,278,RC,10022801,CDM,,,,,,both,,,2059.5400,1359.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1235.72,,,,,,,1000.9400,2059.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,059.54 in Billed Charges for Rev 278 = $1,235.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,AETNA,AETNA HSHS,5011.67,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,758.00 in Billed Charges for Rev 278 = $5,011.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,AETNA,ALL COMMERCIAL AETNA,7758.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,758.00 in Billed Charges for Rev 278 = $7,758.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,ANTHEM,ANTHEM POS/HMO,4034.16,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,758.00 in Billed Charges for Rev 278 = $4,034.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,ANTHEM,ANTHEM PPO,4034.16,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,758.00 in Billed Charges for Rev 278 = $4,034.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7758.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,758.00 in Billed Charges for Rev 278 = $7,758.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,CENPATICO,ALL MEDICAID CENPATICO,7758.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,758.00 in Billed Charges for Rev 278 = $7,758.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6594.30,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,758.00 in Billed Charges for Rev 278 = $6,594.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,CIGNA,ALL COMMERCIAL CIGNA,5430.60,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,758.00 in Billed Charges for Rev 278 = $5,430.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,COFINITY,COFINITY,7758.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,758.00 in Billed Charges for Rev 278 = $7,758.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7370.10,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,758.00 in Billed Charges for Rev 278 = $7,370.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6516.72,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,758.00 in Billed Charges for Rev 278 = $6,516.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5508.18,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,758.00 in Billed Charges for Rev 278 = $5,508.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5663.34,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,758.00 in Billed Charges for Rev 278 = $5,663.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3770.39,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,758.00 in Billed Charges for Rev 278 = $3,770.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6594.30,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,758.00 in Billed Charges for Rev 278 = $6,594.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,HUMANA,HUMANA CHOICE CARE HMO,3879.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,758.00 in Billed Charges for Rev 278 = $3,879.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,HUMANA,HUMANA CHOICE CARE PPO,6594.30,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,758.00 in Billed Charges for Rev 278 = $6,594.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,HUMANA,HUMANA NATIIONAL POS HMO,3879.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,758.00 in Billed Charges for Rev 278 = $3,879.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5663.34,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,758.00 in Billed Charges for Rev 278 = $5,663.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,7758.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,758.00 in Billed Charges for Rev 278 = $7,758.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3879.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,758.00 in Billed Charges for Rev 278 = $3,879.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6516.72,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,758.00 in Billed Charges for Rev 278 = $6,516.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5818.50,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,758.00 in Billed Charges for Rev 278 = $5,818.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7137.36,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,758.00 in Billed Charges for Rev 278 = $7,137.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3879.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,758.00 in Billed Charges for Rev 278 = $3,879.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3879.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,758.00 in Billed Charges for Rev 278 = $3,879.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,PREVEA HEALTH NETWORK,PREVEA360,3879.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,758.00 in Billed Charges for Rev 278 = $3,879.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3879.00,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,758.00 in Billed Charges for Rev 278 = $3,879.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4951.93,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,758.00 in Billed Charges for Rev 278 = $4,951.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5585.76,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,758.00 in Billed Charges for Rev 278 = $5,585.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3615.23,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,758.00 in Billed Charges for Rev 278 = $3,615.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,3615.23,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,758.00 in Billed Charges for Rev 278 = $3,615.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,3615.23,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,758.00 in Billed Charges for Rev 278 = $3,615.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5585.76,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,758.00 in Billed Charges for Rev 278 = $5,585.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4809.96,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,758.00 in Billed Charges for Rev 278 = $4,809.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5585.76,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,758.00 in Billed Charges for Rev 278 = $5,585.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5585.76,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,758.00 in Billed Charges for Rev 278 = $5,585.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE SMALL,278,RC,10040161,CDM,,,,,,both,,,7758.0000,5120.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4654.80,,,,,,,3615.2300,7758.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,758.00 in Billed Charges for Rev 278 = $4,654.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,AETNA,AETNA HSHS,2523.28,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,906.00 in Billed Charges for Rev 278 = $2,523.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,AETNA,ALL COMMERCIAL AETNA,3906.00,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,906.00 in Billed Charges for Rev 278 = $3,906.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,ANTHEM,ANTHEM POS/HMO,2031.12,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,906.00 in Billed Charges for Rev 278 = $2,031.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,ANTHEM,ANTHEM PPO,2031.12,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,906.00 in Billed Charges for Rev 278 = $2,031.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3906.00,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,906.00 in Billed Charges for Rev 278 = $3,906.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,CENPATICO,ALL MEDICAID CENPATICO,3906.00,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,906.00 in Billed Charges for Rev 278 = $3,906.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3320.10,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,906.00 in Billed Charges for Rev 278 = $3,320.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,CIGNA,ALL COMMERCIAL CIGNA,2734.20,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,906.00 in Billed Charges for Rev 278 = $2,734.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,COFINITY,COFINITY,3906.00,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,906.00 in Billed Charges for Rev 278 = $3,906.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3710.70,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,906.00 in Billed Charges for Rev 278 = $3,710.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,3281.04,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,906.00 in Billed Charges for Rev 278 = $3,281.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2773.26,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,906.00 in Billed Charges for Rev 278 = $2,773.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2851.38,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,906.00 in Billed Charges for Rev 278 = $2,851.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,1898.32,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,906.00 in Billed Charges for Rev 278 = $1,898.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3320.10,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,906.00 in Billed Charges for Rev 278 = $3,320.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,HUMANA,HUMANA CHOICE CARE HMO,1953.00,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,906.00 in Billed Charges for Rev 278 = $1,953.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,HUMANA,HUMANA CHOICE CARE PPO,3320.10,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,906.00 in Billed Charges for Rev 278 = $3,320.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,HUMANA,HUMANA NATIIONAL POS HMO,1953.00,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,906.00 in Billed Charges for Rev 278 = $1,953.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2851.38,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,906.00 in Billed Charges for Rev 278 = $2,851.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,3906.00,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,906.00 in Billed Charges for Rev 278 = $3,906.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1953.00,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,906.00 in Billed Charges for Rev 278 = $1,953.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3281.04,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,906.00 in Billed Charges for Rev 278 = $3,281.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2929.50,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,906.00 in Billed Charges for Rev 278 = $2,929.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3593.52,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,906.00 in Billed Charges for Rev 278 = $3,593.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2493.20,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,906.00 in Billed Charges for Rev 278 = $2,493.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2812.32,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,906.00 in Billed Charges for Rev 278 = $2,812.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2812.32,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,906.00 in Billed Charges for Rev 278 = $2,812.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2421.72,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,906.00 in Billed Charges for Rev 278 = $2,421.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2812.32,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,906.00 in Billed Charges for Rev 278 = $2,812.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2812.32,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,906.00 in Billed Charges for Rev 278 = $2,812.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT INFUSE BONE XSMALL,278,RC,10041930,CDM,,,,,,both,,,3906.0000,2577.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2343.60,,,,,,,1898.3200,3906.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,906.00 in Billed Charges for Rev 278 = $2,343.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,AETNA,AETNA HSHS,14360.58,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $22,230.00 in Billed Charges for Rev 278 = $14,360.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,AETNA,ALL COMMERCIAL AETNA,22230.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $22,230.00 in Billed Charges for Rev 278 = $22,230.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,ANTHEM,ANTHEM POS/HMO,11559.60,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $22,230.00 in Billed Charges for Rev 278 = $11,559.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,ANTHEM,ANTHEM PPO,11559.60,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $22,230.00 in Billed Charges for Rev 278 = $11,559.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,22230.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $22,230.00 in Billed Charges for Rev 278 = $22,230.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,CENPATICO,ALL MEDICAID CENPATICO,22230.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $22,230.00 in Billed Charges for Rev 278 = $22,230.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18895.50,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $22,230.00 in Billed Charges for Rev 278 = $18,895.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,CIGNA,ALL COMMERCIAL CIGNA,15561.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $22,230.00 in Billed Charges for Rev 278 = $15,561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,COFINITY,COFINITY,22230.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $22,230.00 in Billed Charges for Rev 278 = $22,230.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,21118.50,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $22,230.00 in Billed Charges for Rev 278 = $21,118.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,18673.20,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $22,230.00 in Billed Charges for Rev 278 = $18,673.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15783.30,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $22,230.00 in Billed Charges for Rev 278 = $15,783.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16227.90,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $22,230.00 in Billed Charges for Rev 278 = $16,227.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,10803.78,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $22,230.00 in Billed Charges for Rev 278 = $10,803.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18895.50,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $22,230.00 in Billed Charges for Rev 278 = $18,895.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,HUMANA,HUMANA CHOICE CARE HMO,11115.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $22,230.00 in Billed Charges for Rev 278 = $11,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,HUMANA,HUMANA CHOICE CARE PPO,18895.50,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $22,230.00 in Billed Charges for Rev 278 = $18,895.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,HUMANA,HUMANA NATIIONAL POS HMO,11115.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $22,230.00 in Billed Charges for Rev 278 = $11,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16227.90,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $22,230.00 in Billed Charges for Rev 278 = $16,227.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,22230.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $22,230.00 in Billed Charges for Rev 278 = $22,230.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11115.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $22,230.00 in Billed Charges for Rev 278 = $11,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18673.20,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $22,230.00 in Billed Charges for Rev 278 = $18,673.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16672.50,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $22,230.00 in Billed Charges for Rev 278 = $16,672.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,20451.60,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $22,230.00 in Billed Charges for Rev 278 = $20,451.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11115.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $22,230.00 in Billed Charges for Rev 278 = $11,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11115.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $22,230.00 in Billed Charges for Rev 278 = $11,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,PREVEA HEALTH NETWORK,PREVEA360,11115.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $22,230.00 in Billed Charges for Rev 278 = $11,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11115.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $22,230.00 in Billed Charges for Rev 278 = $11,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14189.41,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $22,230.00 in Billed Charges for Rev 278 = $14,189.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,16005.60,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $22,230.00 in Billed Charges for Rev 278 = $16,005.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10359.18,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $22,230.00 in Billed Charges for Rev 278 = $10,359.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,10359.18,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $22,230.00 in Billed Charges for Rev 278 = $10,359.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,10359.18,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $22,230.00 in Billed Charges for Rev 278 = $10,359.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,16005.60,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $22,230.00 in Billed Charges for Rev 278 = $16,005.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13782.60,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $22,230.00 in Billed Charges for Rev 278 = $13,782.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,16005.60,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $22,230.00 in Billed Charges for Rev 278 = $16,005.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,16005.60,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $22,230.00 in Billed Charges for Rev 278 = $16,005.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST SAME,278,RC,10053794,CDM,,,,,,both,,,22230.0000,14671.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13338.00,,,,,,,10359.1800,22230.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $22,230.00 in Billed Charges for Rev 278 = $13,338.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,AETNA,AETNA HSHS,1258.09,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,947.50 in Billed Charges for Rev 278 = $1,258.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,AETNA,ALL COMMERCIAL AETNA,1947.50,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,947.50 in Billed Charges for Rev 278 = $1,947.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,ANTHEM,ANTHEM POS/HMO,1012.70,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,947.50 in Billed Charges for Rev 278 = $1,012.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,ANTHEM,ANTHEM PPO,1012.70,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,947.50 in Billed Charges for Rev 278 = $1,012.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1947.50,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,947.50 in Billed Charges for Rev 278 = $1,947.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,CENPATICO,ALL MEDICAID CENPATICO,1947.50,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,947.50 in Billed Charges for Rev 278 = $1,947.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1655.38,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,947.50 in Billed Charges for Rev 278 = $1,655.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,CIGNA,ALL COMMERCIAL CIGNA,1363.25,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,947.50 in Billed Charges for Rev 278 = $1,363.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,COFINITY,COFINITY,1947.50,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,947.50 in Billed Charges for Rev 278 = $1,947.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1850.13,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,947.50 in Billed Charges for Rev 278 = $1,850.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,1635.90,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,947.50 in Billed Charges for Rev 278 = $1,635.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1382.73,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,947.50 in Billed Charges for Rev 278 = $1,382.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1421.68,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,947.50 in Billed Charges for Rev 278 = $1,421.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,946.49,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,947.50 in Billed Charges for Rev 278 = $946.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1655.38,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,947.50 in Billed Charges for Rev 278 = $1,655.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,HUMANA,HUMANA CHOICE CARE PPO,1655.38,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,947.50 in Billed Charges for Rev 278 = $1,655.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1421.68,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,947.50 in Billed Charges for Rev 278 = $1,421.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1947.50,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,947.50 in Billed Charges for Rev 278 = $1,947.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,973.75,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,947.50 in Billed Charges for Rev 278 = $973.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1635.90,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,947.50 in Billed Charges for Rev 278 = $1,635.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1460.63,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,947.50 in Billed Charges for Rev 278 = $1,460.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1791.70,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,947.50 in Billed Charges for Rev 278 = $1,791.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1243.09,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,947.50 in Billed Charges for Rev 278 = $1,243.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1402.20,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,947.50 in Billed Charges for Rev 278 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1402.20,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,947.50 in Billed Charges for Rev 278 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1207.45,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,947.50 in Billed Charges for Rev 278 = $1,207.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1402.20,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,947.50 in Billed Charges for Rev 278 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1402.20,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,947.50 in Billed Charges for Rev 278 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 2X2CM GRAFIX CORE,278,RC,10068384,CDM,,,,,,both,,,1947.5000,1285.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1168.50,,,,,,,946.4900,1947.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,947.50 in Billed Charges for Rev 278 = $1,168.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,AETNA,AETNA HSHS,1509.70,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,337.00 in Billed Charges for Rev 278 = $1,509.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,AETNA,ALL COMMERCIAL AETNA,2337.00,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,337.00 in Billed Charges for Rev 278 = $2,337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,ANTHEM,ANTHEM POS/HMO,1215.24,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,337.00 in Billed Charges for Rev 278 = $1,215.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,ANTHEM,ANTHEM PPO,1215.24,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,337.00 in Billed Charges for Rev 278 = $1,215.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2337.00,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,337.00 in Billed Charges for Rev 278 = $2,337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,CENPATICO,ALL MEDICAID CENPATICO,2337.00,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,337.00 in Billed Charges for Rev 278 = $2,337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1986.45,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,337.00 in Billed Charges for Rev 278 = $1,986.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,CIGNA,ALL COMMERCIAL CIGNA,1635.90,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,337.00 in Billed Charges for Rev 278 = $1,635.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,COFINITY,COFINITY,2337.00,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,337.00 in Billed Charges for Rev 278 = $2,337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2220.15,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,337.00 in Billed Charges for Rev 278 = $2,220.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,1963.08,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,337.00 in Billed Charges for Rev 278 = $1,963.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1659.27,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,337.00 in Billed Charges for Rev 278 = $1,659.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1706.01,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,337.00 in Billed Charges for Rev 278 = $1,706.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,1135.78,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,337.00 in Billed Charges for Rev 278 = $1,135.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1986.45,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,337.00 in Billed Charges for Rev 278 = $1,986.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,HUMANA,HUMANA CHOICE CARE PPO,1986.45,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,337.00 in Billed Charges for Rev 278 = $1,986.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1706.01,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,337.00 in Billed Charges for Rev 278 = $1,706.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2337.00,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,337.00 in Billed Charges for Rev 278 = $2,337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1168.50,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,337.00 in Billed Charges for Rev 278 = $1,168.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1963.08,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,337.00 in Billed Charges for Rev 278 = $1,963.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1752.75,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,337.00 in Billed Charges for Rev 278 = $1,752.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2150.04,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,337.00 in Billed Charges for Rev 278 = $2,150.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1491.71,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,337.00 in Billed Charges for Rev 278 = $1,491.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1682.64,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,337.00 in Billed Charges for Rev 278 = $1,682.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1682.64,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,337.00 in Billed Charges for Rev 278 = $1,682.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1448.94,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,337.00 in Billed Charges for Rev 278 = $1,448.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1682.64,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,337.00 in Billed Charges for Rev 278 = $1,682.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1682.64,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,337.00 in Billed Charges for Rev 278 = $1,682.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE 3X4CM GRAFIX CORE,278,RC,10077126,CDM,,,,,,both,,,2337.0000,1542.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1402.20,,,,,,,1135.7800,2337.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,337.00 in Billed Charges for Rev 278 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,AETNA,AETNA HSHS,1590.71,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,462.40 in Billed Charges for Rev 278 = $1,590.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,AETNA,ALL COMMERCIAL AETNA,2462.40,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,462.40 in Billed Charges for Rev 278 = $2,462.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,ANTHEM,ANTHEM POS/HMO,1280.45,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,462.40 in Billed Charges for Rev 278 = $1,280.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,ANTHEM,ANTHEM PPO,1280.45,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,462.40 in Billed Charges for Rev 278 = $1,280.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2462.40,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,462.40 in Billed Charges for Rev 278 = $2,462.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,CENPATICO,ALL MEDICAID CENPATICO,2462.40,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,462.40 in Billed Charges for Rev 278 = $2,462.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2093.04,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,462.40 in Billed Charges for Rev 278 = $2,093.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,CIGNA,ALL COMMERCIAL CIGNA,1723.68,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,462.40 in Billed Charges for Rev 278 = $1,723.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,COFINITY,COFINITY,2462.40,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,462.40 in Billed Charges for Rev 278 = $2,462.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2339.28,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,462.40 in Billed Charges for Rev 278 = $2,339.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,2068.42,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,462.40 in Billed Charges for Rev 278 = $2,068.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1748.30,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,462.40 in Billed Charges for Rev 278 = $1,748.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1797.55,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,462.40 in Billed Charges for Rev 278 = $1,797.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,1196.73,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,462.40 in Billed Charges for Rev 278 = $1,196.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2093.04,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,462.40 in Billed Charges for Rev 278 = $2,093.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,HUMANA,HUMANA CHOICE CARE PPO,2093.04,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,462.40 in Billed Charges for Rev 278 = $2,093.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1797.55,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,462.40 in Billed Charges for Rev 278 = $1,797.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2462.40,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,462.40 in Billed Charges for Rev 278 = $2,462.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1231.20,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,462.40 in Billed Charges for Rev 278 = $1,231.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2068.42,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,462.40 in Billed Charges for Rev 278 = $2,068.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1846.80,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,462.40 in Billed Charges for Rev 278 = $1,846.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2265.41,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,462.40 in Billed Charges for Rev 278 = $2,265.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1571.75,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,462.40 in Billed Charges for Rev 278 = $1,571.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1772.93,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,462.40 in Billed Charges for Rev 278 = $1,772.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1772.93,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,462.40 in Billed Charges for Rev 278 = $1,772.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1526.69,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,462.40 in Billed Charges for Rev 278 = $1,526.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1772.93,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,462.40 in Billed Charges for Rev 278 = $1,772.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1772.93,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,462.40 in Billed Charges for Rev 278 = $1,772.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SOFT TISSUE EPIFIX 6SQ CM AMNIOTIC MEMBRANE ALLOGRAFT,278,RC,10062839,CDM,,,,,,both,,,2462.4000,1625.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1477.44,,,,,,,1196.7300,2462.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,462.40 in Billed Charges for Rev 278 = $1,477.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,AETNA,AETNA HSHS,1261.48,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,952.75 in Billed Charges for Rev 278 = $1,261.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,AETNA,ALL COMMERCIAL AETNA,1952.75,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,952.75 in Billed Charges for Rev 278 = $1,952.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,ANTHEM,ANTHEM POS/HMO,1015.43,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,952.75 in Billed Charges for Rev 278 = $1,015.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,ANTHEM,ANTHEM PPO,1015.43,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,952.75 in Billed Charges for Rev 278 = $1,015.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1952.75,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,952.75 in Billed Charges for Rev 278 = $1,952.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,CENPATICO,ALL MEDICAID CENPATICO,1952.75,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,952.75 in Billed Charges for Rev 278 = $1,952.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1659.84,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,952.75 in Billed Charges for Rev 278 = $1,659.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,CIGNA,ALL COMMERCIAL CIGNA,1366.93,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,952.75 in Billed Charges for Rev 278 = $1,366.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,COFINITY,COFINITY,1952.75,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,952.75 in Billed Charges for Rev 278 = $1,952.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1855.11,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,952.75 in Billed Charges for Rev 278 = $1,855.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,1640.31,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,952.75 in Billed Charges for Rev 278 = $1,640.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1386.45,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,952.75 in Billed Charges for Rev 278 = $1,386.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1425.51,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,952.75 in Billed Charges for Rev 278 = $1,425.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,949.04,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,952.75 in Billed Charges for Rev 278 = $949.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1659.84,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,952.75 in Billed Charges for Rev 278 = $1,659.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,HUMANA,HUMANA CHOICE CARE PPO,1659.84,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,952.75 in Billed Charges for Rev 278 = $1,659.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1425.51,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,952.75 in Billed Charges for Rev 278 = $1,425.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1952.75,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,952.75 in Billed Charges for Rev 278 = $1,952.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,976.38,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,952.75 in Billed Charges for Rev 278 = $976.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1640.31,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,952.75 in Billed Charges for Rev 278 = $1,640.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1464.56,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,952.75 in Billed Charges for Rev 278 = $1,464.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1796.53,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,952.75 in Billed Charges for Rev 278 = $1,796.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1246.44,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,952.75 in Billed Charges for Rev 278 = $1,246.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1405.98,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,952.75 in Billed Charges for Rev 278 = $1,405.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1405.98,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,952.75 in Billed Charges for Rev 278 = $1,405.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1210.71,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,952.75 in Billed Charges for Rev 278 = $1,210.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1405.98,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,952.75 in Billed Charges for Rev 278 = $1,405.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1405.98,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,952.75 in Billed Charges for Rev 278 = $1,405.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS CONTR 25X50X6MM POLYETH PORS MDPR BLOCK,278,RC,10007133,CDM,,,,,,both,,,1952.7500,1288.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1171.65,,,,,,,949.0400,1952.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,952.75 in Billed Charges for Rev 278 = $1,171.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,AETNA,AETNA HSHS,803.35,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,243.57 in Billed Charges for Rev 278 = $803.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,AETNA,ALL COMMERCIAL AETNA,1243.57,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,243.57 in Billed Charges for Rev 278 = $1,243.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,ANTHEM,ANTHEM POS/HMO,646.66,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,243.57 in Billed Charges for Rev 278 = $646.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,ANTHEM,ANTHEM PPO,646.66,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,243.57 in Billed Charges for Rev 278 = $646.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1243.57,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,243.57 in Billed Charges for Rev 278 = $1,243.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,CENPATICO,ALL MEDICAID CENPATICO,1243.57,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,243.57 in Billed Charges for Rev 278 = $1,243.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1057.03,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,243.57 in Billed Charges for Rev 278 = $1,057.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,CIGNA,ALL COMMERCIAL CIGNA,870.50,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,243.57 in Billed Charges for Rev 278 = $870.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,COFINITY,COFINITY,1243.57,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,243.57 in Billed Charges for Rev 278 = $1,243.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1181.39,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,243.57 in Billed Charges for Rev 278 = $1,181.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,1044.60,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,243.57 in Billed Charges for Rev 278 = $1,044.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,882.93,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,243.57 in Billed Charges for Rev 278 = $882.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,907.81,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,243.57 in Billed Charges for Rev 278 = $907.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,604.38,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,243.57 in Billed Charges for Rev 278 = $604.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1057.03,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,243.57 in Billed Charges for Rev 278 = $1,057.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,HUMANA,HUMANA CHOICE CARE PPO,1057.03,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,243.57 in Billed Charges for Rev 278 = $1,057.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,907.81,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,243.57 in Billed Charges for Rev 278 = $907.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1243.57,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,243.57 in Billed Charges for Rev 278 = $1,243.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,621.79,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,243.57 in Billed Charges for Rev 278 = $621.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1044.60,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,243.57 in Billed Charges for Rev 278 = $1,044.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,932.68,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,243.57 in Billed Charges for Rev 278 = $932.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1144.08,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,243.57 in Billed Charges for Rev 278 = $1,144.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,793.77,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,243.57 in Billed Charges for Rev 278 = $793.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,895.37,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,243.57 in Billed Charges for Rev 278 = $895.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,895.37,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,243.57 in Billed Charges for Rev 278 = $895.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,771.01,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,243.57 in Billed Charges for Rev 278 = $771.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,895.37,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,243.57 in Billed Charges for Rev 278 = $895.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,895.37,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,243.57 in Billed Charges for Rev 278 = $895.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS REG 31X22X7MM POLYETH 2ML MDPR WEDGE,278,RC,10010816,CDM,,,,,,both,,,1243.5700,820.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,746.14,,,,,,,604.3800,1243.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,243.57 in Billed Charges for Rev 278 = $746.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,AETNA,AETNA HSHS,895.49,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,386.21 in Billed Charges for Rev 278 = $895.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,AETNA,ALL COMMERCIAL AETNA,1386.21,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,386.21 in Billed Charges for Rev 278 = $1,386.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,ANTHEM,ANTHEM POS/HMO,720.83,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,386.21 in Billed Charges for Rev 278 = $720.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,ANTHEM,ANTHEM PPO,720.83,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,386.21 in Billed Charges for Rev 278 = $720.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1386.21,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,386.21 in Billed Charges for Rev 278 = $1,386.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,CENPATICO,ALL MEDICAID CENPATICO,1386.21,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,386.21 in Billed Charges for Rev 278 = $1,386.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1178.28,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,386.21 in Billed Charges for Rev 278 = $1,178.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,CIGNA,ALL COMMERCIAL CIGNA,970.35,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,386.21 in Billed Charges for Rev 278 = $970.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,COFINITY,COFINITY,1386.21,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,386.21 in Billed Charges for Rev 278 = $1,386.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1316.90,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,386.21 in Billed Charges for Rev 278 = $1,316.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,1164.42,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,386.21 in Billed Charges for Rev 278 = $1,164.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,984.21,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,386.21 in Billed Charges for Rev 278 = $984.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1011.93,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,386.21 in Billed Charges for Rev 278 = $1,011.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,673.70,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,386.21 in Billed Charges for Rev 278 = $673.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1178.28,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,386.21 in Billed Charges for Rev 278 = $1,178.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,HUMANA,HUMANA CHOICE CARE PPO,1178.28,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,386.21 in Billed Charges for Rev 278 = $1,178.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1011.93,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,386.21 in Billed Charges for Rev 278 = $1,011.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1386.21,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,386.21 in Billed Charges for Rev 278 = $1,386.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,693.11,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,386.21 in Billed Charges for Rev 278 = $693.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1164.42,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,386.21 in Billed Charges for Rev 278 = $1,164.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1039.66,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,386.21 in Billed Charges for Rev 278 = $1,039.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1275.31,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,386.21 in Billed Charges for Rev 278 = $1,275.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,884.82,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,386.21 in Billed Charges for Rev 278 = $884.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,998.07,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,386.21 in Billed Charges for Rev 278 = $998.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,998.07,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,386.21 in Billed Charges for Rev 278 = $998.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,859.45,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,386.21 in Billed Charges for Rev 278 = $859.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,998.07,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,386.21 in Billed Charges for Rev 278 = $998.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,998.07,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,386.21 in Billed Charges for Rev 278 = $998.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SYNTH TISS TRUMP 50X38X1MM HDPE NONPOR MDPR SHT ORBT,278,RC,10007134,CDM,,,,,,both,,,1386.2100,914.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,831.73,,,,,,,673.7000,1386.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,386.21 in Billed Charges for Rev 278 = $831.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,AETNA,AETNA HSHS,454.34,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $703.31 in Billed Charges for Rev 278 = $454.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,AETNA,ALL COMMERCIAL AETNA,703.31,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.31 in Billed Charges for Rev 278 = $703.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,703.31,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.31 in Billed Charges for Rev 278 = $703.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,CENPATICO,ALL MEDICAID CENPATICO,703.31,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.31 in Billed Charges for Rev 278 = $703.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,597.81,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $703.31 in Billed Charges for Rev 278 = $597.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,CIGNA,ALL COMMERCIAL CIGNA,492.32,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $703.31 in Billed Charges for Rev 278 = $492.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,COFINITY,COFINITY,703.31,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.31 in Billed Charges for Rev 278 = $703.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,668.14,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $703.31 in Billed Charges for Rev 278 = $668.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,590.78,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $703.31 in Billed Charges for Rev 278 = $590.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,499.35,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $703.31 in Billed Charges for Rev 278 = $499.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,513.42,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $703.31 in Billed Charges for Rev 278 = $513.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,341.81,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $703.31 in Billed Charges for Rev 278 = $341.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,597.81,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $703.31 in Billed Charges for Rev 278 = $597.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,HUMANA,HUMANA CHOICE CARE PPO,597.81,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $703.31 in Billed Charges for Rev 278 = $597.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,513.42,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $703.31 in Billed Charges for Rev 278 = $513.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,703.31,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $703.31 in Billed Charges for Rev 278 = $703.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,351.66,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $703.31 in Billed Charges for Rev 278 = $351.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,590.78,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $703.31 in Billed Charges for Rev 278 = $590.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,527.48,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $703.31 in Billed Charges for Rev 278 = $527.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,647.05,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $703.31 in Billed Charges for Rev 278 = $647.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,448.92,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $703.31 in Billed Charges for Rev 278 = $448.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,506.38,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $703.31 in Billed Charges for Rev 278 = $506.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,506.38,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $703.31 in Billed Charges for Rev 278 = $506.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,436.05,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $703.31 in Billed Charges for Rev 278 = $436.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,506.38,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $703.31 in Billed Charges for Rev 278 = $506.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,506.38,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $703.31 in Billed Charges for Rev 278 = $506.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 1 X 3,278,RC,10030397,CDM,,,,,,both,,,703.3100,464.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,421.99,,,,,,,341.8100,703.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $703.31 in Billed Charges for Rev 278 = $421.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,AETNA,AETNA HSHS,530.70,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $821.52 in Billed Charges for Rev 278 = $530.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,AETNA,ALL COMMERCIAL AETNA,821.52,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $821.52 in Billed Charges for Rev 278 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,821.52,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $821.52 in Billed Charges for Rev 278 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,CENPATICO,ALL MEDICAID CENPATICO,821.52,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $821.52 in Billed Charges for Rev 278 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,698.29,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $821.52 in Billed Charges for Rev 278 = $698.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,CIGNA,ALL COMMERCIAL CIGNA,575.06,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $821.52 in Billed Charges for Rev 278 = $575.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,COFINITY,COFINITY,821.52,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $821.52 in Billed Charges for Rev 278 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,780.44,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $821.52 in Billed Charges for Rev 278 = $780.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,690.08,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $821.52 in Billed Charges for Rev 278 = $690.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,583.28,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $821.52 in Billed Charges for Rev 278 = $583.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,599.71,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $821.52 in Billed Charges for Rev 278 = $599.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,399.26,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $821.52 in Billed Charges for Rev 278 = $399.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,698.29,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $821.52 in Billed Charges for Rev 278 = $698.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,HUMANA,HUMANA CHOICE CARE PPO,698.29,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $821.52 in Billed Charges for Rev 278 = $698.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,599.71,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $821.52 in Billed Charges for Rev 278 = $599.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,821.52,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $821.52 in Billed Charges for Rev 278 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,410.76,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $821.52 in Billed Charges for Rev 278 = $410.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,690.08,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $821.52 in Billed Charges for Rev 278 = $690.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,616.14,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $821.52 in Billed Charges for Rev 278 = $616.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,755.80,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $821.52 in Billed Charges for Rev 278 = $755.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,524.38,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $821.52 in Billed Charges for Rev 278 = $524.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,591.49,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $821.52 in Billed Charges for Rev 278 = $591.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,591.49,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $821.52 in Billed Charges for Rev 278 = $591.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,509.34,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $821.52 in Billed Charges for Rev 278 = $509.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,591.49,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $821.52 in Billed Charges for Rev 278 = $591.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,591.49,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $821.52 in Billed Charges for Rev 278 = $591.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DURAFORM 2 X 2,278,RC,10030395,CDM,,,,,,both,,,821.5200,542.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,492.91,,,,,,,399.2600,821.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $821.52 in Billed Charges for Rev 278 = $492.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,AETNA,AETNA HSHS,1594.15,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,467.72 in Billed Charges for Rev 278 = $1,594.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,AETNA,ALL COMMERCIAL AETNA,2467.72,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,467.72 in Billed Charges for Rev 278 = $2,467.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,ANTHEM,ANTHEM POS/HMO,1283.21,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,467.72 in Billed Charges for Rev 278 = $1,283.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,ANTHEM,ANTHEM PPO,1283.21,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,467.72 in Billed Charges for Rev 278 = $1,283.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2467.72,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,467.72 in Billed Charges for Rev 278 = $2,467.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,CENPATICO,ALL MEDICAID CENPATICO,2467.72,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,467.72 in Billed Charges for Rev 278 = $2,467.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2097.56,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,467.72 in Billed Charges for Rev 278 = $2,097.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,CIGNA,ALL COMMERCIAL CIGNA,1727.40,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,467.72 in Billed Charges for Rev 278 = $1,727.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,COFINITY,COFINITY,2467.72,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,467.72 in Billed Charges for Rev 278 = $2,467.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2344.33,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,467.72 in Billed Charges for Rev 278 = $2,344.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,2072.88,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,467.72 in Billed Charges for Rev 278 = $2,072.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1752.08,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,467.72 in Billed Charges for Rev 278 = $1,752.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1801.44,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,467.72 in Billed Charges for Rev 278 = $1,801.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,1199.31,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,467.72 in Billed Charges for Rev 278 = $1,199.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2097.56,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,467.72 in Billed Charges for Rev 278 = $2,097.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,HUMANA,HUMANA CHOICE CARE PPO,2097.56,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,467.72 in Billed Charges for Rev 278 = $2,097.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1801.44,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,467.72 in Billed Charges for Rev 278 = $1,801.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2467.72,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,467.72 in Billed Charges for Rev 278 = $2,467.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1233.86,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,467.72 in Billed Charges for Rev 278 = $1,233.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2072.88,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,467.72 in Billed Charges for Rev 278 = $2,072.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1850.79,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,467.72 in Billed Charges for Rev 278 = $1,850.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2270.30,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,467.72 in Billed Charges for Rev 278 = $2,270.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1575.15,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,467.72 in Billed Charges for Rev 278 = $1,575.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1776.76,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,467.72 in Billed Charges for Rev 278 = $1,776.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1776.76,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,467.72 in Billed Charges for Rev 278 = $1,776.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1529.99,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,467.72 in Billed Charges for Rev 278 = $1,529.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1776.76,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,467.72 in Billed Charges for Rev 278 = $1,776.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1776.76,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,467.72 in Billed Charges for Rev 278 = $1,776.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT DUREPAIR 4 X 5,278,RC,10028523,CDM,,,,,,both,,,2467.7200,1628.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1480.63,,,,,,,1199.3100,2467.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,467.72 in Billed Charges for Rev 278 = $1,480.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,AETNA,AETNA HSHS,973.36,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,506.75 in Billed Charges for Rev 278 = $973.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,AETNA,ALL COMMERCIAL AETNA,1506.75,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,506.75 in Billed Charges for Rev 278 = $1,506.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,ANTHEM,ANTHEM POS/HMO,783.51,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,506.75 in Billed Charges for Rev 278 = $783.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,ANTHEM,ANTHEM PPO,783.51,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,506.75 in Billed Charges for Rev 278 = $783.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1506.75,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,506.75 in Billed Charges for Rev 278 = $1,506.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,CENPATICO,ALL MEDICAID CENPATICO,1506.75,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,506.75 in Billed Charges for Rev 278 = $1,506.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1280.74,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,506.75 in Billed Charges for Rev 278 = $1,280.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,CIGNA,ALL COMMERCIAL CIGNA,1054.73,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,506.75 in Billed Charges for Rev 278 = $1,054.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,COFINITY,COFINITY,1506.75,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,506.75 in Billed Charges for Rev 278 = $1,506.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1431.41,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,506.75 in Billed Charges for Rev 278 = $1,431.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,1265.67,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,506.75 in Billed Charges for Rev 278 = $1,265.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1069.79,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,506.75 in Billed Charges for Rev 278 = $1,069.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1099.93,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,506.75 in Billed Charges for Rev 278 = $1,099.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,732.28,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,506.75 in Billed Charges for Rev 278 = $732.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1280.74,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,506.75 in Billed Charges for Rev 278 = $1,280.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,HUMANA,HUMANA CHOICE CARE PPO,1280.74,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,506.75 in Billed Charges for Rev 278 = $1,280.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1099.93,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,506.75 in Billed Charges for Rev 278 = $1,099.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1506.75,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,506.75 in Billed Charges for Rev 278 = $1,506.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,753.38,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,506.75 in Billed Charges for Rev 278 = $753.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1265.67,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,506.75 in Billed Charges for Rev 278 = $1,265.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1130.06,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,506.75 in Billed Charges for Rev 278 = $1,130.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1386.21,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,506.75 in Billed Charges for Rev 278 = $1,386.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,961.76,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,506.75 in Billed Charges for Rev 278 = $961.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1084.86,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,506.75 in Billed Charges for Rev 278 = $1,084.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1084.86,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,506.75 in Billed Charges for Rev 278 = $1,084.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,934.19,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,506.75 in Billed Charges for Rev 278 = $934.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1084.86,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,506.75 in Billed Charges for Rev 278 = $1,084.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1084.86,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,506.75 in Billed Charges for Rev 278 = $1,084.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT PROLARYN PLUS INJECTABLE MERZ 1.0CC,278,RC,10064944,CDM,,,,,,both,,,1506.7500,994.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,904.05,,,,,,,732.2800,1506.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,506.75 in Billed Charges for Rev 278 = $904.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,AETNA,AETNA HSHS,47.97,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $74.25 in Billed Charges for Rev 278 = $47.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,AETNA,ALL COMMERCIAL AETNA,74.25,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.25 in Billed Charges for Rev 278 = $74.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,74.25,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.25 in Billed Charges for Rev 278 = $74.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,CENPATICO,ALL MEDICAID CENPATICO,74.25,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.25 in Billed Charges for Rev 278 = $74.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,63.11,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.25 in Billed Charges for Rev 278 = $63.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,CIGNA,ALL COMMERCIAL CIGNA,51.98,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $74.25 in Billed Charges for Rev 278 = $51.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,COFINITY,COFINITY,74.25,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.25 in Billed Charges for Rev 278 = $74.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,70.54,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $74.25 in Billed Charges for Rev 278 = $70.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,62.37,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.25 in Billed Charges for Rev 278 = $62.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.72,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $74.25 in Billed Charges for Rev 278 = $52.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.20,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.25 in Billed Charges for Rev 278 = $54.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,36.09,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $74.25 in Billed Charges for Rev 278 = $36.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,63.11,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.25 in Billed Charges for Rev 278 = $63.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,HUMANA,HUMANA CHOICE CARE PPO,63.11,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.25 in Billed Charges for Rev 278 = $63.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.20,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.25 in Billed Charges for Rev 278 = $54.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,74.25,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.25 in Billed Charges for Rev 278 = $74.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.13,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $74.25 in Billed Charges for Rev 278 = $37.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,62.37,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.25 in Billed Charges for Rev 278 = $62.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.69,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $74.25 in Billed Charges for Rev 278 = $55.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,68.31,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $74.25 in Billed Charges for Rev 278 = $68.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.39,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $74.25 in Billed Charges for Rev 278 = $47.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.46,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.25 in Billed Charges for Rev 278 = $53.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.46,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.25 in Billed Charges for Rev 278 = $53.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,46.04,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $74.25 in Billed Charges for Rev 278 = $46.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.46,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.25 in Billed Charges for Rev 278 = $53.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.46,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.25 in Billed Charges for Rev 278 = $53.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  225 (STRIP),278,RC,70500154,CDM,,,,,,both,,,74.2500,49.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.55,,,,,,,36.0900,74.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.25 in Billed Charges for Rev 278 = $44.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,AETNA,AETNA HSHS,17.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $27.00 in Billed Charges for Rev 278 = $17.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,AETNA,ALL COMMERCIAL AETNA,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 278 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 278 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,CENPATICO,ALL MEDICAID CENPATICO,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 278 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,22.95,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.00 in Billed Charges for Rev 278 = $22.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,CIGNA,ALL COMMERCIAL CIGNA,18.90,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $27.00 in Billed Charges for Rev 278 = $18.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,COFINITY,COFINITY,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 278 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,25.65,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $27.00 in Billed Charges for Rev 278 = $25.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,22.68,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.00 in Billed Charges for Rev 278 = $22.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19.17,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $27.00 in Billed Charges for Rev 278 = $19.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,19.71,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.00 in Billed Charges for Rev 278 = $19.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,13.12,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $27.00 in Billed Charges for Rev 278 = $13.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,22.95,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.00 in Billed Charges for Rev 278 = $22.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,HUMANA,HUMANA CHOICE CARE PPO,22.95,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.00 in Billed Charges for Rev 278 = $22.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,19.71,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.00 in Billed Charges for Rev 278 = $19.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 278 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.50,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $27.00 in Billed Charges for Rev 278 = $13.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,22.68,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.00 in Billed Charges for Rev 278 = $22.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20.25,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $27.00 in Billed Charges for Rev 278 = $20.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,24.84,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $27.00 in Billed Charges for Rev 278 = $24.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.23,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $27.00 in Billed Charges for Rev 278 = $17.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,19.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.00 in Billed Charges for Rev 278 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,19.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.00 in Billed Charges for Rev 278 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.74,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $27.00 in Billed Charges for Rev 278 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,19.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.00 in Billed Charges for Rev 278 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,19.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.00 in Billed Charges for Rev 278 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL  280 (TIRE),278,RC,70500472,CDM,,,,,,both,,,27.0000,17.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16.20,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.00 in Billed Charges for Rev 278 = $16.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,AETNA,AETNA HSHS,27.91,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $43.20 in Billed Charges for Rev 278 = $27.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,AETNA,ALL COMMERCIAL AETNA,43.20,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.20 in Billed Charges for Rev 278 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,43.20,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.20 in Billed Charges for Rev 278 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,CENPATICO,ALL MEDICAID CENPATICO,43.20,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.20 in Billed Charges for Rev 278 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,36.72,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $43.20 in Billed Charges for Rev 278 = $36.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,CIGNA,ALL COMMERCIAL CIGNA,30.24,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $43.20 in Billed Charges for Rev 278 = $30.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,COFINITY,COFINITY,43.20,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.20 in Billed Charges for Rev 278 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,41.04,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $43.20 in Billed Charges for Rev 278 = $41.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,36.29,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $43.20 in Billed Charges for Rev 278 = $36.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,30.67,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $43.20 in Billed Charges for Rev 278 = $30.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,31.54,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $43.20 in Billed Charges for Rev 278 = $31.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,21.00,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $43.20 in Billed Charges for Rev 278 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,36.72,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $43.20 in Billed Charges for Rev 278 = $36.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,HUMANA,HUMANA CHOICE CARE PPO,36.72,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $43.20 in Billed Charges for Rev 278 = $36.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,31.54,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $43.20 in Billed Charges for Rev 278 = $31.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,43.20,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.20 in Billed Charges for Rev 278 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,21.60,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $43.20 in Billed Charges for Rev 278 = $21.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,36.29,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $43.20 in Billed Charges for Rev 278 = $36.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,32.40,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $43.20 in Billed Charges for Rev 278 = $32.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,39.74,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $43.20 in Billed Charges for Rev 278 = $39.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,27.57,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $43.20 in Billed Charges for Rev 278 = $27.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,31.10,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $43.20 in Billed Charges for Rev 278 = $31.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,31.10,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $43.20 in Billed Charges for Rev 278 = $31.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,26.78,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $43.20 in Billed Charges for Rev 278 = $26.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,31.10,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $43.20 in Billed Charges for Rev 278 = $31.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,31.10,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $43.20 in Billed Charges for Rev 278 = $31.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL 286 (TIRE),278,RC,10043800,CDM,,,,,,both,,,43.2000,28.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,25.92,,,,,,,21.0000,43.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $43.20 in Billed Charges for Rev 278 = $25.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,AETNA,AETNA HSHS,25.29,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $39.15 in Billed Charges for Rev 278 = $25.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,AETNA,ALL COMMERCIAL AETNA,39.15,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.15 in Billed Charges for Rev 278 = $39.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,39.15,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.15 in Billed Charges for Rev 278 = $39.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,CENPATICO,ALL MEDICAID CENPATICO,39.15,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.15 in Billed Charges for Rev 278 = $39.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,33.28,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.15 in Billed Charges for Rev 278 = $33.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,CIGNA,ALL COMMERCIAL CIGNA,27.41,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $39.15 in Billed Charges for Rev 278 = $27.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,COFINITY,COFINITY,39.15,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.15 in Billed Charges for Rev 278 = $39.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,37.19,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $39.15 in Billed Charges for Rev 278 = $37.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,32.89,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $39.15 in Billed Charges for Rev 278 = $32.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,27.80,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $39.15 in Billed Charges for Rev 278 = $27.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,28.58,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $39.15 in Billed Charges for Rev 278 = $28.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,19.03,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $39.15 in Billed Charges for Rev 278 = $19.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,33.28,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.15 in Billed Charges for Rev 278 = $33.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,HUMANA,HUMANA CHOICE CARE PPO,33.28,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.15 in Billed Charges for Rev 278 = $33.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,28.58,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $39.15 in Billed Charges for Rev 278 = $28.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,39.15,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.15 in Billed Charges for Rev 278 = $39.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.58,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $39.15 in Billed Charges for Rev 278 = $19.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,32.89,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $39.15 in Billed Charges for Rev 278 = $32.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,29.36,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $39.15 in Billed Charges for Rev 278 = $29.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,36.02,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $39.15 in Billed Charges for Rev 278 = $36.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,24.99,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $39.15 in Billed Charges for Rev 278 = $24.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,28.19,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.15 in Billed Charges for Rev 278 = $28.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,28.19,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.15 in Billed Charges for Rev 278 = $28.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,24.27,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $39.15 in Billed Charges for Rev 278 = $24.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,28.19,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.15 in Billed Charges for Rev 278 = $28.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,28.19,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.15 in Billed Charges for Rev 278 = $28.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL BAND CIRCLING STYLE  40,278,RC,10060185,CDM,,,,,,both,,,39.1500,25.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,23.49,,,,,,,19.0300,39.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $39.15 in Billed Charges for Rev 278 = $23.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,AETNA,AETNA HSHS,18.02,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $27.90 in Billed Charges for Rev 278 = $18.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,AETNA,ALL COMMERCIAL AETNA,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 278 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 278 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,CENPATICO,ALL MEDICAID CENPATICO,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 278 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 278 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,CIGNA,ALL COMMERCIAL CIGNA,19.53,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $27.90 in Billed Charges for Rev 278 = $19.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,COFINITY,COFINITY,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 278 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,26.51,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $27.90 in Billed Charges for Rev 278 = $26.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,23.44,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.90 in Billed Charges for Rev 278 = $23.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19.81,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $27.90 in Billed Charges for Rev 278 = $19.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,20.37,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.90 in Billed Charges for Rev 278 = $20.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,13.56,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $27.90 in Billed Charges for Rev 278 = $13.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 278 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,HUMANA,HUMANA CHOICE CARE PPO,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 278 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,20.37,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.90 in Billed Charges for Rev 278 = $20.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 278 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.95,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $27.90 in Billed Charges for Rev 278 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,23.44,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.90 in Billed Charges for Rev 278 = $23.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20.93,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $27.90 in Billed Charges for Rev 278 = $20.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,25.67,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $27.90 in Billed Charges for Rev 278 = $25.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.81,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $27.90 in Billed Charges for Rev 278 = $17.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 278 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 278 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.30,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $27.90 in Billed Charges for Rev 278 = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 278 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 278 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL SLEEVE SILICONE STYLE  70,278,RC,10060196,CDM,,,,,,both,,,27.9000,18.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 278 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,AETNA,AETNA HSHS,33.72,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $52.20 in Billed Charges for Rev 278 = $33.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,AETNA,ALL COMMERCIAL AETNA,52.20,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.20 in Billed Charges for Rev 278 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,52.20,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.20 in Billed Charges for Rev 278 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,CENPATICO,ALL MEDICAID CENPATICO,52.20,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.20 in Billed Charges for Rev 278 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,44.37,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.20 in Billed Charges for Rev 278 = $44.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,CIGNA,ALL COMMERCIAL CIGNA,36.54,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $52.20 in Billed Charges for Rev 278 = $36.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,COFINITY,COFINITY,52.20,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.20 in Billed Charges for Rev 278 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,49.59,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $52.20 in Billed Charges for Rev 278 = $49.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,43.85,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.20 in Billed Charges for Rev 278 = $43.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,37.06,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $52.20 in Billed Charges for Rev 278 = $37.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,38.11,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.20 in Billed Charges for Rev 278 = $38.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,25.37,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $52.20 in Billed Charges for Rev 278 = $25.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,44.37,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.20 in Billed Charges for Rev 278 = $44.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,HUMANA,HUMANA CHOICE CARE PPO,44.37,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.20 in Billed Charges for Rev 278 = $44.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,38.11,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.20 in Billed Charges for Rev 278 = $38.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,52.20,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.20 in Billed Charges for Rev 278 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.10,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $52.20 in Billed Charges for Rev 278 = $26.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,43.85,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.20 in Billed Charges for Rev 278 = $43.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,39.15,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $52.20 in Billed Charges for Rev 278 = $39.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,48.02,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $52.20 in Billed Charges for Rev 278 = $48.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,33.32,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $52.20 in Billed Charges for Rev 278 = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,37.58,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.20 in Billed Charges for Rev 278 = $37.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,37.58,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.20 in Billed Charges for Rev 278 = $37.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.36,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $52.20 in Billed Charges for Rev 278 = $32.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,37.58,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.20 in Billed Charges for Rev 278 = $37.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,37.58,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.20 in Billed Charges for Rev 278 = $37.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL STRIP SILICONE STYLE  41,278,RC,10060186,CDM,,,,,,both,,,52.2000,34.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.32,,,,,,,25.3700,52.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.20 in Billed Charges for Rev 278 = $31.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,AETNA,AETNA HSHS,38.66,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $59.85 in Billed Charges for Rev 278 = $38.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,AETNA,ALL COMMERCIAL AETNA,59.85,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.85 in Billed Charges for Rev 278 = $59.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,59.85,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.85 in Billed Charges for Rev 278 = $59.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,CENPATICO,ALL MEDICAID CENPATICO,59.85,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.85 in Billed Charges for Rev 278 = $59.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,50.87,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.85 in Billed Charges for Rev 278 = $50.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,CIGNA,ALL COMMERCIAL CIGNA,41.90,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $59.85 in Billed Charges for Rev 278 = $41.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,COFINITY,COFINITY,59.85,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.85 in Billed Charges for Rev 278 = $59.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,56.86,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $59.85 in Billed Charges for Rev 278 = $56.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,50.27,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $59.85 in Billed Charges for Rev 278 = $50.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42.49,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $59.85 in Billed Charges for Rev 278 = $42.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,43.69,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $59.85 in Billed Charges for Rev 278 = $43.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,29.09,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $59.85 in Billed Charges for Rev 278 = $29.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,50.87,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.85 in Billed Charges for Rev 278 = $50.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,HUMANA,HUMANA CHOICE CARE PPO,50.87,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.85 in Billed Charges for Rev 278 = $50.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,43.69,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $59.85 in Billed Charges for Rev 278 = $43.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,59.85,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.85 in Billed Charges for Rev 278 = $59.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,29.93,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $59.85 in Billed Charges for Rev 278 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,50.27,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $59.85 in Billed Charges for Rev 278 = $50.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,44.89,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $59.85 in Billed Charges for Rev 278 = $44.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,55.06,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $59.85 in Billed Charges for Rev 278 = $55.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38.20,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $59.85 in Billed Charges for Rev 278 = $38.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,43.09,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.85 in Billed Charges for Rev 278 = $43.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,43.09,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.85 in Billed Charges for Rev 278 = $43.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37.11,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $59.85 in Billed Charges for Rev 278 = $37.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,43.09,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.85 in Billed Charges for Rev 278 = $43.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,43.09,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.85 in Billed Charges for Rev 278 = $43.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT RETINAL TIRE SILICONE STYLE 276,278,RC,10060190,CDM,,,,,,both,,,59.8500,39.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,35.91,,,,,,,29.0900,59.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.85 in Billed Charges for Rev 278 = $35.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,AETNA,AETNA HSHS,3370.96,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,218.20 in Billed Charges for Rev 278 = $3,370.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,AETNA,ALL COMMERCIAL AETNA,5218.20,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,218.20 in Billed Charges for Rev 278 = $5,218.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,ANTHEM,ANTHEM POS/HMO,2713.46,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,218.20 in Billed Charges for Rev 278 = $2,713.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,ANTHEM,ANTHEM PPO,2713.46,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,218.20 in Billed Charges for Rev 278 = $2,713.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5218.20,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,218.20 in Billed Charges for Rev 278 = $5,218.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,CENPATICO,ALL MEDICAID CENPATICO,5218.20,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,218.20 in Billed Charges for Rev 278 = $5,218.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4435.47,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,218.20 in Billed Charges for Rev 278 = $4,435.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,CIGNA,ALL COMMERCIAL CIGNA,3652.74,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,218.20 in Billed Charges for Rev 278 = $3,652.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,COFINITY,COFINITY,5218.20,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,218.20 in Billed Charges for Rev 278 = $5,218.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4957.29,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,218.20 in Billed Charges for Rev 278 = $4,957.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,4383.29,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,218.20 in Billed Charges for Rev 278 = $4,383.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3704.92,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,218.20 in Billed Charges for Rev 278 = $3,704.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3809.29,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,218.20 in Billed Charges for Rev 278 = $3,809.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,2536.05,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,218.20 in Billed Charges for Rev 278 = $2,536.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4435.47,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,218.20 in Billed Charges for Rev 278 = $4,435.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,HUMANA,HUMANA CHOICE CARE HMO,2609.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,218.20 in Billed Charges for Rev 278 = $2,609.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,HUMANA,HUMANA CHOICE CARE PPO,4435.47,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,218.20 in Billed Charges for Rev 278 = $4,435.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,HUMANA,HUMANA NATIIONAL POS HMO,2609.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,218.20 in Billed Charges for Rev 278 = $2,609.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3809.29,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,218.20 in Billed Charges for Rev 278 = $3,809.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,5218.20,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,218.20 in Billed Charges for Rev 278 = $5,218.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2609.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,218.20 in Billed Charges for Rev 278 = $2,609.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4383.29,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,218.20 in Billed Charges for Rev 278 = $4,383.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3913.65,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,218.20 in Billed Charges for Rev 278 = $3,913.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4800.74,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,218.20 in Billed Charges for Rev 278 = $4,800.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2609.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,218.20 in Billed Charges for Rev 278 = $2,609.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2609.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,218.20 in Billed Charges for Rev 278 = $2,609.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,PREVEA HEALTH NETWORK,PREVEA360,2609.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,218.20 in Billed Charges for Rev 278 = $2,609.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2609.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,218.20 in Billed Charges for Rev 278 = $2,609.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3330.78,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,218.20 in Billed Charges for Rev 278 = $3,330.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3757.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,218.20 in Billed Charges for Rev 278 = $3,757.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3757.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,218.20 in Billed Charges for Rev 278 = $3,757.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3235.28,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,218.20 in Billed Charges for Rev 278 = $3,235.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3757.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,218.20 in Billed Charges for Rev 278 = $3,757.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3757.10,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,218.20 in Billed Charges for Rev 278 = $3,757.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYNTHETIC CARTILAGE CARTIVA,278,RC,10073635,CDM,,,,,,both,,,5218.2000,3444.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3130.92,,,,,,,2536.0500,5218.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,218.20 in Billed Charges for Rev 278 = $3,130.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,AETNA,AETNA HSHS,1012.43,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,567.23 in Billed Charges for Rev 278 = $1,012.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,AETNA,ALL COMMERCIAL AETNA,1567.23,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,567.23 in Billed Charges for Rev 278 = $1,567.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,ANTHEM,ANTHEM POS/HMO,814.96,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,567.23 in Billed Charges for Rev 278 = $814.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,ANTHEM,ANTHEM PPO,814.96,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,567.23 in Billed Charges for Rev 278 = $814.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1567.23,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,567.23 in Billed Charges for Rev 278 = $1,567.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,CENPATICO,ALL MEDICAID CENPATICO,1567.23,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,567.23 in Billed Charges for Rev 278 = $1,567.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1332.15,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,567.23 in Billed Charges for Rev 278 = $1,332.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,CIGNA,ALL COMMERCIAL CIGNA,1097.06,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,567.23 in Billed Charges for Rev 278 = $1,097.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,COFINITY,COFINITY,1567.23,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,567.23 in Billed Charges for Rev 278 = $1,567.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1488.87,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,567.23 in Billed Charges for Rev 278 = $1,488.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,1316.47,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,567.23 in Billed Charges for Rev 278 = $1,316.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1112.73,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,567.23 in Billed Charges for Rev 278 = $1,112.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1144.08,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,567.23 in Billed Charges for Rev 278 = $1,144.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,761.67,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,567.23 in Billed Charges for Rev 278 = $761.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1332.15,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,567.23 in Billed Charges for Rev 278 = $1,332.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,HUMANA,HUMANA CHOICE CARE PPO,1332.15,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,567.23 in Billed Charges for Rev 278 = $1,332.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1144.08,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,567.23 in Billed Charges for Rev 278 = $1,144.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1567.23,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,567.23 in Billed Charges for Rev 278 = $1,567.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,783.62,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,567.23 in Billed Charges for Rev 278 = $783.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1316.47,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,567.23 in Billed Charges for Rev 278 = $1,316.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1175.42,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,567.23 in Billed Charges for Rev 278 = $1,175.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1441.85,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,567.23 in Billed Charges for Rev 278 = $1,441.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1000.36,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,567.23 in Billed Charges for Rev 278 = $1,000.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1128.41,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,567.23 in Billed Charges for Rev 278 = $1,128.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1128.41,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,567.23 in Billed Charges for Rev 278 = $1,128.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,971.68,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,567.23 in Billed Charges for Rev 278 = $971.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1128.41,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,567.23 in Billed Charges for Rev 278 = $1,128.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1128.41,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,567.23 in Billed Charges for Rev 278 = $1,128.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM CMC LIGAMENT RECONSTRUCTION,278,RC,10075732,CDM,,,,,,both,,,1567.2300,1034.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,940.34,,,,,,,761.6700,1567.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,567.23 in Billed Charges for Rev 278 = $940.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,AETNA,AETNA HSHS,1527.79,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,365.00 in Billed Charges for Rev 278 = $1,527.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,AETNA,ALL COMMERCIAL AETNA,2365.00,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,365.00 in Billed Charges for Rev 278 = $2,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,ANTHEM,ANTHEM POS/HMO,1229.80,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,365.00 in Billed Charges for Rev 278 = $1,229.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,ANTHEM,ANTHEM PPO,1229.80,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,365.00 in Billed Charges for Rev 278 = $1,229.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2365.00,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,365.00 in Billed Charges for Rev 278 = $2,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,CENPATICO,ALL MEDICAID CENPATICO,2365.00,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,365.00 in Billed Charges for Rev 278 = $2,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2010.25,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,365.00 in Billed Charges for Rev 278 = $2,010.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,CIGNA,ALL COMMERCIAL CIGNA,1655.50,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,365.00 in Billed Charges for Rev 278 = $1,655.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,COFINITY,COFINITY,2365.00,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,365.00 in Billed Charges for Rev 278 = $2,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2246.75,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,365.00 in Billed Charges for Rev 278 = $2,246.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,1986.60,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,365.00 in Billed Charges for Rev 278 = $1,986.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1679.15,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,365.00 in Billed Charges for Rev 278 = $1,679.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1726.45,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,365.00 in Billed Charges for Rev 278 = $1,726.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,1149.39,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,365.00 in Billed Charges for Rev 278 = $1,149.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2010.25,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,365.00 in Billed Charges for Rev 278 = $2,010.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,HUMANA,HUMANA CHOICE CARE PPO,2010.25,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,365.00 in Billed Charges for Rev 278 = $2,010.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1726.45,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,365.00 in Billed Charges for Rev 278 = $1,726.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2365.00,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,365.00 in Billed Charges for Rev 278 = $2,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1182.50,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,365.00 in Billed Charges for Rev 278 = $1,182.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1986.60,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,365.00 in Billed Charges for Rev 278 = $1,986.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1773.75,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,365.00 in Billed Charges for Rev 278 = $1,773.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2175.80,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,365.00 in Billed Charges for Rev 278 = $2,175.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1509.58,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,365.00 in Billed Charges for Rev 278 = $1,509.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1702.80,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,365.00 in Billed Charges for Rev 278 = $1,702.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1702.80,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,365.00 in Billed Charges for Rev 278 = $1,702.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1466.30,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,365.00 in Billed Charges for Rev 278 = $1,466.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1702.80,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,365.00 in Billed Charges for Rev 278 = $1,702.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1702.80,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,365.00 in Billed Charges for Rev 278 = $1,702.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT SYSTEM INTERNALBRACE LIGAMENT ARTHREX,278,RC,10079181,CDM,,,,,,both,,,2365.0000,1560.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1419.00,,,,,,,1149.3900,2365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,365.00 in Billed Charges for Rev 278 = $1,419.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,AETNA,AETNA HSHS,687.51,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,064.25 in Billed Charges for Rev 278 = $687.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,AETNA,ALL COMMERCIAL AETNA,1064.25,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,064.25 in Billed Charges for Rev 278 = $1,064.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,ANTHEM,ANTHEM POS/HMO,553.41,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,064.25 in Billed Charges for Rev 278 = $553.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,ANTHEM,ANTHEM PPO,553.41,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,064.25 in Billed Charges for Rev 278 = $553.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1064.25,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,064.25 in Billed Charges for Rev 278 = $1,064.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,CENPATICO,ALL MEDICAID CENPATICO,1064.25,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,064.25 in Billed Charges for Rev 278 = $1,064.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,904.61,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,064.25 in Billed Charges for Rev 278 = $904.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,CIGNA,ALL COMMERCIAL CIGNA,744.98,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,064.25 in Billed Charges for Rev 278 = $744.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,COFINITY,COFINITY,1064.25,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,064.25 in Billed Charges for Rev 278 = $1,064.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1011.04,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,064.25 in Billed Charges for Rev 278 = $1,011.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,893.97,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,064.25 in Billed Charges for Rev 278 = $893.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,755.62,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,064.25 in Billed Charges for Rev 278 = $755.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,776.90,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,064.25 in Billed Charges for Rev 278 = $776.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,517.23,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,064.25 in Billed Charges for Rev 278 = $517.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,904.61,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,064.25 in Billed Charges for Rev 278 = $904.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,HUMANA,HUMANA CHOICE CARE PPO,904.61,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,064.25 in Billed Charges for Rev 278 = $904.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,776.90,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,064.25 in Billed Charges for Rev 278 = $776.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1064.25,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,064.25 in Billed Charges for Rev 278 = $1,064.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,532.13,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,064.25 in Billed Charges for Rev 278 = $532.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,893.97,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,064.25 in Billed Charges for Rev 278 = $893.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,798.19,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,064.25 in Billed Charges for Rev 278 = $798.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,979.11,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,064.25 in Billed Charges for Rev 278 = $979.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,679.31,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,064.25 in Billed Charges for Rev 278 = $679.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,766.26,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,064.25 in Billed Charges for Rev 278 = $766.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,766.26,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,064.25 in Billed Charges for Rev 278 = $766.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,659.84,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,064.25 in Billed Charges for Rev 278 = $659.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,766.26,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,064.25 in Billed Charges for Rev 278 = $766.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,766.26,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,064.25 in Billed Charges for Rev 278 = $766.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT AC TIGHTROPE ARTHREX,278,RC,10040603,CDM,,,,,,both,,,1064.2500,702.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,638.55,,,,,,,517.2300,1064.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,064.25 in Billed Charges for Rev 278 = $638.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,AETNA,AETNA HSHS,1189.22,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,840.90 in Billed Charges for Rev 278 = $1,189.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,AETNA,ALL COMMERCIAL AETNA,1840.90,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,840.90 in Billed Charges for Rev 278 = $1,840.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,ANTHEM,ANTHEM POS/HMO,957.27,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,840.90 in Billed Charges for Rev 278 = $957.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,ANTHEM,ANTHEM PPO,957.27,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,840.90 in Billed Charges for Rev 278 = $957.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1840.90,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,840.90 in Billed Charges for Rev 278 = $1,840.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,CENPATICO,ALL MEDICAID CENPATICO,1840.90,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,840.90 in Billed Charges for Rev 278 = $1,840.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1564.77,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,840.90 in Billed Charges for Rev 278 = $1,564.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,CIGNA,ALL COMMERCIAL CIGNA,1288.63,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,840.90 in Billed Charges for Rev 278 = $1,288.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,COFINITY,COFINITY,1840.90,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,840.90 in Billed Charges for Rev 278 = $1,840.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1748.86,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,840.90 in Billed Charges for Rev 278 = $1,748.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,1546.36,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,840.90 in Billed Charges for Rev 278 = $1,546.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1307.04,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,840.90 in Billed Charges for Rev 278 = $1,307.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1343.86,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,840.90 in Billed Charges for Rev 278 = $1,343.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,894.68,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,840.90 in Billed Charges for Rev 278 = $894.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1564.77,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,840.90 in Billed Charges for Rev 278 = $1,564.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,HUMANA,HUMANA CHOICE CARE PPO,1564.77,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,840.90 in Billed Charges for Rev 278 = $1,564.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1343.86,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,840.90 in Billed Charges for Rev 278 = $1,343.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1840.90,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,840.90 in Billed Charges for Rev 278 = $1,840.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,920.45,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,840.90 in Billed Charges for Rev 278 = $920.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1546.36,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,840.90 in Billed Charges for Rev 278 = $1,546.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1380.68,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,840.90 in Billed Charges for Rev 278 = $1,380.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1693.63,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,840.90 in Billed Charges for Rev 278 = $1,693.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1175.05,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,840.90 in Billed Charges for Rev 278 = $1,175.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1325.45,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,840.90 in Billed Charges for Rev 278 = $1,325.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1325.45,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,840.90 in Billed Charges for Rev 278 = $1,325.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1141.36,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,840.90 in Billed Charges for Rev 278 = $1,141.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1325.45,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,840.90 in Billed Charges for Rev 278 = $1,325.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1325.45,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,840.90 in Billed Charges for Rev 278 = $1,325.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT INTRACRANIAL PRESSURE-TEMP,278,RC,70448181,CDM,,,,,,both,,,1840.9000,1214.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1104.54,,,,,,,894.6800,1840.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,840.90 in Billed Charges for Rev 278 = $1,104.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,AETNA,AETNA HSHS,9662.87,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $14,958.00 in Billed Charges for Rev 278 = $9,662.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,AETNA,ALL COMMERCIAL AETNA,14958.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,958.00 in Billed Charges for Rev 278 = $14,958.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,ANTHEM,ANTHEM POS/HMO,7778.16,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $14,958.00 in Billed Charges for Rev 278 = $7,778.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,ANTHEM,ANTHEM PPO,7778.16,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $14,958.00 in Billed Charges for Rev 278 = $7,778.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14958.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,958.00 in Billed Charges for Rev 278 = $14,958.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,CENPATICO,ALL MEDICAID CENPATICO,14958.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,958.00 in Billed Charges for Rev 278 = $14,958.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12714.30,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,958.00 in Billed Charges for Rev 278 = $12,714.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,CIGNA,ALL COMMERCIAL CIGNA,10470.60,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $14,958.00 in Billed Charges for Rev 278 = $10,470.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,COFINITY,COFINITY,14958.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,958.00 in Billed Charges for Rev 278 = $14,958.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14210.10,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $14,958.00 in Billed Charges for Rev 278 = $14,210.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,12564.72,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,958.00 in Billed Charges for Rev 278 = $12,564.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10620.18,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $14,958.00 in Billed Charges for Rev 278 = $10,620.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10919.34,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,958.00 in Billed Charges for Rev 278 = $10,919.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,7269.59,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $14,958.00 in Billed Charges for Rev 278 = $7,269.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12714.30,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,958.00 in Billed Charges for Rev 278 = $12,714.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,HUMANA,HUMANA CHOICE CARE HMO,7479.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,958.00 in Billed Charges for Rev 278 = $7,479.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,HUMANA,HUMANA CHOICE CARE PPO,12714.30,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,958.00 in Billed Charges for Rev 278 = $12,714.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,HUMANA,HUMANA NATIIONAL POS HMO,7479.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,958.00 in Billed Charges for Rev 278 = $7,479.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10919.34,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,958.00 in Billed Charges for Rev 278 = $10,919.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,14958.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,958.00 in Billed Charges for Rev 278 = $14,958.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7479.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,958.00 in Billed Charges for Rev 278 = $7,479.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12564.72,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,958.00 in Billed Charges for Rev 278 = $12,564.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11218.50,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $14,958.00 in Billed Charges for Rev 278 = $11,218.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13761.36,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $14,958.00 in Billed Charges for Rev 278 = $13,761.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7479.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,958.00 in Billed Charges for Rev 278 = $7,479.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7479.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,958.00 in Billed Charges for Rev 278 = $7,479.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,PREVEA HEALTH NETWORK,PREVEA360,7479.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,958.00 in Billed Charges for Rev 278 = $7,479.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7479.00,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,958.00 in Billed Charges for Rev 278 = $7,479.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9547.69,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $14,958.00 in Billed Charges for Rev 278 = $9,547.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10769.76,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,958.00 in Billed Charges for Rev 278 = $10,769.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6970.43,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $14,958.00 in Billed Charges for Rev 278 = $6,970.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,6970.43,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $14,958.00 in Billed Charges for Rev 278 = $6,970.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,6970.43,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $14,958.00 in Billed Charges for Rev 278 = $6,970.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10769.76,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,958.00 in Billed Charges for Rev 278 = $10,769.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9273.96,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $14,958.00 in Billed Charges for Rev 278 = $9,273.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10769.76,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,958.00 in Billed Charges for Rev 278 = $10,769.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10769.76,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,958.00 in Billed Charges for Rev 278 = $10,769.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LEAD BIPOLAR VAGUS NERVE (MODEL 304-20),278,RC,10050022,CDM,,,,,,both,,,14958.0000,9872.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8974.80,,,,,,,6970.4300,14958.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $14,958.00 in Billed Charges for Rev 278 = $8,974.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,AETNA,AETNA HSHS,1233.54,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,909.50 in Billed Charges for Rev 278 = $1,233.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,AETNA,ALL COMMERCIAL AETNA,1909.50,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.50 in Billed Charges for Rev 278 = $1,909.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,ANTHEM,ANTHEM POS/HMO,992.94,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,909.50 in Billed Charges for Rev 278 = $992.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,ANTHEM,ANTHEM PPO,992.94,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,909.50 in Billed Charges for Rev 278 = $992.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1909.50,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.50 in Billed Charges for Rev 278 = $1,909.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,CENPATICO,ALL MEDICAID CENPATICO,1909.50,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.50 in Billed Charges for Rev 278 = $1,909.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1623.08,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,909.50 in Billed Charges for Rev 278 = $1,623.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,CIGNA,ALL COMMERCIAL CIGNA,1336.65,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,909.50 in Billed Charges for Rev 278 = $1,336.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,COFINITY,COFINITY,1909.50,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.50 in Billed Charges for Rev 278 = $1,909.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1814.03,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,909.50 in Billed Charges for Rev 278 = $1,814.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,1603.98,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,909.50 in Billed Charges for Rev 278 = $1,603.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1355.75,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,909.50 in Billed Charges for Rev 278 = $1,355.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1393.94,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,909.50 in Billed Charges for Rev 278 = $1,393.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,928.02,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,909.50 in Billed Charges for Rev 278 = $928.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1623.08,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,909.50 in Billed Charges for Rev 278 = $1,623.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,HUMANA,HUMANA CHOICE CARE PPO,1623.08,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,909.50 in Billed Charges for Rev 278 = $1,623.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1393.94,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,909.50 in Billed Charges for Rev 278 = $1,393.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1909.50,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.50 in Billed Charges for Rev 278 = $1,909.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,954.75,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,909.50 in Billed Charges for Rev 278 = $954.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1603.98,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,909.50 in Billed Charges for Rev 278 = $1,603.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1432.13,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,909.50 in Billed Charges for Rev 278 = $1,432.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1756.74,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,909.50 in Billed Charges for Rev 278 = $1,756.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1218.83,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,909.50 in Billed Charges for Rev 278 = $1,218.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1374.84,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,909.50 in Billed Charges for Rev 278 = $1,374.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1374.84,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,909.50 in Billed Charges for Rev 278 = $1,374.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1183.89,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,909.50 in Billed Charges for Rev 278 = $1,183.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1374.84,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,909.50 in Billed Charges for Rev 278 = $1,374.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1374.84,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,909.50 in Billed Charges for Rev 278 = $1,374.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
LINER ZIMMER BIOMET ACETABULAR 36MM E G7 VIT-E NEUT,278,RC,10086975,CDM,,,,,,both,,,1909.5000,1260.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1145.70,,,,,,,928.0200,1909.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,909.50 in Billed Charges for Rev 278 = $1,145.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,AETNA,AETNA HSHS,989.25,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,531.35 in Billed Charges for Rev 278 = $989.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,AETNA,ALL COMMERCIAL AETNA,1531.35,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,531.35 in Billed Charges for Rev 278 = $1,531.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,ANTHEM,ANTHEM POS/HMO,796.30,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,531.35 in Billed Charges for Rev 278 = $796.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,ANTHEM,ANTHEM PPO,796.30,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,531.35 in Billed Charges for Rev 278 = $796.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1531.35,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,531.35 in Billed Charges for Rev 278 = $1,531.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,CENPATICO,ALL MEDICAID CENPATICO,1531.35,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,531.35 in Billed Charges for Rev 278 = $1,531.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1301.65,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,531.35 in Billed Charges for Rev 278 = $1,301.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,CIGNA,ALL COMMERCIAL CIGNA,1071.95,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,531.35 in Billed Charges for Rev 278 = $1,071.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,COFINITY,COFINITY,1531.35,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,531.35 in Billed Charges for Rev 278 = $1,531.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1454.78,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,531.35 in Billed Charges for Rev 278 = $1,454.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,1286.33,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,531.35 in Billed Charges for Rev 278 = $1,286.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1087.26,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,531.35 in Billed Charges for Rev 278 = $1,087.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1117.89,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,531.35 in Billed Charges for Rev 278 = $1,117.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,744.24,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,531.35 in Billed Charges for Rev 278 = $744.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1301.65,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,531.35 in Billed Charges for Rev 278 = $1,301.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,HUMANA,HUMANA CHOICE CARE PPO,1301.65,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,531.35 in Billed Charges for Rev 278 = $1,301.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1117.89,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,531.35 in Billed Charges for Rev 278 = $1,117.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1531.35,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,531.35 in Billed Charges for Rev 278 = $1,531.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,765.68,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,531.35 in Billed Charges for Rev 278 = $765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1286.33,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,531.35 in Billed Charges for Rev 278 = $1,286.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1148.51,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,531.35 in Billed Charges for Rev 278 = $1,148.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1408.84,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,531.35 in Billed Charges for Rev 278 = $1,408.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,977.46,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,531.35 in Billed Charges for Rev 278 = $977.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1102.57,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,531.35 in Billed Charges for Rev 278 = $1,102.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1102.57,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,531.35 in Billed Charges for Rev 278 = $1,102.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,949.44,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,531.35 in Billed Charges for Rev 278 = $949.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1102.57,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,531.35 in Billed Charges for Rev 278 = $1,102.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1102.57,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,531.35 in Billed Charges for Rev 278 = $1,102.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 7X3CM ALLOD SLCT THK.4-1.6MM 21SQ CM MED RECT,278,RC,10090693,CDM,,,,,,both,,,1531.3500,1010.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,918.81,,,,,,,744.2400,1531.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,531.35 in Billed Charges for Rev 278 = $918.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,AETNA,AETNA HSHS,1131.32,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,751.27 in Billed Charges for Rev 278 = $1,131.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,AETNA,ALL COMMERCIAL AETNA,1751.27,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,751.27 in Billed Charges for Rev 278 = $1,751.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,ANTHEM,ANTHEM POS/HMO,910.66,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,751.27 in Billed Charges for Rev 278 = $910.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,ANTHEM,ANTHEM PPO,910.66,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,751.27 in Billed Charges for Rev 278 = $910.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1751.27,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,751.27 in Billed Charges for Rev 278 = $1,751.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,CENPATICO,ALL MEDICAID CENPATICO,1751.27,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,751.27 in Billed Charges for Rev 278 = $1,751.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1488.58,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,751.27 in Billed Charges for Rev 278 = $1,488.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,CIGNA,ALL COMMERCIAL CIGNA,1225.89,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,751.27 in Billed Charges for Rev 278 = $1,225.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,COFINITY,COFINITY,1751.27,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,751.27 in Billed Charges for Rev 278 = $1,751.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1663.71,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,751.27 in Billed Charges for Rev 278 = $1,663.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,1471.07,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,751.27 in Billed Charges for Rev 278 = $1,471.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1243.40,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,751.27 in Billed Charges for Rev 278 = $1,243.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1278.43,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,751.27 in Billed Charges for Rev 278 = $1,278.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,851.12,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,751.27 in Billed Charges for Rev 278 = $851.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1488.58,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,751.27 in Billed Charges for Rev 278 = $1,488.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,HUMANA,HUMANA CHOICE CARE PPO,1488.58,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,751.27 in Billed Charges for Rev 278 = $1,488.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1278.43,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,751.27 in Billed Charges for Rev 278 = $1,278.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1751.27,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,751.27 in Billed Charges for Rev 278 = $1,751.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,875.64,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,751.27 in Billed Charges for Rev 278 = $875.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1471.07,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,751.27 in Billed Charges for Rev 278 = $1,471.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1313.45,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,751.27 in Billed Charges for Rev 278 = $1,313.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1611.17,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,751.27 in Billed Charges for Rev 278 = $1,611.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1117.84,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,751.27 in Billed Charges for Rev 278 = $1,117.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1260.91,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,751.27 in Billed Charges for Rev 278 = $1,260.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1260.91,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,751.27 in Billed Charges for Rev 278 = $1,260.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1085.79,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,751.27 in Billed Charges for Rev 278 = $1,085.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1260.91,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,751.27 in Billed Charges for Rev 278 = $1,260.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1260.91,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,751.27 in Billed Charges for Rev 278 = $1,260.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 4X4CM PRIMATRIX,278,RC,10045784,CDM,,,,,,both,,,1751.2700,1155.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1050.76,,,,,,,851.1200,1751.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,751.27 in Billed Charges for Rev 278 = $1,050.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,AETNA,AETNA HSHS,1783.41,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,760.70 in Billed Charges for Rev 278 = $1,783.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,AETNA,ALL COMMERCIAL AETNA,2760.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,760.70 in Billed Charges for Rev 278 = $2,760.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,ANTHEM,ANTHEM POS/HMO,1435.56,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,760.70 in Billed Charges for Rev 278 = $1,435.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,ANTHEM,ANTHEM PPO,1435.56,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,760.70 in Billed Charges for Rev 278 = $1,435.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2760.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,760.70 in Billed Charges for Rev 278 = $2,760.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,CENPATICO,ALL MEDICAID CENPATICO,2760.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,760.70 in Billed Charges for Rev 278 = $2,760.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2346.60,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,760.70 in Billed Charges for Rev 278 = $2,346.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,CIGNA,ALL COMMERCIAL CIGNA,1932.49,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,760.70 in Billed Charges for Rev 278 = $1,932.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,COFINITY,COFINITY,2760.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,760.70 in Billed Charges for Rev 278 = $2,760.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2622.67,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,760.70 in Billed Charges for Rev 278 = $2,622.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,2318.99,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,760.70 in Billed Charges for Rev 278 = $2,318.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1960.10,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,760.70 in Billed Charges for Rev 278 = $1,960.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2015.31,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,760.70 in Billed Charges for Rev 278 = $2,015.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,1341.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,760.70 in Billed Charges for Rev 278 = $1,341.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2346.60,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,760.70 in Billed Charges for Rev 278 = $2,346.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,HUMANA,HUMANA CHOICE CARE HMO,1380.35,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,760.70 in Billed Charges for Rev 278 = $1,380.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,HUMANA,HUMANA CHOICE CARE PPO,2346.60,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,760.70 in Billed Charges for Rev 278 = $2,346.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,HUMANA,HUMANA NATIIONAL POS HMO,1380.35,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,760.70 in Billed Charges for Rev 278 = $1,380.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2015.31,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,760.70 in Billed Charges for Rev 278 = $2,015.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2760.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,760.70 in Billed Charges for Rev 278 = $2,760.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1380.35,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,760.70 in Billed Charges for Rev 278 = $1,380.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2318.99,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,760.70 in Billed Charges for Rev 278 = $2,318.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2070.53,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,760.70 in Billed Charges for Rev 278 = $2,070.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2539.84,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,760.70 in Billed Charges for Rev 278 = $2,539.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1762.15,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,760.70 in Billed Charges for Rev 278 = $1,762.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1987.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,760.70 in Billed Charges for Rev 278 = $1,987.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1987.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,760.70 in Billed Charges for Rev 278 = $1,987.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1711.63,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,760.70 in Billed Charges for Rev 278 = $1,711.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1987.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,760.70 in Billed Charges for Rev 278 = $1,987.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1987.70,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,760.70 in Billed Charges for Rev 278 = $1,987.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISSUE 6X6CM PRIMATRIX FETAL BOVINE DERMIS,278,RC,10064691,CDM,,,,,,both,,,2760.7000,1822.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1656.42,,,,,,,1341.7000,2760.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,760.70 in Billed Charges for Rev 278 = $1,656.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,AETNA,AETNA HSHS,604.17,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $935.25 in Billed Charges for Rev 278 = $604.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,AETNA,ALL COMMERCIAL AETNA,935.25,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.25 in Billed Charges for Rev 278 = $935.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,935.25,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.25 in Billed Charges for Rev 278 = $935.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,CENPATICO,ALL MEDICAID CENPATICO,935.25,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.25 in Billed Charges for Rev 278 = $935.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,794.96,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $935.25 in Billed Charges for Rev 278 = $794.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,CIGNA,ALL COMMERCIAL CIGNA,654.68,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $935.25 in Billed Charges for Rev 278 = $654.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,COFINITY,COFINITY,935.25,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.25 in Billed Charges for Rev 278 = $935.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,888.49,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $935.25 in Billed Charges for Rev 278 = $888.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,785.61,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $935.25 in Billed Charges for Rev 278 = $785.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,664.03,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $935.25 in Billed Charges for Rev 278 = $664.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,682.73,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $935.25 in Billed Charges for Rev 278 = $682.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,454.53,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $935.25 in Billed Charges for Rev 278 = $454.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,794.96,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $935.25 in Billed Charges for Rev 278 = $794.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,HUMANA,HUMANA CHOICE CARE PPO,794.96,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $935.25 in Billed Charges for Rev 278 = $794.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,682.73,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $935.25 in Billed Charges for Rev 278 = $682.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,935.25,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.25 in Billed Charges for Rev 278 = $935.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,467.63,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $935.25 in Billed Charges for Rev 278 = $467.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,785.61,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $935.25 in Billed Charges for Rev 278 = $785.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,701.44,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $935.25 in Billed Charges for Rev 278 = $701.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,860.43,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $935.25 in Billed Charges for Rev 278 = $860.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,596.97,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $935.25 in Billed Charges for Rev 278 = $596.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,673.38,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $935.25 in Billed Charges for Rev 278 = $673.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,673.38,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $935.25 in Billed Charges for Rev 278 = $673.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,579.86,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $935.25 in Billed Charges for Rev 278 = $579.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,673.38,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $935.25 in Billed Charges for Rev 278 = $673.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,673.38,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $935.25 in Billed Charges for Rev 278 = $673.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH VASC 8X6CM XENOSURE BOVN PERICRD NONSTRL DISP,278,RC,10065682,CDM,,,,,,both,,,935.2500,617.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,561.15,,,,,,,454.5300,935.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $935.25 in Billed Charges for Rev 278 = $561.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,AETNA,AETNA HSHS,477.09,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $738.53 in Billed Charges for Rev 278 = $477.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,AETNA,ALL COMMERCIAL AETNA,738.53,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $738.53 in Billed Charges for Rev 278 = $738.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,738.53,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $738.53 in Billed Charges for Rev 278 = $738.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,CENPATICO,ALL MEDICAID CENPATICO,738.53,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $738.53 in Billed Charges for Rev 278 = $738.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,627.75,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $738.53 in Billed Charges for Rev 278 = $627.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,CIGNA,ALL COMMERCIAL CIGNA,516.97,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $738.53 in Billed Charges for Rev 278 = $516.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,COFINITY,COFINITY,738.53,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $738.53 in Billed Charges for Rev 278 = $738.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,701.60,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $738.53 in Billed Charges for Rev 278 = $701.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,620.37,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $738.53 in Billed Charges for Rev 278 = $620.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,524.36,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $738.53 in Billed Charges for Rev 278 = $524.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,539.13,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $738.53 in Billed Charges for Rev 278 = $539.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,358.93,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $738.53 in Billed Charges for Rev 278 = $358.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,627.75,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $738.53 in Billed Charges for Rev 278 = $627.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,HUMANA,HUMANA CHOICE CARE PPO,627.75,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $738.53 in Billed Charges for Rev 278 = $627.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,539.13,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $738.53 in Billed Charges for Rev 278 = $539.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,738.53,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $738.53 in Billed Charges for Rev 278 = $738.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,369.27,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $738.53 in Billed Charges for Rev 278 = $369.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,620.37,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $738.53 in Billed Charges for Rev 278 = $620.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,553.90,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $738.53 in Billed Charges for Rev 278 = $553.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,679.45,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $738.53 in Billed Charges for Rev 278 = $679.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,471.40,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $738.53 in Billed Charges for Rev 278 = $471.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,531.74,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $738.53 in Billed Charges for Rev 278 = $531.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,531.74,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $738.53 in Billed Charges for Rev 278 = $531.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,457.89,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $738.53 in Billed Charges for Rev 278 = $457.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,531.74,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $738.53 in Billed Charges for Rev 278 = $531.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,531.74,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $738.53 in Billed Charges for Rev 278 = $531.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS OSS 4MM .6MM 1MM RCHRD TITAN BCKT HANDL,278,RC,10031859,CDM,,,,,,both,,,738.5300,487.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,443.12,,,,,,,358.9300,738.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $738.53 in Billed Charges for Rev 278 = $443.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,AETNA,AETNA HSHS,326.39,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $505.25 in Billed Charges for Rev 278 = $326.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,AETNA,ALL COMMERCIAL AETNA,505.25,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $505.25 in Billed Charges for Rev 278 = $505.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,505.25,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $505.25 in Billed Charges for Rev 278 = $505.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,CENPATICO,ALL MEDICAID CENPATICO,505.25,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $505.25 in Billed Charges for Rev 278 = $505.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,429.46,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $505.25 in Billed Charges for Rev 278 = $429.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,CIGNA,ALL COMMERCIAL CIGNA,353.68,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $505.25 in Billed Charges for Rev 278 = $353.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,COFINITY,COFINITY,505.25,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $505.25 in Billed Charges for Rev 278 = $505.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,479.99,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $505.25 in Billed Charges for Rev 278 = $479.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,424.41,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $505.25 in Billed Charges for Rev 278 = $424.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,358.73,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $505.25 in Billed Charges for Rev 278 = $358.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,368.83,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $505.25 in Billed Charges for Rev 278 = $368.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,245.55,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $505.25 in Billed Charges for Rev 278 = $245.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,429.46,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $505.25 in Billed Charges for Rev 278 = $429.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,HUMANA,HUMANA CHOICE CARE PPO,429.46,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $505.25 in Billed Charges for Rev 278 = $429.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,368.83,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $505.25 in Billed Charges for Rev 278 = $368.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,505.25,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $505.25 in Billed Charges for Rev 278 = $505.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,252.63,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $505.25 in Billed Charges for Rev 278 = $252.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,424.41,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $505.25 in Billed Charges for Rev 278 = $424.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,378.94,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $505.25 in Billed Charges for Rev 278 = $378.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,464.83,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $505.25 in Billed Charges for Rev 278 = $464.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,322.50,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $505.25 in Billed Charges for Rev 278 = $322.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,363.78,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $505.25 in Billed Charges for Rev 278 = $363.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,363.78,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $505.25 in Billed Charges for Rev 278 = $363.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,313.26,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $505.25 in Billed Charges for Rev 278 = $313.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,363.78,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $505.25 in Billed Charges for Rev 278 = $363.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,363.78,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $505.25 in Billed Charges for Rev 278 = $363.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROS VOICE 8MM PRVX 2 TE LOW ARFLW RST SFPLC SIL STER,278,RC,10011079,CDM,,,,,,both,,,505.2500,333.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,303.15,,,,,,,245.5500,505.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $505.25 in Billed Charges for Rev 278 = $303.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,AETNA,AETNA HSHS,381.95,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $591.25 in Billed Charges for Rev 278 = $381.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,AETNA,ALL COMMERCIAL AETNA,591.25,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.25 in Billed Charges for Rev 278 = $591.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,591.25,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.25 in Billed Charges for Rev 278 = $591.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,CENPATICO,ALL MEDICAID CENPATICO,591.25,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.25 in Billed Charges for Rev 278 = $591.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,502.56,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $591.25 in Billed Charges for Rev 278 = $502.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,CIGNA,ALL COMMERCIAL CIGNA,413.88,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $591.25 in Billed Charges for Rev 278 = $413.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,COFINITY,COFINITY,591.25,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.25 in Billed Charges for Rev 278 = $591.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,561.69,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $591.25 in Billed Charges for Rev 278 = $561.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,496.65,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $591.25 in Billed Charges for Rev 278 = $496.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,419.79,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $591.25 in Billed Charges for Rev 278 = $419.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,431.61,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $591.25 in Billed Charges for Rev 278 = $431.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,287.35,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $591.25 in Billed Charges for Rev 278 = $287.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,502.56,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $591.25 in Billed Charges for Rev 278 = $502.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,HUMANA,HUMANA CHOICE CARE PPO,502.56,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $591.25 in Billed Charges for Rev 278 = $502.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,431.61,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $591.25 in Billed Charges for Rev 278 = $431.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,591.25,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.25 in Billed Charges for Rev 278 = $591.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,295.63,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $591.25 in Billed Charges for Rev 278 = $295.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,496.65,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $591.25 in Billed Charges for Rev 278 = $496.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,443.44,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $591.25 in Billed Charges for Rev 278 = $443.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,543.95,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $591.25 in Billed Charges for Rev 278 = $543.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,377.39,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $591.25 in Billed Charges for Rev 278 = $377.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,425.70,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $591.25 in Billed Charges for Rev 278 = $425.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,425.70,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $591.25 in Billed Charges for Rev 278 = $425.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,366.58,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $591.25 in Billed Charges for Rev 278 = $366.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,425.70,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $591.25 in Billed Charges for Rev 278 = $425.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,425.70,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $591.25 in Billed Charges for Rev 278 = $425.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.2GM,278,RC,10013343,CDM,,,,,,both,,,591.2500,390.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,354.75,,,,,,,287.3500,591.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $591.25 in Billed Charges for Rev 278 = $354.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,AETNA,AETNA HSHS,493.06,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $763.25 in Billed Charges for Rev 278 = $493.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,AETNA,ALL COMMERCIAL AETNA,763.25,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $763.25 in Billed Charges for Rev 278 = $763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,763.25,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $763.25 in Billed Charges for Rev 278 = $763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,CENPATICO,ALL MEDICAID CENPATICO,763.25,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $763.25 in Billed Charges for Rev 278 = $763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,648.76,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $763.25 in Billed Charges for Rev 278 = $648.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,CIGNA,ALL COMMERCIAL CIGNA,534.28,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $763.25 in Billed Charges for Rev 278 = $534.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,COFINITY,COFINITY,763.25,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $763.25 in Billed Charges for Rev 278 = $763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,725.09,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $763.25 in Billed Charges for Rev 278 = $725.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,641.13,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $763.25 in Billed Charges for Rev 278 = $641.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,541.91,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $763.25 in Billed Charges for Rev 278 = $541.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,557.17,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $763.25 in Billed Charges for Rev 278 = $557.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,370.94,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $763.25 in Billed Charges for Rev 278 = $370.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,648.76,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $763.25 in Billed Charges for Rev 278 = $648.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,HUMANA,HUMANA CHOICE CARE PPO,648.76,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $763.25 in Billed Charges for Rev 278 = $648.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,557.17,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $763.25 in Billed Charges for Rev 278 = $557.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,763.25,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $763.25 in Billed Charges for Rev 278 = $763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,381.63,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $763.25 in Billed Charges for Rev 278 = $381.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,641.13,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $763.25 in Billed Charges for Rev 278 = $641.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,572.44,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $763.25 in Billed Charges for Rev 278 = $572.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,702.19,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $763.25 in Billed Charges for Rev 278 = $702.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,487.18,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $763.25 in Billed Charges for Rev 278 = $487.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,549.54,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $763.25 in Billed Charges for Rev 278 = $549.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,549.54,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $763.25 in Billed Charges for Rev 278 = $549.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,473.22,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $763.25 in Billed Charges for Rev 278 = $473.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,549.54,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $763.25 in Billed Charges for Rev 278 = $549.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,549.54,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $763.25 in Billed Charges for Rev 278 = $549.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTH GOLD EYELID 1.6GM,278,RC,10032841,CDM,,,,,,both,,,763.2500,503.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,457.95,,,,,,,370.9400,763.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $763.25 in Billed Charges for Rev 278 = $457.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,AETNA,AETNA HSHS,484.03,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $749.28 in Billed Charges for Rev 278 = $484.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,AETNA,ALL COMMERCIAL AETNA,749.28,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.28 in Billed Charges for Rev 278 = $749.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,749.28,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.28 in Billed Charges for Rev 278 = $749.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,CENPATICO,ALL MEDICAID CENPATICO,749.28,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.28 in Billed Charges for Rev 278 = $749.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,636.89,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.28 in Billed Charges for Rev 278 = $636.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,CIGNA,ALL COMMERCIAL CIGNA,524.50,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $749.28 in Billed Charges for Rev 278 = $524.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,COFINITY,COFINITY,749.28,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.28 in Billed Charges for Rev 278 = $749.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,711.82,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $749.28 in Billed Charges for Rev 278 = $711.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,629.40,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $749.28 in Billed Charges for Rev 278 = $629.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,531.99,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $749.28 in Billed Charges for Rev 278 = $531.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,546.97,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $749.28 in Billed Charges for Rev 278 = $546.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,364.15,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $749.28 in Billed Charges for Rev 278 = $364.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,636.89,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.28 in Billed Charges for Rev 278 = $636.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,HUMANA,HUMANA CHOICE CARE PPO,636.89,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.28 in Billed Charges for Rev 278 = $636.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,546.97,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $749.28 in Billed Charges for Rev 278 = $546.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,749.28,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.28 in Billed Charges for Rev 278 = $749.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,374.64,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $749.28 in Billed Charges for Rev 278 = $374.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,629.40,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $749.28 in Billed Charges for Rev 278 = $629.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,561.96,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $749.28 in Billed Charges for Rev 278 = $561.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,689.34,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $749.28 in Billed Charges for Rev 278 = $689.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.27,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $749.28 in Billed Charges for Rev 278 = $478.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,539.48,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.28 in Billed Charges for Rev 278 = $539.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,539.48,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.28 in Billed Charges for Rev 278 = $539.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,464.55,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $749.28 in Billed Charges for Rev 278 = $464.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,539.48,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.28 in Billed Charges for Rev 278 = $539.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,539.48,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.28 in Billed Charges for Rev 278 = $539.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS CLASSIC STAPES,278,RC,10012969,CDM,,,,,,both,,,749.2800,494.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,449.57,,,,,,,364.1500,749.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.28 in Billed Charges for Rev 278 = $449.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,AETNA,AETNA HSHS,427.78,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $662.20 in Billed Charges for Rev 278 = $427.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,AETNA,ALL COMMERCIAL AETNA,662.20,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.20 in Billed Charges for Rev 278 = $662.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,662.20,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.20 in Billed Charges for Rev 278 = $662.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,CENPATICO,ALL MEDICAID CENPATICO,662.20,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.20 in Billed Charges for Rev 278 = $662.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,562.87,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.20 in Billed Charges for Rev 278 = $562.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,CIGNA,ALL COMMERCIAL CIGNA,463.54,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $662.20 in Billed Charges for Rev 278 = $463.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,COFINITY,COFINITY,662.20,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.20 in Billed Charges for Rev 278 = $662.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,629.09,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $662.20 in Billed Charges for Rev 278 = $629.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,556.25,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $662.20 in Billed Charges for Rev 278 = $556.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,470.16,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $662.20 in Billed Charges for Rev 278 = $470.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,483.41,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $662.20 in Billed Charges for Rev 278 = $483.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,321.83,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $662.20 in Billed Charges for Rev 278 = $321.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,562.87,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.20 in Billed Charges for Rev 278 = $562.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,HUMANA,HUMANA CHOICE CARE PPO,562.87,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.20 in Billed Charges for Rev 278 = $562.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,483.41,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $662.20 in Billed Charges for Rev 278 = $483.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,662.20,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.20 in Billed Charges for Rev 278 = $662.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,331.10,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $662.20 in Billed Charges for Rev 278 = $331.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,556.25,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $662.20 in Billed Charges for Rev 278 = $556.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,496.65,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $662.20 in Billed Charges for Rev 278 = $496.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,609.22,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $662.20 in Billed Charges for Rev 278 = $609.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,422.68,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $662.20 in Billed Charges for Rev 278 = $422.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,476.78,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.20 in Billed Charges for Rev 278 = $476.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,476.78,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.20 in Billed Charges for Rev 278 = $476.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,410.56,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $662.20 in Billed Charges for Rev 278 = $410.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,476.78,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.20 in Billed Charges for Rev 278 = $476.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,476.78,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.20 in Billed Charges for Rev 278 = $476.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS GYRUS LIPPY MOD STAPES 4.15MM X 5.0MM TITANIUM,278,RC,10019785,CDM,,,,,,both,,,662.2000,437.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,397.32,,,,,,,321.8300,662.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $662.20 in Billed Charges for Rev 278 = $397.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,AETNA,AETNA HSHS,203.49,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $315.00 in Billed Charges for Rev 278 = $203.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,AETNA,ALL COMMERCIAL AETNA,315.00,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 278 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,315.00,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 278 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,CENPATICO,ALL MEDICAID CENPATICO,315.00,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 278 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,267.75,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 278 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,CIGNA,ALL COMMERCIAL CIGNA,220.50,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $315.00 in Billed Charges for Rev 278 = $220.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,COFINITY,COFINITY,315.00,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 278 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,299.25,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $315.00 in Billed Charges for Rev 278 = $299.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,264.60,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $315.00 in Billed Charges for Rev 278 = $264.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,223.65,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $315.00 in Billed Charges for Rev 278 = $223.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,229.95,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $315.00 in Billed Charges for Rev 278 = $229.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,153.09,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $315.00 in Billed Charges for Rev 278 = $153.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,267.75,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 278 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,HUMANA,HUMANA CHOICE CARE PPO,267.75,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 278 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,229.95,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $315.00 in Billed Charges for Rev 278 = $229.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,315.00,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 278 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,157.50,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $315.00 in Billed Charges for Rev 278 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,264.60,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $315.00 in Billed Charges for Rev 278 = $264.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,236.25,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $315.00 in Billed Charges for Rev 278 = $236.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,289.80,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $315.00 in Billed Charges for Rev 278 = $289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,201.06,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $315.00 in Billed Charges for Rev 278 = $201.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,226.80,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 278 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,226.80,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 278 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,195.30,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $315.00 in Billed Charges for Rev 278 = $195.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,226.80,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 278 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,226.80,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 278 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS HAPEX PORP EAR,278,RC,10025500,CDM,,,,,,both,,,315.0000,207.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,189.00,,,,,,,153.0900,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $315.00 in Billed Charges for Rev 278 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,AETNA,AETNA HSHS,210.76,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $326.25 in Billed Charges for Rev 278 = $210.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,AETNA,ALL COMMERCIAL AETNA,326.25,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $326.25 in Billed Charges for Rev 278 = $326.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,326.25,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $326.25 in Billed Charges for Rev 278 = $326.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,CENPATICO,ALL MEDICAID CENPATICO,326.25,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $326.25 in Billed Charges for Rev 278 = $326.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,277.31,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $326.25 in Billed Charges for Rev 278 = $277.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,CIGNA,ALL COMMERCIAL CIGNA,228.38,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $326.25 in Billed Charges for Rev 278 = $228.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,COFINITY,COFINITY,326.25,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $326.25 in Billed Charges for Rev 278 = $326.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,309.94,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $326.25 in Billed Charges for Rev 278 = $309.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,274.05,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $326.25 in Billed Charges for Rev 278 = $274.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,231.64,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $326.25 in Billed Charges for Rev 278 = $231.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,238.16,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $326.25 in Billed Charges for Rev 278 = $238.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,158.56,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $326.25 in Billed Charges for Rev 278 = $158.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,277.31,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $326.25 in Billed Charges for Rev 278 = $277.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,HUMANA,HUMANA CHOICE CARE PPO,277.31,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $326.25 in Billed Charges for Rev 278 = $277.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,238.16,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $326.25 in Billed Charges for Rev 278 = $238.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,326.25,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $326.25 in Billed Charges for Rev 278 = $326.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,163.13,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $326.25 in Billed Charges for Rev 278 = $163.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,274.05,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $326.25 in Billed Charges for Rev 278 = $274.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,244.69,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $326.25 in Billed Charges for Rev 278 = $244.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,300.15,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $326.25 in Billed Charges for Rev 278 = $300.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,208.25,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $326.25 in Billed Charges for Rev 278 = $208.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,234.90,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $326.25 in Billed Charges for Rev 278 = $234.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,234.90,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $326.25 in Billed Charges for Rev 278 = $234.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,202.28,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $326.25 in Billed Charges for Rev 278 = $202.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,234.90,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $326.25 in Billed Charges for Rev 278 = $234.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,234.90,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $326.25 in Billed Charges for Rev 278 = $234.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON -PLATINUM EAR .6MM X 3.5MM,278,RC,10025497,CDM,,,,,,both,,,326.2500,215.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,195.75,,,,,,,158.5600,326.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $326.25 in Billed Charges for Rev 278 = $195.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,AETNA,AETNA HSHS,268.68,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $415.91 in Billed Charges for Rev 278 = $268.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,AETNA,ALL COMMERCIAL AETNA,415.91,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.91 in Billed Charges for Rev 278 = $415.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,415.91,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.91 in Billed Charges for Rev 278 = $415.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,CENPATICO,ALL MEDICAID CENPATICO,415.91,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.91 in Billed Charges for Rev 278 = $415.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,353.52,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $415.91 in Billed Charges for Rev 278 = $353.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,CIGNA,ALL COMMERCIAL CIGNA,291.14,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $415.91 in Billed Charges for Rev 278 = $291.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,COFINITY,COFINITY,415.91,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.91 in Billed Charges for Rev 278 = $415.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,395.11,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $415.91 in Billed Charges for Rev 278 = $395.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,349.36,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $415.91 in Billed Charges for Rev 278 = $349.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,295.30,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $415.91 in Billed Charges for Rev 278 = $295.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,303.61,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $415.91 in Billed Charges for Rev 278 = $303.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,202.13,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $415.91 in Billed Charges for Rev 278 = $202.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,353.52,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $415.91 in Billed Charges for Rev 278 = $353.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,HUMANA,HUMANA CHOICE CARE PPO,353.52,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $415.91 in Billed Charges for Rev 278 = $353.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,303.61,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $415.91 in Billed Charges for Rev 278 = $303.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,415.91,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.91 in Billed Charges for Rev 278 = $415.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,207.96,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $415.91 in Billed Charges for Rev 278 = $207.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,349.36,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $415.91 in Billed Charges for Rev 278 = $349.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,311.93,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $415.91 in Billed Charges for Rev 278 = $311.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,382.64,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $415.91 in Billed Charges for Rev 278 = $382.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,265.48,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $415.91 in Billed Charges for Rev 278 = $265.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,299.46,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $415.91 in Billed Charges for Rev 278 = $299.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,299.46,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $415.91 in Billed Charges for Rev 278 = $299.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,257.86,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $415.91 in Billed Charges for Rev 278 = $257.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,299.46,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $415.91 in Billed Charges for Rev 278 = $299.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,299.46,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $415.91 in Billed Charges for Rev 278 = $299.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM,278,RC,10025502,CDM,,,,,,both,,,415.9100,274.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,249.55,,,,,,,202.1300,415.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $415.91 in Billed Charges for Rev 278 = $249.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,AETNA,AETNA HSHS,216.57,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $335.25 in Billed Charges for Rev 278 = $216.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,AETNA,ALL COMMERCIAL AETNA,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,CENPATICO,ALL MEDICAID CENPATICO,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,284.96,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.25 in Billed Charges for Rev 278 = $284.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,CIGNA,ALL COMMERCIAL CIGNA,234.68,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $335.25 in Billed Charges for Rev 278 = $234.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,COFINITY,COFINITY,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,318.49,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $335.25 in Billed Charges for Rev 278 = $318.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,281.61,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $335.25 in Billed Charges for Rev 278 = $281.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,238.03,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $335.25 in Billed Charges for Rev 278 = $238.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,244.73,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $335.25 in Billed Charges for Rev 278 = $244.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,162.93,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $335.25 in Billed Charges for Rev 278 = $162.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,284.96,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.25 in Billed Charges for Rev 278 = $284.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,HUMANA,HUMANA CHOICE CARE PPO,284.96,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.25 in Billed Charges for Rev 278 = $284.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,244.73,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $335.25 in Billed Charges for Rev 278 = $244.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,167.63,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $335.25 in Billed Charges for Rev 278 = $167.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,281.61,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $335.25 in Billed Charges for Rev 278 = $281.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,251.44,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $335.25 in Billed Charges for Rev 278 = $251.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,308.43,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $335.25 in Billed Charges for Rev 278 = $308.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,213.99,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $335.25 in Billed Charges for Rev 278 = $213.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,241.38,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.25 in Billed Charges for Rev 278 = $241.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,241.38,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.25 in Billed Charges for Rev 278 = $241.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,207.86,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $335.25 in Billed Charges for Rev 278 = $207.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,241.38,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.25 in Billed Charges for Rev 278 = $241.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,241.38,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.25 in Billed Charges for Rev 278 = $241.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS RICHARDS PISTON-PLATINUM EAR,278,RC,10025501,CDM,,,,,,both,,,335.2500,221.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,201.15,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $335.25 in Billed Charges for Rev 278 = $201.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,AETNA,AETNA HSHS,595.84,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $922.35 in Billed Charges for Rev 278 = $595.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,AETNA,ALL COMMERCIAL AETNA,922.35,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $922.35 in Billed Charges for Rev 278 = $922.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,922.35,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $922.35 in Billed Charges for Rev 278 = $922.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,CENPATICO,ALL MEDICAID CENPATICO,922.35,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $922.35 in Billed Charges for Rev 278 = $922.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,784.00,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $922.35 in Billed Charges for Rev 278 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,CIGNA,ALL COMMERCIAL CIGNA,645.65,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $922.35 in Billed Charges for Rev 278 = $645.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,COFINITY,COFINITY,922.35,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $922.35 in Billed Charges for Rev 278 = $922.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,876.23,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $922.35 in Billed Charges for Rev 278 = $876.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,774.77,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $922.35 in Billed Charges for Rev 278 = $774.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,654.87,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $922.35 in Billed Charges for Rev 278 = $654.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,673.32,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $922.35 in Billed Charges for Rev 278 = $673.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,448.26,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $922.35 in Billed Charges for Rev 278 = $448.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,784.00,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $922.35 in Billed Charges for Rev 278 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,HUMANA,HUMANA CHOICE CARE PPO,784.00,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $922.35 in Billed Charges for Rev 278 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,673.32,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $922.35 in Billed Charges for Rev 278 = $673.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,922.35,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $922.35 in Billed Charges for Rev 278 = $922.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,461.18,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $922.35 in Billed Charges for Rev 278 = $461.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,774.77,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $922.35 in Billed Charges for Rev 278 = $774.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,691.76,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $922.35 in Billed Charges for Rev 278 = $691.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,848.56,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $922.35 in Billed Charges for Rev 278 = $848.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,588.74,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $922.35 in Billed Charges for Rev 278 = $588.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,664.09,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $922.35 in Billed Charges for Rev 278 = $664.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,664.09,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $922.35 in Billed Charges for Rev 278 = $664.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,571.86,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $922.35 in Billed Charges for Rev 278 = $571.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,664.09,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $922.35 in Billed Charges for Rev 278 = $664.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,664.09,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $922.35 in Billed Charges for Rev 278 = $664.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUSH LOCK ARTHREX 4.5 X 18.5MM,278,RC,10043717,CDM,,,,,,both,,,922.3500,608.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,553.41,,,,,,,448.2600,922.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $922.35 in Billed Charges for Rev 278 = $553.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,AETNA,AETNA HSHS,1224.98,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,896.25 in Billed Charges for Rev 278 = $1,224.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,AETNA,ALL COMMERCIAL AETNA,1896.25,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,896.25 in Billed Charges for Rev 278 = $1,896.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,ANTHEM,ANTHEM POS/HMO,986.05,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,896.25 in Billed Charges for Rev 278 = $986.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,ANTHEM,ANTHEM PPO,986.05,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,896.25 in Billed Charges for Rev 278 = $986.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1896.25,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,896.25 in Billed Charges for Rev 278 = $1,896.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,CENPATICO,ALL MEDICAID CENPATICO,1896.25,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,896.25 in Billed Charges for Rev 278 = $1,896.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1611.81,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,896.25 in Billed Charges for Rev 278 = $1,611.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,CIGNA,ALL COMMERCIAL CIGNA,1327.38,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,896.25 in Billed Charges for Rev 278 = $1,327.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,COFINITY,COFINITY,1896.25,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,896.25 in Billed Charges for Rev 278 = $1,896.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1801.44,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,896.25 in Billed Charges for Rev 278 = $1,801.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,HEALTH CARE ALLIANCE,THE ALLIANCE,1592.85,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,896.25 in Billed Charges for Rev 278 = $1,592.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1346.34,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,896.25 in Billed Charges for Rev 278 = $1,346.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1384.26,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,896.25 in Billed Charges for Rev 278 = $1,384.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,HSHS EMPLOYEES,HSHS EMPLOYEES,921.58,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,896.25 in Billed Charges for Rev 278 = $921.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1611.81,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,896.25 in Billed Charges for Rev 278 = $1,611.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,HUMANA,HUMANA CHOICE CARE PPO,1611.81,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,896.25 in Billed Charges for Rev 278 = $1,611.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1384.26,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,896.25 in Billed Charges for Rev 278 = $1,384.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1896.25,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,896.25 in Billed Charges for Rev 278 = $1,896.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,948.13,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,896.25 in Billed Charges for Rev 278 = $948.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1592.85,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,896.25 in Billed Charges for Rev 278 = $1,592.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1422.19,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,896.25 in Billed Charges for Rev 278 = $1,422.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1744.55,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,896.25 in Billed Charges for Rev 278 = $1,744.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1210.38,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,896.25 in Billed Charges for Rev 278 = $1,210.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1365.30,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,896.25 in Billed Charges for Rev 278 = $1,365.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1365.30,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,896.25 in Billed Charges for Rev 278 = $1,365.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1175.68,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,896.25 in Billed Charges for Rev 278 = $1,175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1365.30,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,896.25 in Billed Charges for Rev 278 = $1,365.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1365.30,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,896.25 in Billed Charges for Rev 278 = $1,365.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUTTY XEMPLIFI DBM PLUSS 10ML,278,RC,10077272,CDM,,,,,,both,,,1896.2500,1251.5300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1137.75,,,,,,,921.5800,1896.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,896.25 in Billed Charges for Rev 278 = $1,137.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,AETNA,AETNA HSHS,63.52,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $98.33 in Billed Charges for Rev 278 = $63.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,AETNA,ALL COMMERCIAL AETNA,98.33,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.33 in Billed Charges for Rev 278 = $98.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,98.33,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.33 in Billed Charges for Rev 278 = $98.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,CENPATICO,ALL MEDICAID CENPATICO,98.33,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.33 in Billed Charges for Rev 278 = $98.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,83.58,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.33 in Billed Charges for Rev 278 = $83.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,CIGNA,ALL COMMERCIAL CIGNA,68.83,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $98.33 in Billed Charges for Rev 278 = $68.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,COFINITY,COFINITY,98.33,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.33 in Billed Charges for Rev 278 = $98.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,93.41,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $98.33 in Billed Charges for Rev 278 = $93.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,82.60,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $98.33 in Billed Charges for Rev 278 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,69.81,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $98.33 in Billed Charges for Rev 278 = $69.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,71.78,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $98.33 in Billed Charges for Rev 278 = $71.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,47.79,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $98.33 in Billed Charges for Rev 278 = $47.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,83.58,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.33 in Billed Charges for Rev 278 = $83.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,HUMANA,HUMANA CHOICE CARE PPO,83.58,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.33 in Billed Charges for Rev 278 = $83.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,71.78,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $98.33 in Billed Charges for Rev 278 = $71.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,98.33,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.33 in Billed Charges for Rev 278 = $98.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,49.17,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $98.33 in Billed Charges for Rev 278 = $49.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,82.60,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $98.33 in Billed Charges for Rev 278 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,73.75,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $98.33 in Billed Charges for Rev 278 = $73.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,90.46,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $98.33 in Billed Charges for Rev 278 = $90.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,62.76,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $98.33 in Billed Charges for Rev 278 = $62.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,70.80,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.33 in Billed Charges for Rev 278 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,70.80,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.33 in Billed Charges for Rev 278 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,60.96,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $98.33 in Billed Charges for Rev 278 = $60.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,70.80,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.33 in Billed Charges for Rev 278 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,70.80,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.33 in Billed Charges for Rev 278 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESTRICTOR CEMENT SMALL ACETABULAR,278,RC,10027135,CDM,,,,,,both,,,98.3300,64.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,59.00,,,,,,,47.7900,98.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $98.33 in Billed Charges for Rev 278 = $59.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,AETNA,AETNA HSHS,3308.17,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,121.00 in Billed Charges for Rev 278 = $3,308.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,AETNA,ALL COMMERCIAL AETNA,5121.00,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,121.00 in Billed Charges for Rev 278 = $5,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,ANTHEM,ANTHEM POS/HMO,2662.92,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,121.00 in Billed Charges for Rev 278 = $2,662.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,ANTHEM,ANTHEM PPO,2662.92,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,121.00 in Billed Charges for Rev 278 = $2,662.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5121.00,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,121.00 in Billed Charges for Rev 278 = $5,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,CENPATICO,ALL MEDICAID CENPATICO,5121.00,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,121.00 in Billed Charges for Rev 278 = $5,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4352.85,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,121.00 in Billed Charges for Rev 278 = $4,352.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,CIGNA,ALL COMMERCIAL CIGNA,3584.70,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,121.00 in Billed Charges for Rev 278 = $3,584.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,COFINITY,COFINITY,5121.00,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,121.00 in Billed Charges for Rev 278 = $5,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4864.95,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,121.00 in Billed Charges for Rev 278 = $4,864.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,4301.64,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,121.00 in Billed Charges for Rev 278 = $4,301.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3635.91,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,121.00 in Billed Charges for Rev 278 = $3,635.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3738.33,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,121.00 in Billed Charges for Rev 278 = $3,738.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,2488.81,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,121.00 in Billed Charges for Rev 278 = $2,488.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4352.85,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,121.00 in Billed Charges for Rev 278 = $4,352.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,HUMANA,HUMANA CHOICE CARE HMO,2560.50,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,121.00 in Billed Charges for Rev 278 = $2,560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,HUMANA,HUMANA CHOICE CARE PPO,4352.85,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,121.00 in Billed Charges for Rev 278 = $4,352.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,HUMANA,HUMANA NATIIONAL POS HMO,2560.50,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,121.00 in Billed Charges for Rev 278 = $2,560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3738.33,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,121.00 in Billed Charges for Rev 278 = $3,738.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,5121.00,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,121.00 in Billed Charges for Rev 278 = $5,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2560.50,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,121.00 in Billed Charges for Rev 278 = $2,560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4301.64,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,121.00 in Billed Charges for Rev 278 = $4,301.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3840.75,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,121.00 in Billed Charges for Rev 278 = $3,840.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4711.32,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,121.00 in Billed Charges for Rev 278 = $4,711.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2560.50,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,121.00 in Billed Charges for Rev 278 = $2,560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2560.50,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,121.00 in Billed Charges for Rev 278 = $2,560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,PREVEA HEALTH NETWORK,PREVEA360,2560.50,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,121.00 in Billed Charges for Rev 278 = $2,560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2560.50,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,121.00 in Billed Charges for Rev 278 = $2,560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3268.73,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,121.00 in Billed Charges for Rev 278 = $3,268.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3687.12,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,121.00 in Billed Charges for Rev 278 = $3,687.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3687.12,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,121.00 in Billed Charges for Rev 278 = $3,687.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3175.02,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,121.00 in Billed Charges for Rev 278 = $3,175.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3687.12,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,121.00 in Billed Charges for Rev 278 = $3,687.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3687.12,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,121.00 in Billed Charges for Rev 278 = $3,687.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING ANLPLS 34MM TRCSD,278,RC,10031854,CDM,,,,,,both,,,5121.0000,3379.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3072.60,,,,,,,2488.8100,5121.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,121.00 in Billed Charges for Rev 278 = $3,072.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,AETNA,AETNA HSHS,1059.53,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,059.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,AETNA,ALL COMMERCIAL AETNA,1640.14,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,640.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,ANTHEM,ANTHEM POS/HMO,852.87,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $852.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,ANTHEM,ANTHEM PPO,852.87,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $852.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1640.14,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,640.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,CENPATICO,ALL MEDICAID CENPATICO,1640.14,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,640.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1394.12,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,394.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,CIGNA,ALL COMMERCIAL CIGNA,1148.10,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,148.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,COFINITY,COFINITY,1640.14,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,640.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1558.13,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,558.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,HEALTH CARE ALLIANCE,THE ALLIANCE,1377.72,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,377.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1164.50,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,164.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1197.30,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,197.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,HSHS EMPLOYEES,HSHS EMPLOYEES,797.11,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $797.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1394.12,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,394.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,HUMANA,HUMANA CHOICE CARE PPO,1394.12,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,394.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1197.30,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,197.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1640.14,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,640.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,820.07,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $820.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1377.72,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,377.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1230.11,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,230.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1508.93,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,508.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1046.90,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,046.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1180.90,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,180.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1180.90,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,180.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1016.89,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,016.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1180.90,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,180.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1180.90,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $1,180.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LCP L-FUSION SHORT RIGHT,C1713,HCPCS,278,RC,10084069,CDM,,,,both,,,1640.1400,1082.4900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,984.08,,,,,,,797.1100,1640.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,640.14 in Billed Charges for Rev 278 Proc C1713 = $984.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,AETNA,AETNA HSHS,1111.96,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,111.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,AETNA,ALL COMMERCIAL AETNA,1721.30,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,721.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,ANTHEM,ANTHEM POS/HMO,895.08,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $895.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,ANTHEM,ANTHEM PPO,895.08,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $895.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1721.30,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,721.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,CENPATICO,ALL MEDICAID CENPATICO,1721.30,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,721.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1463.11,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,463.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,CIGNA,ALL COMMERCIAL CIGNA,1204.91,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,204.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,COFINITY,COFINITY,1721.30,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,721.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1635.24,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,635.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,1445.89,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,445.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1222.12,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,222.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1256.55,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,256.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,836.55,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $836.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1463.11,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,463.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,HUMANA,HUMANA CHOICE CARE PPO,1463.11,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,463.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1256.55,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,256.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1721.30,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,721.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,860.65,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $860.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1445.89,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,445.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1290.98,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,290.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1583.60,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,583.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1098.71,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,098.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1239.34,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,239.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1239.34,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,239.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1067.21,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,067.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1239.34,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,239.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1239.34,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,239.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084047,CDM,,,,both,,,1721.3000,1136.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1032.78,,,,,,,836.5500,1721.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,721.30 in Billed Charges for Rev 278 Proc C1713 = $1,032.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,AETNA,AETNA HSHS,1142.66,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,142.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,AETNA,ALL COMMERCIAL AETNA,1768.82,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,768.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,ANTHEM,ANTHEM POS/HMO,919.79,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $919.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,ANTHEM,ANTHEM PPO,919.79,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $919.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1768.82,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,768.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,CENPATICO,ALL MEDICAID CENPATICO,1768.82,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,768.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1503.50,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,503.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,CIGNA,ALL COMMERCIAL CIGNA,1238.17,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,238.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,COFINITY,COFINITY,1768.82,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,768.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1680.38,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,680.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,1485.81,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,485.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1255.86,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,255.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1291.24,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,291.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,859.65,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $859.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1503.50,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,503.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,HUMANA,HUMANA CHOICE CARE PPO,1503.50,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,503.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1291.24,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,291.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1768.82,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,768.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,884.41,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $884.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1485.81,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,485.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1326.62,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,326.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1627.31,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,627.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1129.04,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,129.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1273.55,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,273.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1273.55,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,273.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1096.67,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,096.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1273.55,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,273.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1273.55,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,273.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084050,CDM,,,,both,,,1768.8200,1167.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1061.29,,,,,,,859.6500,1768.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,768.82 in Billed Charges for Rev 278 Proc C1713 = $1,061.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,AETNA,AETNA HSHS,382.30,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $382.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,AETNA,ALL COMMERCIAL AETNA,591.79,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $591.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,591.79,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $591.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,CENPATICO,ALL MEDICAID CENPATICO,591.79,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $591.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,503.02,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $503.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,CIGNA,ALL COMMERCIAL CIGNA,414.25,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $414.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,COFINITY,COFINITY,591.79,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $591.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,562.20,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $562.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,497.10,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $497.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,420.17,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $420.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,432.01,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $432.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,287.61,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $287.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,503.02,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $503.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,HUMANA,HUMANA CHOICE CARE PPO,503.02,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $503.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,432.01,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $432.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,591.79,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $591.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,295.90,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $295.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,497.10,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $497.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,443.84,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $443.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,544.45,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $544.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,377.74,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $377.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,426.09,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $426.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,426.09,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $426.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,366.91,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $366.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,426.09,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $426.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,426.09,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $426.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001245,CDM,,,,both,,,591.7900,390.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,355.07,,,,,,,287.6100,591.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $591.79 in Billed Charges for Rev 278 Proc C1713 = $355.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,AETNA,AETNA HSHS,409.64,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $409.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,AETNA,ALL COMMERCIAL AETNA,634.12,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $634.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,634.12,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $634.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,CENPATICO,ALL MEDICAID CENPATICO,634.12,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $634.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,539.00,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $539.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,CIGNA,ALL COMMERCIAL CIGNA,443.88,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $443.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,COFINITY,COFINITY,634.12,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $634.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,602.41,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $602.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,532.66,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $532.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,450.23,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $450.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,462.91,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $462.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,308.18,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $308.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,539.00,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $539.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,HUMANA,HUMANA CHOICE CARE PPO,539.00,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $539.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,462.91,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $462.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,634.12,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $634.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,317.06,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $317.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,532.66,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $532.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,475.59,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $475.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,583.39,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $583.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,404.76,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $404.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,456.57,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $456.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,456.57,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $456.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,393.15,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $393.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,456.57,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $456.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,456.57,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $456.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 4 HOLES/31MM,C1713,HCPCS,278,RC,10026122,CDM,,,,both,,,634.1200,418.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,380.47,,,,,,,308.1800,634.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $634.12 in Billed Charges for Rev 278 Proc C1713 = $380.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,AETNA,AETNA HSHS,346.82,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $346.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,AETNA,ALL COMMERCIAL AETNA,536.88,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $536.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,536.88,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $536.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,CENPATICO,ALL MEDICAID CENPATICO,536.88,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $536.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,456.35,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $456.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,CIGNA,ALL COMMERCIAL CIGNA,375.82,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $375.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,COFINITY,COFINITY,536.88,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $536.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,510.04,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $510.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,450.98,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $450.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,381.18,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $381.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,391.92,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $391.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,260.92,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $260.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,456.35,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $456.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,HUMANA,HUMANA CHOICE CARE PPO,456.35,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $456.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,391.92,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $391.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,536.88,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $536.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,268.44,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $268.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,450.98,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $450.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,402.66,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $402.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,493.93,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $493.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,342.69,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $342.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,386.55,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $386.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,386.55,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $386.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,332.87,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $332.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,386.55,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $386.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,386.55,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $386.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 12 HOLES/72MM,C1713,HCPCS,278,RC,10001251,CDM,,,,both,,,536.8800,354.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,322.13,,,,,,,260.9200,536.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $536.88 in Billed Charges for Rev 278 Proc C1713 = $322.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,AETNA,AETNA HSHS,293.78,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $293.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,AETNA,ALL COMMERCIAL AETNA,454.77,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $454.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,454.77,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $454.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,CENPATICO,ALL MEDICAID CENPATICO,454.77,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $454.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,386.55,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $386.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,CIGNA,ALL COMMERCIAL CIGNA,318.34,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $318.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,COFINITY,COFINITY,454.77,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $454.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,432.03,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $432.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,382.01,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $382.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,322.89,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $322.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,331.98,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $331.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,221.02,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $221.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,386.55,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $386.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,HUMANA,HUMANA CHOICE CARE PPO,386.55,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $386.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,331.98,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $331.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,454.77,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $454.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,227.39,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $227.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,382.01,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $382.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,341.08,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $341.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,418.39,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $418.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,290.28,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $290.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,327.43,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $327.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,327.43,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $327.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,281.96,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $281.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,327.43,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $327.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,327.43,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $327.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI STRAIGHT 6 HOLES/36MM,C1713,HCPCS,278,RC,10001255,CDM,,,,both,,,454.7700,300.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,272.86,,,,,,,221.0200,454.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $454.77 in Billed Charges for Rev 278 Proc C1713 = $272.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,AETNA,AETNA HSHS,395.40,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $395.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,AETNA,ALL COMMERCIAL AETNA,612.08,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $612.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,612.08,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $612.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,CENPATICO,ALL MEDICAID CENPATICO,612.08,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $612.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,520.27,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $520.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,CIGNA,ALL COMMERCIAL CIGNA,428.46,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $428.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,COFINITY,COFINITY,612.08,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $612.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,581.48,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $581.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,514.15,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $514.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,434.58,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $434.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,446.82,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $446.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,297.47,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $297.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,520.27,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $520.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,HUMANA,HUMANA CHOICE CARE PPO,520.27,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $520.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,446.82,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $446.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,612.08,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $612.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,306.04,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $306.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,514.15,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $514.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,459.06,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $459.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,563.11,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $563.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,390.69,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $390.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,440.70,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $440.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,440.70,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $440.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,379.49,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $379.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,440.70,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $440.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,440.70,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $440.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  8H 64MM,C1713,HCPCS,278,RC,10032963,CDM,,,,both,,,612.0800,403.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,367.25,,,,,,,297.4700,612.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $612.08 in Billed Charges for Rev 278 Proc C1713 = $367.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,AETNA,AETNA HSHS,2106.71,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,106.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,AETNA,ALL COMMERCIAL AETNA,3261.16,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $3,261.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,ANTHEM,ANTHEM POS/HMO,1695.80,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $1,695.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,ANTHEM,ANTHEM PPO,1695.80,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $1,695.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3261.16,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $3,261.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,CENPATICO,ALL MEDICAID CENPATICO,3261.16,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $3,261.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2771.99,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,771.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,CIGNA,ALL COMMERCIAL CIGNA,2282.81,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,282.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,COFINITY,COFINITY,3261.16,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $3,261.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3098.10,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $3,098.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,2739.37,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,739.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2315.42,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,315.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2380.65,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,380.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,1584.92,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $1,584.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2771.99,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,771.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,HUMANA,HUMANA CHOICE CARE HMO,1630.58,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $1,630.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,HUMANA,HUMANA CHOICE CARE PPO,2771.99,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,771.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,HUMANA,HUMANA NATIIONAL POS HMO,1630.58,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $1,630.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2380.65,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,380.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,3261.16,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $3,261.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1630.58,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $1,630.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2739.37,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,739.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2445.87,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,445.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3000.27,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $3,000.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2081.60,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,081.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2348.04,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,348.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2348.04,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,348.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2021.92,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,021.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2348.04,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,348.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2348.04,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $2,348.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083967,CDM,,,,both,,,3261.1600,2152.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1956.70,,,,,,,1584.9200,3261.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,261.16 in Billed Charges for Rev 278 Proc C1713 = $1,956.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,AETNA,AETNA HSHS,1819.74,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,819.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,AETNA,ALL COMMERCIAL AETNA,2816.94,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,816.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,ANTHEM,ANTHEM POS/HMO,1464.81,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,464.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,ANTHEM,ANTHEM PPO,1464.81,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,464.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2816.94,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,816.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,CENPATICO,ALL MEDICAID CENPATICO,2816.94,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,816.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2394.40,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,394.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,CIGNA,ALL COMMERCIAL CIGNA,1971.86,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,971.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,COFINITY,COFINITY,2816.94,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,816.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2676.09,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,676.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,2366.23,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,366.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2000.03,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,000.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2056.37,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,056.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,1369.03,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,369.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2394.40,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,394.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,HUMANA,HUMANA CHOICE CARE HMO,1408.47,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,408.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,HUMANA,HUMANA CHOICE CARE PPO,2394.40,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,394.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,HUMANA,HUMANA NATIIONAL POS HMO,1408.47,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,408.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2056.37,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,056.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2816.94,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,816.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1408.47,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,408.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2366.23,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,366.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2112.71,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,112.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2591.58,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,591.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1798.05,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,798.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2028.20,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,028.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2028.20,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,028.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1746.50,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,746.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2028.20,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,028.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2028.20,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $2,028.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083961,CDM,,,,both,,,2816.9400,1859.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1690.16,,,,,,,1369.0300,2816.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,816.94 in Billed Charges for Rev 278 Proc C1713 = $1,690.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,AETNA,AETNA HSHS,1838.65,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,838.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,AETNA,ALL COMMERCIAL AETNA,2846.20,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,846.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,ANTHEM,ANTHEM POS/HMO,1480.02,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,480.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,ANTHEM,ANTHEM PPO,1480.02,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,480.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2846.20,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,846.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,CENPATICO,ALL MEDICAID CENPATICO,2846.20,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,846.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2419.27,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,419.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,CIGNA,ALL COMMERCIAL CIGNA,1992.34,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,992.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,COFINITY,COFINITY,2846.20,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,846.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2703.89,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,703.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,HEALTH CARE ALLIANCE,THE ALLIANCE,2390.81,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,390.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2020.80,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,020.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2077.73,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,077.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,HSHS EMPLOYEES,HSHS EMPLOYEES,1383.25,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,383.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2419.27,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,419.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,HUMANA,HUMANA CHOICE CARE HMO,1423.10,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,423.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,HUMANA,HUMANA CHOICE CARE PPO,2419.27,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,419.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,HUMANA,HUMANA NATIIONAL POS HMO,1423.10,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,423.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2077.73,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,077.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,LIVE360,LIVE360 HSHS HEALTHY PLAN,2846.20,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,846.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1423.10,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,423.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2390.81,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,390.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2134.65,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,134.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2618.50,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,618.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1816.73,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,816.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2049.26,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,049.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2049.26,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,049.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1764.64,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,764.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2049.26,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,049.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2049.26,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $2,049.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083963,CDM,,,,both,,,2846.2000,1878.4900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1707.72,,,,,,,1383.2500,2846.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,846.20 in Billed Charges for Rev 278 Proc C1713 = $1,707.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,AETNA,AETNA HSHS,2270.81,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,270.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,AETNA,ALL COMMERCIAL AETNA,3515.19,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $3,515.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,ANTHEM,ANTHEM POS/HMO,1827.90,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $1,827.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,ANTHEM,ANTHEM PPO,1827.90,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $1,827.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3515.19,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $3,515.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,CENPATICO,ALL MEDICAID CENPATICO,3515.19,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $3,515.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2987.91,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,987.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,CIGNA,ALL COMMERCIAL CIGNA,2460.63,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,460.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,COFINITY,COFINITY,3515.19,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $3,515.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3339.43,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $3,339.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,HEALTH CARE ALLIANCE,THE ALLIANCE,2952.76,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,952.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2495.78,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,495.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2566.09,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,566.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,HSHS EMPLOYEES,HSHS EMPLOYEES,1708.38,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $1,708.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2987.91,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,987.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,HUMANA,HUMANA CHOICE CARE HMO,1757.60,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $1,757.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,HUMANA,HUMANA CHOICE CARE PPO,2987.91,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,987.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,HUMANA,HUMANA NATIIONAL POS HMO,1757.60,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $1,757.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2566.09,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,566.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,LIVE360,LIVE360 HSHS HEALTHY PLAN,3515.19,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $3,515.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1757.60,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $1,757.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2952.76,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,952.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2636.39,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,636.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3233.97,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $3,233.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2243.75,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,243.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2530.94,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,530.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2530.94,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,530.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2179.42,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,179.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2530.94,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,530.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2530.94,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,530.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083957,CDM,,,,both,,,3515.1900,2320.0300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2109.11,,,,,,,1708.3800,3515.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,515.19 in Billed Charges for Rev 278 Proc C1713 = $2,109.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,AETNA,AETNA HSHS,1690.87,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,690.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,AETNA,ALL COMMERCIAL AETNA,2617.44,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,617.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,ANTHEM,ANTHEM POS/HMO,1361.07,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,361.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,ANTHEM,ANTHEM PPO,1361.07,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,361.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2617.44,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,617.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,CENPATICO,ALL MEDICAID CENPATICO,2617.44,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,617.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2224.82,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,224.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,CIGNA,ALL COMMERCIAL CIGNA,1832.21,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,832.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,COFINITY,COFINITY,2617.44,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,617.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2486.57,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,486.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,2198.65,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,198.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1858.38,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,858.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1910.73,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,910.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,1272.08,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,272.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2224.82,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,224.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,HUMANA,HUMANA CHOICE CARE HMO,1308.72,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,308.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,HUMANA,HUMANA CHOICE CARE PPO,2224.82,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,224.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,HUMANA,HUMANA NATIIONAL POS HMO,1308.72,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,308.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1910.73,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,910.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,2617.44,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,617.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1308.72,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,308.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2198.65,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,198.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1963.08,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,963.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2408.04,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $2,408.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1670.71,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,670.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1884.56,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,884.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1884.56,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,884.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1622.81,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,622.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1884.56,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,884.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1884.56,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,884.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083947,CDM,,,,both,,,2617.4400,1727.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1570.46,,,,,,,1272.0800,2617.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,617.44 in Billed Charges for Rev 278 Proc C1713 = $1,570.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,AETNA,AETNA HSHS,1726.95,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,726.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,AETNA,ALL COMMERCIAL AETNA,2673.30,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,673.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,ANTHEM,ANTHEM POS/HMO,1390.12,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,390.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,ANTHEM,ANTHEM PPO,1390.12,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,390.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2673.30,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,673.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,CENPATICO,ALL MEDICAID CENPATICO,2673.30,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,673.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2272.31,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,272.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,CIGNA,ALL COMMERCIAL CIGNA,1871.31,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,871.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,COFINITY,COFINITY,2673.30,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,673.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2539.64,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,539.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,2245.57,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,245.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1898.04,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,898.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1951.51,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,951.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,1299.22,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,299.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2272.31,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,272.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,HUMANA,HUMANA CHOICE CARE HMO,1336.65,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,336.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,HUMANA,HUMANA CHOICE CARE PPO,2272.31,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,272.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,HUMANA,HUMANA NATIIONAL POS HMO,1336.65,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,336.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1951.51,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,951.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2673.30,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,673.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1336.65,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,336.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2245.57,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,245.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2004.98,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,004.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2459.44,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $2,459.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1706.37,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,706.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1924.78,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,924.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1924.78,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,924.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1657.45,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,657.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1924.78,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,924.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1924.78,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,924.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083951,CDM,,,,both,,,2673.3000,1764.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1603.98,,,,,,,1299.2200,2673.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,673.30 in Billed Charges for Rev 278 Proc C1713 = $1,603.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,AETNA,AETNA HSHS,592.09,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $592.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,AETNA,ALL COMMERCIAL AETNA,916.55,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $916.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,916.55,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $916.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,CENPATICO,ALL MEDICAID CENPATICO,916.55,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $916.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,779.07,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $779.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,CIGNA,ALL COMMERCIAL CIGNA,641.59,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $641.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,COFINITY,COFINITY,916.55,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $916.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,870.72,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $870.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,769.90,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $769.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,650.75,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $650.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,669.08,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $669.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,445.44,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $445.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,779.07,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $779.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,HUMANA,HUMANA CHOICE CARE PPO,779.07,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $779.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,669.08,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $669.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,916.55,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $916.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,458.28,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $458.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,769.90,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $769.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,687.41,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $687.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,843.23,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $843.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,585.03,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $585.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,659.92,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $659.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,659.92,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $659.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,568.26,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $568.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,659.92,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $659.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,659.92,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $659.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 12H/97MM ADAPTION,C1713,HCPCS,278,RC,10033621,CDM,,,,both,,,916.5500,604.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,549.93,,,,,,,445.4400,916.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $916.55 in Billed Charges for Rev 278 Proc C1713 = $549.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,AETNA,AETNA HSHS,793.52,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $793.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,AETNA,ALL COMMERCIAL AETNA,1228.36,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,228.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,ANTHEM,ANTHEM POS/HMO,638.75,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $638.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,ANTHEM,ANTHEM PPO,638.75,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $638.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1228.36,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,228.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,CENPATICO,ALL MEDICAID CENPATICO,1228.36,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,228.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1044.11,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,044.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,CIGNA,ALL COMMERCIAL CIGNA,859.85,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $859.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,COFINITY,COFINITY,1228.36,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,228.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1166.94,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,166.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,1031.82,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,031.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,872.14,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $872.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,896.70,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $896.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,596.98,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $596.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1044.11,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,044.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,HUMANA,HUMANA CHOICE CARE PPO,1044.11,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,044.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,896.70,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $896.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1228.36,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,228.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,614.18,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $614.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1031.82,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,031.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,921.27,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $921.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1130.09,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $1,130.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,784.06,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $784.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,884.42,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $884.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,884.42,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $884.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,761.58,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $761.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,884.42,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $884.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,884.42,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $884.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP 7H/66MM,C1713,HCPCS,278,RC,10064042,CDM,,,,both,,,1228.3600,810.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,737.02,,,,,,,596.9800,1228.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,228.36 in Billed Charges for Rev 278 Proc C1713 = $737.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,AETNA,AETNA HSHS,890.86,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $890.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,AETNA,ALL COMMERCIAL AETNA,1379.04,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,379.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,ANTHEM,ANTHEM POS/HMO,717.10,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $717.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,ANTHEM,ANTHEM PPO,717.10,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $717.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1379.04,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,379.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,CENPATICO,ALL MEDICAID CENPATICO,1379.04,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,379.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1172.18,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,172.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,CIGNA,ALL COMMERCIAL CIGNA,965.33,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $965.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,COFINITY,COFINITY,1379.04,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,379.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1310.09,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,310.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,1158.39,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,158.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,979.12,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $979.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1006.70,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,006.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,670.21,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $670.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1172.18,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,172.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,HUMANA,HUMANA CHOICE CARE PPO,1172.18,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,172.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1006.70,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,006.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1379.04,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,379.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,689.52,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $689.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1158.39,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,158.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1034.28,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,034.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1268.72,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $1,268.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,880.24,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $880.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,992.91,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $992.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,992.91,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $992.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,855.00,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $855.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,992.91,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $992.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,992.91,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $992.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7 LCP T 2H HEAD 3H SHAFT,C1713,HCPCS,278,RC,10064043,CDM,,,,both,,,1379.0400,910.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,827.42,,,,,,,670.2100,1379.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,379.04 in Billed Charges for Rev 278 Proc C1713 = $827.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,AETNA,AETNA HSHS,120.06,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $120.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,AETNA,ALL COMMERCIAL AETNA,185.85,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $185.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,185.85,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $185.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,CENPATICO,ALL MEDICAID CENPATICO,185.85,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $185.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,157.97,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $157.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,CIGNA,ALL COMMERCIAL CIGNA,130.10,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $130.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,COFINITY,COFINITY,185.85,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $185.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,176.56,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $176.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,156.11,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $156.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,131.95,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $131.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,135.67,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $135.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,90.32,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $90.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,157.97,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $157.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,HUMANA,HUMANA CHOICE CARE PPO,157.97,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $157.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,135.67,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $135.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,185.85,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $185.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,92.93,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $92.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,156.11,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $156.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,139.39,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $139.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,170.98,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $170.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,118.63,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $118.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,133.81,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $133.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,133.81,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $133.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,115.23,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $115.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,133.81,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $133.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,133.81,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $133.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001578,CDM,,,,both,,,185.8500,122.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,111.51,,,,,,,90.3200,185.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $185.85 in Billed Charges for Rev 278 Proc C1713 = $111.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,AETNA,AETNA HSHS,138.37,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $138.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,AETNA,ALL COMMERCIAL AETNA,214.20,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,214.20,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,CENPATICO,ALL MEDICAID CENPATICO,214.20,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,182.07,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $182.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,CIGNA,ALL COMMERCIAL CIGNA,149.94,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $149.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,COFINITY,COFINITY,214.20,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,203.49,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $203.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,179.93,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $179.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,152.08,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $152.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,156.37,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $156.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,104.10,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $104.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,182.07,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $182.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,HUMANA,HUMANA CHOICE CARE PPO,182.07,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $182.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,156.37,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $156.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,214.20,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,107.10,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $107.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,179.93,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $179.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,160.65,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $160.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,197.06,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $197.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,136.72,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $136.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,154.22,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $154.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,154.22,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $154.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,132.80,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $132.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,154.22,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $154.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,154.22,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $154.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  7 HOLE 55MM,C1713,HCPCS,278,RC,10053163,CDM,,,,both,,,214.2000,141.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,128.52,,,,,,,104.1000,214.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $214.20 in Billed Charges for Rev 278 Proc C1713 = $128.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,AETNA,AETNA HSHS,82.92,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $82.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,AETNA,ALL COMMERCIAL AETNA,128.36,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $128.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,128.36,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $128.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,CENPATICO,ALL MEDICAID CENPATICO,128.36,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $128.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,109.11,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $109.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,CIGNA,ALL COMMERCIAL CIGNA,89.85,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $89.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,COFINITY,COFINITY,128.36,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $128.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,121.94,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $121.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,107.82,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $107.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,91.14,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $91.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,93.70,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $93.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,62.38,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $62.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,109.11,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $109.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,HUMANA,HUMANA CHOICE CARE PPO,109.11,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $109.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,93.70,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $93.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,128.36,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $128.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,64.18,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $64.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,107.82,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $107.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,96.27,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $96.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,118.09,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $118.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,81.93,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $81.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,92.42,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $92.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,92.42,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $92.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,79.58,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $79.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,92.42,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $92.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,92.42,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $92.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 T  3 HOLE 32MM,C1713,HCPCS,278,RC,10053167,CDM,,,,both,,,128.3600,84.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,77.02,,,,,,,62.3800,128.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $128.36 in Billed Charges for Rev 278 Proc C1713 = $77.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,AETNA,AETNA HSHS,1320.06,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,320.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,AETNA,ALL COMMERCIAL AETNA,2043.44,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $2,043.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,ANTHEM,ANTHEM POS/HMO,1062.59,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,062.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,ANTHEM,ANTHEM PPO,1062.59,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,062.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2043.44,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $2,043.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,CENPATICO,ALL MEDICAID CENPATICO,2043.44,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $2,043.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1736.92,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,736.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,CIGNA,ALL COMMERCIAL CIGNA,1430.41,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,430.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,COFINITY,COFINITY,2043.44,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $2,043.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1941.27,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,941.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,1716.49,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,716.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1450.84,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,450.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1491.71,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,491.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,993.11,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $993.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1736.92,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,736.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,HUMANA,HUMANA CHOICE CARE PPO,1736.92,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,736.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1491.71,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,491.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,2043.44,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $2,043.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1021.72,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,021.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1716.49,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,716.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1532.58,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,532.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1879.96,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,879.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1304.33,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,304.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1471.28,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,471.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1471.28,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,471.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1266.93,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,266.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1471.28,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,471.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1471.28,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,471.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083980,CDM,,,,both,,,2043.4400,1348.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1226.06,,,,,,,993.1100,2043.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,043.44 in Billed Charges for Rev 278 Proc C1713 = $1,226.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,AETNA,AETNA HSHS,1316.26,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,316.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,AETNA,ALL COMMERCIAL AETNA,2037.56,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $2,037.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,ANTHEM,ANTHEM POS/HMO,1059.53,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,059.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,ANTHEM,ANTHEM PPO,1059.53,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,059.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2037.56,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $2,037.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,CENPATICO,ALL MEDICAID CENPATICO,2037.56,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $2,037.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1731.93,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,731.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,CIGNA,ALL COMMERCIAL CIGNA,1426.29,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,426.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,COFINITY,COFINITY,2037.56,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $2,037.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1935.68,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,935.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,1711.55,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,711.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1446.67,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,446.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1487.42,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,487.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,990.25,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $990.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1731.93,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,731.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,HUMANA,HUMANA CHOICE CARE PPO,1731.93,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,731.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1487.42,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,487.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,2037.56,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $2,037.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1018.78,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,018.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1711.55,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,711.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1528.17,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,528.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1874.56,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,874.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1300.57,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,300.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1467.04,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,467.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1467.04,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,467.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1263.29,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,263.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1467.04,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,467.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1467.04,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,467.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083982,CDM,,,,both,,,2037.5600,1344.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1222.54,,,,,,,990.2500,2037.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,037.56 in Billed Charges for Rev 278 Proc C1713 = $1,222.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,AETNA,AETNA HSHS,1204.19,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,204.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,AETNA,ALL COMMERCIAL AETNA,1864.07,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,864.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,ANTHEM,ANTHEM POS/HMO,969.32,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $969.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,ANTHEM,ANTHEM PPO,969.32,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $969.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1864.07,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,864.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,CENPATICO,ALL MEDICAID CENPATICO,1864.07,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,864.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1584.46,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,584.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,CIGNA,ALL COMMERCIAL CIGNA,1304.85,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,304.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,COFINITY,COFINITY,1864.07,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,864.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1770.87,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,770.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,HEALTH CARE ALLIANCE,THE ALLIANCE,1565.82,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,565.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1323.49,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,323.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1360.77,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,360.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,HSHS EMPLOYEES,HSHS EMPLOYEES,905.94,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $905.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1584.46,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,584.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,HUMANA,HUMANA CHOICE CARE PPO,1584.46,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,584.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1360.77,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,360.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1864.07,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,864.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,932.04,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $932.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1565.82,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,565.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1398.05,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,398.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1714.94,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,714.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1189.84,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,189.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1342.13,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,342.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1342.13,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,342.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1155.72,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,155.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1342.13,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,342.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1342.13,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,342.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080601,CDM,,,,both,,,1864.0700,1230.2900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1118.44,,,,,,,905.9400,1864.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,864.07 in Billed Charges for Rev 278 Proc C1713 = $1,118.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,AETNA,AETNA HSHS,1096.66,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,096.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,AETNA,ALL COMMERCIAL AETNA,1697.61,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,697.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,ANTHEM,ANTHEM POS/HMO,882.76,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $882.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,ANTHEM,ANTHEM PPO,882.76,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $882.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1697.61,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,697.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,CENPATICO,ALL MEDICAID CENPATICO,1697.61,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,697.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1442.97,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,442.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,CIGNA,ALL COMMERCIAL CIGNA,1188.33,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,188.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,COFINITY,COFINITY,1697.61,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,697.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1612.73,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,612.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,1425.99,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,425.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1205.30,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,205.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1239.26,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,239.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,825.04,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $825.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1442.97,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,442.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,HUMANA,HUMANA CHOICE CARE PPO,1442.97,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,442.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1239.26,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,239.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1697.61,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,697.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,848.81,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $848.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1425.99,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,425.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1273.21,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,273.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1561.80,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,561.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1083.58,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,083.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1222.28,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,222.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1222.28,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,222.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1052.52,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,052.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1222.28,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,222.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1222.28,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,222.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083973,CDM,,,,both,,,1697.6100,1120.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1018.57,,,,,,,825.0400,1697.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,697.61 in Billed Charges for Rev 278 Proc C1713 = $1,018.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,AETNA,AETNA HSHS,1275.22,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,275.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,AETNA,ALL COMMERCIAL AETNA,1974.02,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,974.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,ANTHEM,ANTHEM POS/HMO,1026.49,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,026.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,ANTHEM,ANTHEM PPO,1026.49,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,026.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1974.02,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,974.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,CENPATICO,ALL MEDICAID CENPATICO,1974.02,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,974.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1677.92,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,677.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,CIGNA,ALL COMMERCIAL CIGNA,1381.81,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,381.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,COFINITY,COFINITY,1974.02,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,974.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1875.32,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,875.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,HEALTH CARE ALLIANCE,THE ALLIANCE,1658.18,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,658.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1401.55,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,401.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1441.03,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,441.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,HSHS EMPLOYEES,HSHS EMPLOYEES,959.37,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $959.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1677.92,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,677.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,HUMANA,HUMANA CHOICE CARE PPO,1677.92,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,677.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1441.03,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,441.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1974.02,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,974.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,987.01,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $987.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1658.18,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,658.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1480.52,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,480.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1816.10,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,816.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1260.02,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,260.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1421.29,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,421.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1421.29,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,421.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1223.89,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,223.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1421.29,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,421.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1421.29,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,421.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080548,CDM,,,,both,,,1974.0200,1302.8500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1184.41,,,,,,,959.3700,1974.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,974.02 in Billed Charges for Rev 278 Proc C1713 = $1,184.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,AETNA,AETNA HSHS,1130.03,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,130.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,AETNA,ALL COMMERCIAL AETNA,1749.27,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,749.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,ANTHEM,ANTHEM POS/HMO,909.62,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $909.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,ANTHEM,ANTHEM PPO,909.62,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $909.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1749.27,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,749.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,CENPATICO,ALL MEDICAID CENPATICO,1749.27,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,749.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1486.88,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,486.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,CIGNA,ALL COMMERCIAL CIGNA,1224.49,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,224.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,COFINITY,COFINITY,1749.27,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,749.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1661.81,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,661.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,1469.39,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,469.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1241.98,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,241.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1276.97,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,276.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,850.15,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $850.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1486.88,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,486.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,HUMANA,HUMANA CHOICE CARE PPO,1486.88,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,486.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1276.97,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,276.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1749.27,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,749.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,874.64,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $874.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1469.39,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,469.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1311.95,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,311.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1609.33,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,609.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1116.56,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,116.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1259.47,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,259.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1259.47,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,259.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1084.55,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,084.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1259.47,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,259.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1259.47,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,259.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070578,CDM,,,,both,,,1749.2700,1154.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1049.56,,,,,,,850.1500,1749.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,749.27 in Billed Charges for Rev 278 Proc C1713 = $1,049.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,AETNA,AETNA HSHS,1251.57,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,251.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,AETNA,ALL COMMERCIAL AETNA,1937.41,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,937.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,ANTHEM,ANTHEM POS/HMO,1007.45,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,007.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,ANTHEM,ANTHEM PPO,1007.45,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,007.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1937.41,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,937.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,CENPATICO,ALL MEDICAID CENPATICO,1937.41,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,937.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1646.80,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,646.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,CIGNA,ALL COMMERCIAL CIGNA,1356.19,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,356.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,COFINITY,COFINITY,1937.41,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,937.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1840.54,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,840.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,1627.42,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,627.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1375.56,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,375.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1414.31,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,414.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,941.58,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $941.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1646.80,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,646.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,HUMANA,HUMANA CHOICE CARE PPO,1646.80,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,646.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1414.31,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,414.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1937.41,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,937.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,968.71,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $968.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1627.42,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,627.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1453.06,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,453.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1782.42,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,782.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1236.65,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,236.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1394.94,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,394.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1394.94,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,394.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1201.19,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,201.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1394.94,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,394.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1394.94,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,394.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058002,CDM,,,,both,,,1937.4100,1278.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1162.45,,,,,,,941.5800,1937.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,937.41 in Billed Charges for Rev 278 Proc C1713 = $1,162.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,AETNA,AETNA HSHS,731.39,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $731.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,AETNA,ALL COMMERCIAL AETNA,1132.19,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $1,132.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,ANTHEM,ANTHEM POS/HMO,588.74,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $588.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,ANTHEM,ANTHEM PPO,588.74,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $588.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1132.19,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $1,132.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,CENPATICO,ALL MEDICAID CENPATICO,1132.19,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $1,132.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,962.36,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $962.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,CIGNA,ALL COMMERCIAL CIGNA,792.53,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $792.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,COFINITY,COFINITY,1132.19,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $1,132.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1075.58,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $1,075.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,HEALTH CARE ALLIANCE,THE ALLIANCE,951.04,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $951.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,803.85,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $803.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,826.50,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $826.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,HSHS EMPLOYEES,HSHS EMPLOYEES,550.24,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $550.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,962.36,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $962.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,HUMANA,HUMANA CHOICE CARE PPO,962.36,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $962.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,826.50,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $826.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1132.19,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $1,132.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,566.10,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $566.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,951.04,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $951.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,849.14,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $849.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1041.61,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $1,041.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,722.68,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $722.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,815.18,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $815.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,815.18,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $815.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,701.96,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $701.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,815.18,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $815.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,815.18,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $815.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037072,CDM,,,,both,,,1132.1900,747.2500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,679.31,,,,,,,550.2400,1132.1900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,132.19 in Billed Charges for Rev 278 Proc C1713 = $679.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,AETNA,AETNA HSHS,744.18,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $744.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,AETNA,ALL COMMERCIAL AETNA,1151.98,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $1,151.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,ANTHEM,ANTHEM POS/HMO,599.03,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $599.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,ANTHEM,ANTHEM PPO,599.03,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $599.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1151.98,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $1,151.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,CENPATICO,ALL MEDICAID CENPATICO,1151.98,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $1,151.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,979.18,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $979.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,CIGNA,ALL COMMERCIAL CIGNA,806.39,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $806.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,COFINITY,COFINITY,1151.98,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $1,151.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1094.38,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $1,094.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,HEALTH CARE ALLIANCE,THE ALLIANCE,967.66,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $967.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,817.91,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $817.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,840.95,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $840.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,HSHS EMPLOYEES,HSHS EMPLOYEES,559.86,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $559.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,979.18,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $979.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,HUMANA,HUMANA CHOICE CARE PPO,979.18,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $979.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,840.95,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $840.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1151.98,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $1,151.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,575.99,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $575.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,967.66,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $967.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,863.99,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $863.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1059.82,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $1,059.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,735.31,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $735.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,829.43,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $829.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,829.43,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $829.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,714.23,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $714.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,829.43,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $829.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,829.43,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $829.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037070,CDM,,,,both,,,1151.9800,760.3100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,691.19,,,,,,,559.8600,1151.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,151.98 in Billed Charges for Rev 278 Proc C1713 = $691.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,AETNA,AETNA HSHS,754.02,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $754.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,AETNA,ALL COMMERCIAL AETNA,1167.21,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $1,167.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,ANTHEM,ANTHEM POS/HMO,606.95,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $606.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,ANTHEM,ANTHEM PPO,606.95,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $606.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1167.21,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $1,167.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,CENPATICO,ALL MEDICAID CENPATICO,1167.21,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $1,167.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,992.13,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $992.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,CIGNA,ALL COMMERCIAL CIGNA,817.05,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $817.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,COFINITY,COFINITY,1167.21,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $1,167.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1108.85,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $1,108.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,980.46,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $980.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,828.72,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $828.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,852.06,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $852.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,567.26,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $567.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,992.13,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $992.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,HUMANA,HUMANA CHOICE CARE PPO,992.13,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $992.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,852.06,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $852.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1167.21,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $1,167.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,583.61,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $583.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,980.46,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $980.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,875.41,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $875.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1073.83,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $1,073.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,745.03,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $745.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,840.39,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $840.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,840.39,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $840.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,723.67,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $723.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,840.39,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $840.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,840.39,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $840.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063115,CDM,,,,both,,,1167.2100,770.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,700.33,,,,,,,567.2600,1167.2100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,167.21 in Billed Charges for Rev 278 Proc C1713 = $700.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,AETNA,AETNA HSHS,765.48,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $765.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,AETNA,ALL COMMERCIAL AETNA,1184.96,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,184.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,ANTHEM,ANTHEM POS/HMO,616.18,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $616.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,ANTHEM,ANTHEM PPO,616.18,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $616.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1184.96,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,184.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,CENPATICO,ALL MEDICAID CENPATICO,1184.96,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,184.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1007.22,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,007.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,CIGNA,ALL COMMERCIAL CIGNA,829.47,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $829.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,COFINITY,COFINITY,1184.96,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,184.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1125.71,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,125.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,995.37,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $995.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,841.32,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $841.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,865.02,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $865.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,575.89,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $575.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1007.22,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,007.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,HUMANA,HUMANA CHOICE CARE PPO,1007.22,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,007.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,865.02,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $865.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1184.96,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,184.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,592.48,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $592.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,995.37,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $995.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,888.72,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $888.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1090.16,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $1,090.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,756.36,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $756.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,853.17,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $853.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,853.17,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $853.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,734.68,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $734.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,853.17,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $853.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,853.17,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $853.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037076,CDM,,,,both,,,1184.9600,782.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,710.98,,,,,,,575.8900,1184.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,184.96 in Billed Charges for Rev 278 Proc C1713 = $710.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,AETNA,AETNA HSHS,1250.27,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,250.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,AETNA,ALL COMMERCIAL AETNA,1935.41,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,935.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,ANTHEM,ANTHEM POS/HMO,1006.41,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,006.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,ANTHEM,ANTHEM PPO,1006.41,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,006.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1935.41,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,935.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,CENPATICO,ALL MEDICAID CENPATICO,1935.41,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,935.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1645.10,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,645.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,CIGNA,ALL COMMERCIAL CIGNA,1354.79,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,354.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,COFINITY,COFINITY,1935.41,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,935.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1838.64,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,838.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,1625.74,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,625.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1374.14,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,374.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1412.85,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,412.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,940.61,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $940.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1645.10,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,645.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,HUMANA,HUMANA CHOICE CARE PPO,1645.10,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,645.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1412.85,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,412.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1935.41,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,935.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,967.71,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $967.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1625.74,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,625.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1451.56,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,451.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1780.58,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,780.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1235.37,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,235.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1393.50,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,393.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1393.50,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,393.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1199.95,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,199.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1393.50,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,393.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1393.50,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,393.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058006,CDM,,,,both,,,1935.4100,1277.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1161.25,,,,,,,940.6100,1935.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,935.41 in Billed Charges for Rev 278 Proc C1713 = $1,161.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,AETNA,AETNA HSHS,433.61,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $433.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,AETNA,ALL COMMERCIAL AETNA,671.23,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $671.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,671.23,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $671.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,CENPATICO,ALL MEDICAID CENPATICO,671.23,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $671.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,570.55,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $570.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,CIGNA,ALL COMMERCIAL CIGNA,469.86,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $469.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,COFINITY,COFINITY,671.23,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $671.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,637.67,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $637.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,563.83,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $563.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,476.57,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $476.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,490.00,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,326.22,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $326.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,570.55,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $570.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,HUMANA,HUMANA CHOICE CARE PPO,570.55,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $570.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,490.00,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $490.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,671.23,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $671.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,335.62,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $335.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,563.83,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $563.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,503.42,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $503.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,617.53,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $617.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,428.45,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $428.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,483.29,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $483.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,483.29,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $483.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,416.16,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $416.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,483.29,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $483.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,483.29,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $483.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001312,CDM,,,,both,,,671.2300,443.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,402.74,,,,,,,326.2200,671.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $671.23 in Billed Charges for Rev 278 Proc C1713 = $402.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,AETNA,AETNA HSHS,1370.24,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,370.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,AETNA,ALL COMMERCIAL AETNA,2121.12,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $2,121.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,ANTHEM,ANTHEM POS/HMO,1102.98,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,102.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,ANTHEM,ANTHEM PPO,1102.98,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,102.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2121.12,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $2,121.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,CENPATICO,ALL MEDICAID CENPATICO,2121.12,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $2,121.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1802.95,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,802.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,CIGNA,ALL COMMERCIAL CIGNA,1484.78,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,484.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,COFINITY,COFINITY,2121.12,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $2,121.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2015.06,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $2,015.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,1781.74,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,781.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1506.00,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,506.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1548.42,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,548.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,1030.86,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,030.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1802.95,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,802.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,HUMANA,HUMANA CHOICE CARE PPO,1802.95,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,802.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1548.42,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,548.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2121.12,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $2,121.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1060.56,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,060.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1781.74,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,781.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1590.84,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,590.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1951.43,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,951.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1353.91,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,353.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1527.21,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,527.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1527.21,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,527.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1315.09,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,315.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1527.21,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,527.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1527.21,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,527.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE LOCKING,C1713,HCPCS,278,RC,10028805,CDM,,,,both,,,2121.1200,1399.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1272.67,,,,,,,1030.8600,2121.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,121.12 in Billed Charges for Rev 278 Proc C1713 = $1,272.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,AETNA,AETNA HSHS,320.40,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,AETNA,ALL COMMERCIAL AETNA,495.98,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $495.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,495.98,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $495.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,CENPATICO,ALL MEDICAID CENPATICO,495.98,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $495.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,421.58,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $421.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,CIGNA,ALL COMMERCIAL CIGNA,347.19,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $347.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,COFINITY,COFINITY,495.98,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $495.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,471.18,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $471.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,416.62,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $416.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,352.15,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $352.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,362.07,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $362.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,241.05,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $241.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,421.58,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $421.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,HUMANA,HUMANA CHOICE CARE PPO,421.58,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $421.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,362.07,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $362.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,495.98,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $495.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,247.99,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $247.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,416.62,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $416.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,371.99,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $371.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,456.30,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $456.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,316.58,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $316.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,357.11,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $357.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,357.11,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $357.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,307.51,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $307.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,357.11,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $357.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,357.11,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $357.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.0MM CHIN 4 HOLE,C1713,HCPCS,278,RC,10052569,CDM,,,,both,,,495.9800,327.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,297.59,,,,,,,241.0500,495.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $495.98 in Billed Charges for Rev 278 Proc C1713 = $297.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,AETNA,AETNA HSHS,1742.42,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,742.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,AETNA,ALL COMMERCIAL AETNA,2697.24,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,697.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,ANTHEM,ANTHEM POS/HMO,1402.56,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,402.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,ANTHEM,ANTHEM PPO,1402.56,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,402.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2697.24,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,697.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,CENPATICO,ALL MEDICAID CENPATICO,2697.24,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,697.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2292.65,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,292.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,CIGNA,ALL COMMERCIAL CIGNA,1888.07,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,888.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,COFINITY,COFINITY,2697.24,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,697.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2562.38,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,562.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,2265.68,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,265.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1915.04,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,915.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1968.99,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,968.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,1310.86,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,310.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2292.65,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,292.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,HUMANA,HUMANA CHOICE CARE HMO,1348.62,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,348.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,HUMANA,HUMANA CHOICE CARE PPO,2292.65,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,292.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,HUMANA,HUMANA NATIIONAL POS HMO,1348.62,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,348.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1968.99,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,968.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2697.24,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,697.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1348.62,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,348.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2265.68,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,265.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2022.93,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,022.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2481.46,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $2,481.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1721.65,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,721.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1942.01,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,942.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1942.01,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,942.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1672.29,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,672.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1942.01,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,942.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1942.01,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,942.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409756,CDM,,,,both,,,2697.2400,1780.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1618.34,,,,,,,1310.8600,2697.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,697.24 in Billed Charges for Rev 278 Proc C1713 = $1,618.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,AETNA,AETNA HSHS,1785.38,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,785.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,AETNA,ALL COMMERCIAL AETNA,2763.74,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,763.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,ANTHEM,ANTHEM POS/HMO,1437.14,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,437.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,ANTHEM,ANTHEM PPO,1437.14,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,437.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2763.74,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,763.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,CENPATICO,ALL MEDICAID CENPATICO,2763.74,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,763.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2349.18,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,349.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,CIGNA,ALL COMMERCIAL CIGNA,1934.62,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,934.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,COFINITY,COFINITY,2763.74,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,763.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2625.55,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,625.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,2321.54,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,321.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1962.26,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,962.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2017.53,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,017.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,1343.18,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,343.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2349.18,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,349.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,HUMANA,HUMANA CHOICE CARE HMO,1381.87,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,381.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,HUMANA,HUMANA CHOICE CARE PPO,2349.18,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,349.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,HUMANA,HUMANA NATIIONAL POS HMO,1381.87,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,381.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2017.53,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,017.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,2763.74,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,763.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1381.87,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,381.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2321.54,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,321.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2072.81,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,072.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2542.64,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $2,542.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1764.10,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,764.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1989.89,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,989.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1989.89,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,989.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1713.52,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,713.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1989.89,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,989.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1989.89,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,989.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409760,CDM,,,,both,,,2763.7400,1824.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1658.24,,,,,,,1343.1800,2763.7400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,763.74 in Billed Charges for Rev 278 Proc C1713 = $1,658.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,AETNA,AETNA HSHS,3093.05,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,788.00 in Billed Charges for Rev 278 = $3,093.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,AETNA,ALL COMMERCIAL AETNA,4788.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,788.00 in Billed Charges for Rev 278 = $4,788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,ANTHEM,ANTHEM POS/HMO,2489.76,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,788.00 in Billed Charges for Rev 278 = $2,489.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,ANTHEM,ANTHEM PPO,2489.76,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,788.00 in Billed Charges for Rev 278 = $2,489.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4788.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,788.00 in Billed Charges for Rev 278 = $4,788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,CENPATICO,ALL MEDICAID CENPATICO,4788.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,788.00 in Billed Charges for Rev 278 = $4,788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4069.80,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,788.00 in Billed Charges for Rev 278 = $4,069.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,CIGNA,ALL COMMERCIAL CIGNA,3351.60,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,788.00 in Billed Charges for Rev 278 = $3,351.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,COFINITY,COFINITY,4788.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,788.00 in Billed Charges for Rev 278 = $4,788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4548.60,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,788.00 in Billed Charges for Rev 278 = $4,548.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,4021.92,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,788.00 in Billed Charges for Rev 278 = $4,021.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3399.48,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,788.00 in Billed Charges for Rev 278 = $3,399.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3495.24,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,788.00 in Billed Charges for Rev 278 = $3,495.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,2326.97,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,788.00 in Billed Charges for Rev 278 = $2,326.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4069.80,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,788.00 in Billed Charges for Rev 278 = $4,069.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,HUMANA,HUMANA CHOICE CARE HMO,2394.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,788.00 in Billed Charges for Rev 278 = $2,394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,HUMANA,HUMANA CHOICE CARE PPO,4069.80,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,788.00 in Billed Charges for Rev 278 = $4,069.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,HUMANA,HUMANA NATIIONAL POS HMO,2394.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,788.00 in Billed Charges for Rev 278 = $2,394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3495.24,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,788.00 in Billed Charges for Rev 278 = $3,495.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,4788.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,788.00 in Billed Charges for Rev 278 = $4,788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2394.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,788.00 in Billed Charges for Rev 278 = $2,394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4021.92,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,788.00 in Billed Charges for Rev 278 = $4,021.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3591.00,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,788.00 in Billed Charges for Rev 278 = $3,591.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4404.96,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,788.00 in Billed Charges for Rev 278 = $4,404.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3056.18,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,788.00 in Billed Charges for Rev 278 = $3,056.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3447.36,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,788.00 in Billed Charges for Rev 278 = $3,447.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3447.36,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,788.00 in Billed Charges for Rev 278 = $3,447.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2968.56,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,788.00 in Billed Charges for Rev 278 = $2,968.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3447.36,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,788.00 in Billed Charges for Rev 278 = $3,447.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3447.36,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,788.00 in Billed Charges for Rev 278 = $3,447.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING CARPENTIER-EDWARDS TRICUSPID 26MM,278,RC,10031405,CDM,,,,,,both,,,4788.0000,3160.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2872.80,,,,,,,2326.9700,4788.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,788.00 in Billed Charges for Rev 278 = $2,872.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,AETNA,AETNA HSHS,277.78,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $430.00 in Billed Charges for Rev 278 = $277.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,AETNA,ALL COMMERCIAL AETNA,430.00,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.00 in Billed Charges for Rev 278 = $430.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,430.00,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.00 in Billed Charges for Rev 278 = $430.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,CENPATICO,ALL MEDICAID CENPATICO,430.00,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.00 in Billed Charges for Rev 278 = $430.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,365.50,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $430.00 in Billed Charges for Rev 278 = $365.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,CIGNA,ALL COMMERCIAL CIGNA,301.00,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $430.00 in Billed Charges for Rev 278 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,COFINITY,COFINITY,430.00,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.00 in Billed Charges for Rev 278 = $430.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,408.50,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $430.00 in Billed Charges for Rev 278 = $408.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,361.20,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $430.00 in Billed Charges for Rev 278 = $361.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,305.30,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $430.00 in Billed Charges for Rev 278 = $305.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,313.90,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $430.00 in Billed Charges for Rev 278 = $313.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,208.98,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $430.00 in Billed Charges for Rev 278 = $208.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,365.50,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $430.00 in Billed Charges for Rev 278 = $365.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,HUMANA,HUMANA CHOICE CARE PPO,365.50,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $430.00 in Billed Charges for Rev 278 = $365.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,313.90,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $430.00 in Billed Charges for Rev 278 = $313.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,430.00,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.00 in Billed Charges for Rev 278 = $430.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,215.00,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $430.00 in Billed Charges for Rev 278 = $215.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,361.20,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $430.00 in Billed Charges for Rev 278 = $361.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,322.50,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $430.00 in Billed Charges for Rev 278 = $322.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,395.60,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $430.00 in Billed Charges for Rev 278 = $395.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,274.47,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $430.00 in Billed Charges for Rev 278 = $274.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,309.60,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $430.00 in Billed Charges for Rev 278 = $309.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,309.60,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $430.00 in Billed Charges for Rev 278 = $309.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,266.60,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $430.00 in Billed Charges for Rev 278 = $266.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,309.60,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $430.00 in Billed Charges for Rev 278 = $309.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,309.60,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $430.00 in Billed Charges for Rev 278 = $309.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RING TENSION CAPSULAR 13MM,278,RC,10011200,CDM,,,,,,both,,,430.0000,283.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,258.00,,,,,,,208.9800,430.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $430.00 in Billed Charges for Rev 278 = $258.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,AETNA,AETNA HSHS,168.84,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $261.36 in Billed Charges for Rev 278 = $168.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,AETNA,ALL COMMERCIAL AETNA,261.36,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.36 in Billed Charges for Rev 278 = $261.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,261.36,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.36 in Billed Charges for Rev 278 = $261.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,CENPATICO,ALL MEDICAID CENPATICO,261.36,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.36 in Billed Charges for Rev 278 = $261.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,222.16,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $261.36 in Billed Charges for Rev 278 = $222.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,CIGNA,ALL COMMERCIAL CIGNA,182.95,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $261.36 in Billed Charges for Rev 278 = $182.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,COFINITY,COFINITY,261.36,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.36 in Billed Charges for Rev 278 = $261.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,248.29,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $261.36 in Billed Charges for Rev 278 = $248.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,219.54,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $261.36 in Billed Charges for Rev 278 = $219.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,185.57,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $261.36 in Billed Charges for Rev 278 = $185.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,190.79,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $261.36 in Billed Charges for Rev 278 = $190.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,127.02,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $261.36 in Billed Charges for Rev 278 = $127.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,222.16,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $261.36 in Billed Charges for Rev 278 = $222.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,HUMANA,HUMANA CHOICE CARE PPO,222.16,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $261.36 in Billed Charges for Rev 278 = $222.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,190.79,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $261.36 in Billed Charges for Rev 278 = $190.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,261.36,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.36 in Billed Charges for Rev 278 = $261.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,130.68,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $261.36 in Billed Charges for Rev 278 = $130.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,219.54,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $261.36 in Billed Charges for Rev 278 = $219.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,196.02,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $261.36 in Billed Charges for Rev 278 = $196.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,240.45,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $261.36 in Billed Charges for Rev 278 = $240.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,166.83,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $261.36 in Billed Charges for Rev 278 = $166.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,188.18,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $261.36 in Billed Charges for Rev 278 = $188.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,188.18,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $261.36 in Billed Charges for Rev 278 = $188.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,162.04,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $261.36 in Billed Charges for Rev 278 = $162.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,188.18,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $261.36 in Billed Charges for Rev 278 = $188.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,188.18,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $261.36 in Billed Charges for Rev 278 = $188.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3  COMPACT MRI 5MM X 150MM,278,RC,70409916,CDM,,,,,,both,,,261.3600,172.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,156.82,,,,,,,127.0200,261.3600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $261.36 in Billed Charges for Rev 278 = $156.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,AETNA,AETNA HSHS,809.15,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,252.55 in Billed Charges for Rev 278 = $809.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,AETNA,ALL COMMERCIAL AETNA,1252.55,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,252.55 in Billed Charges for Rev 278 = $1,252.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,ANTHEM,ANTHEM POS/HMO,651.33,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,252.55 in Billed Charges for Rev 278 = $651.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,ANTHEM,ANTHEM PPO,651.33,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,252.55 in Billed Charges for Rev 278 = $651.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1252.55,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,252.55 in Billed Charges for Rev 278 = $1,252.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,CENPATICO,ALL MEDICAID CENPATICO,1252.55,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,252.55 in Billed Charges for Rev 278 = $1,252.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1064.67,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,252.55 in Billed Charges for Rev 278 = $1,064.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,CIGNA,ALL COMMERCIAL CIGNA,876.79,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,252.55 in Billed Charges for Rev 278 = $876.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,COFINITY,COFINITY,1252.55,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,252.55 in Billed Charges for Rev 278 = $1,252.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1189.92,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,252.55 in Billed Charges for Rev 278 = $1,189.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,1052.14,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,252.55 in Billed Charges for Rev 278 = $1,052.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,889.31,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,252.55 in Billed Charges for Rev 278 = $889.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,914.36,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,252.55 in Billed Charges for Rev 278 = $914.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,608.74,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,252.55 in Billed Charges for Rev 278 = $608.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1064.67,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,252.55 in Billed Charges for Rev 278 = $1,064.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,HUMANA,HUMANA CHOICE CARE PPO,1064.67,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,252.55 in Billed Charges for Rev 278 = $1,064.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,914.36,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,252.55 in Billed Charges for Rev 278 = $914.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1252.55,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,252.55 in Billed Charges for Rev 278 = $1,252.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,626.28,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,252.55 in Billed Charges for Rev 278 = $626.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1052.14,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,252.55 in Billed Charges for Rev 278 = $1,052.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,939.41,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,252.55 in Billed Charges for Rev 278 = $939.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1152.35,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,252.55 in Billed Charges for Rev 278 = $1,152.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,799.50,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,252.55 in Billed Charges for Rev 278 = $799.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,901.84,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,252.55 in Billed Charges for Rev 278 = $901.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,901.84,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,252.55 in Billed Charges for Rev 278 = $901.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,776.58,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,252.55 in Billed Charges for Rev 278 = $776.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,901.84,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,252.55 in Billed Charges for Rev 278 = $901.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,901.84,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,252.55 in Billed Charges for Rev 278 = $901.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN 3 SEMI CIRCULAR CURVED 11X220,278,RC,10071151,CDM,,,,,,both,,,1252.5500,826.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,751.53,,,,,,,608.7400,1252.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,252.55 in Billed Charges for Rev 278 = $751.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,AETNA,AETNA HSHS,451.95,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $699.61 in Billed Charges for Rev 278 = $451.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,AETNA,ALL COMMERCIAL AETNA,699.61,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.61 in Billed Charges for Rev 278 = $699.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,699.61,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.61 in Billed Charges for Rev 278 = $699.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,CENPATICO,ALL MEDICAID CENPATICO,699.61,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.61 in Billed Charges for Rev 278 = $699.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,594.67,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $699.61 in Billed Charges for Rev 278 = $594.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,CIGNA,ALL COMMERCIAL CIGNA,489.73,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $699.61 in Billed Charges for Rev 278 = $489.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,COFINITY,COFINITY,699.61,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.61 in Billed Charges for Rev 278 = $699.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,664.63,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $699.61 in Billed Charges for Rev 278 = $664.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,587.67,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $699.61 in Billed Charges for Rev 278 = $587.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,496.72,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $699.61 in Billed Charges for Rev 278 = $496.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,510.72,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $699.61 in Billed Charges for Rev 278 = $510.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,340.01,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $699.61 in Billed Charges for Rev 278 = $340.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,594.67,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $699.61 in Billed Charges for Rev 278 = $594.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,HUMANA,HUMANA CHOICE CARE PPO,594.67,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $699.61 in Billed Charges for Rev 278 = $594.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,510.72,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $699.61 in Billed Charges for Rev 278 = $510.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,699.61,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.61 in Billed Charges for Rev 278 = $699.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,349.81,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $699.61 in Billed Charges for Rev 278 = $349.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,587.67,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $699.61 in Billed Charges for Rev 278 = $587.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,524.71,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $699.61 in Billed Charges for Rev 278 = $524.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,643.64,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $699.61 in Billed Charges for Rev 278 = $643.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,446.56,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $699.61 in Billed Charges for Rev 278 = $446.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,503.72,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $699.61 in Billed Charges for Rev 278 = $503.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,503.72,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $699.61 in Billed Charges for Rev 278 = $503.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,433.76,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $699.61 in Billed Charges for Rev 278 = $433.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,503.72,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $699.61 in Billed Charges for Rev 278 = $503.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,503.72,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $699.61 in Billed Charges for Rev 278 = $503.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN III VECTRAN COATED CARBON FIBER 8 X 100MM,278,RC,10080115,CDM,,,,,,both,,,699.6100,461.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,419.77,,,,,,,340.0100,699.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $699.61 in Billed Charges for Rev 278 = $419.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,AETNA,AETNA HSHS,728.37,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,127.50 in Billed Charges for Rev 278 = $728.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,AETNA,ALL COMMERCIAL AETNA,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,ANTHEM,ANTHEM POS/HMO,586.30,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,127.50 in Billed Charges for Rev 278 = $586.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,ANTHEM,ANTHEM PPO,586.30,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,127.50 in Billed Charges for Rev 278 = $586.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,CENPATICO,ALL MEDICAID CENPATICO,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,958.38,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,127.50 in Billed Charges for Rev 278 = $958.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,CIGNA,ALL COMMERCIAL CIGNA,789.25,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,127.50 in Billed Charges for Rev 278 = $789.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,COFINITY,COFINITY,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1071.13,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,127.50 in Billed Charges for Rev 278 = $1,071.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,947.10,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,127.50 in Billed Charges for Rev 278 = $947.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,800.53,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,127.50 in Billed Charges for Rev 278 = $800.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,823.08,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,127.50 in Billed Charges for Rev 278 = $823.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,547.97,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,127.50 in Billed Charges for Rev 278 = $547.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,958.38,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,127.50 in Billed Charges for Rev 278 = $958.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,HUMANA,HUMANA CHOICE CARE PPO,958.38,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,127.50 in Billed Charges for Rev 278 = $958.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,823.08,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,127.50 in Billed Charges for Rev 278 = $823.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,563.75,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,127.50 in Billed Charges for Rev 278 = $563.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,947.10,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,127.50 in Billed Charges for Rev 278 = $947.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,845.63,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,127.50 in Billed Charges for Rev 278 = $845.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1037.30,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,127.50 in Billed Charges for Rev 278 = $1,037.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,719.68,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,127.50 in Billed Charges for Rev 278 = $719.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,811.80,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,127.50 in Billed Charges for Rev 278 = $811.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,811.80,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,127.50 in Billed Charges for Rev 278 = $811.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,699.05,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,127.50 in Billed Charges for Rev 278 = $699.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,811.80,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,127.50 in Billed Charges for Rev 278 = $811.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,811.80,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,127.50 in Billed Charges for Rev 278 = $811.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD STRYKER HOFFMAN VECTRAN COATED CARBON FIBER 11 X 400MM,278,RC,10071110,CDM,,,,,,both,,,1127.5000,744.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,676.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,127.50 in Billed Charges for Rev 278 = $676.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,AETNA,AETNA HSHS,318.96,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $493.75 in Billed Charges for Rev 278 = $318.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,AETNA,ALL COMMERCIAL AETNA,493.75,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $493.75 in Billed Charges for Rev 278 = $493.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,493.75,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $493.75 in Billed Charges for Rev 278 = $493.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,CENPATICO,ALL MEDICAID CENPATICO,493.75,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $493.75 in Billed Charges for Rev 278 = $493.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,419.69,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $493.75 in Billed Charges for Rev 278 = $419.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,CIGNA,ALL COMMERCIAL CIGNA,345.63,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $493.75 in Billed Charges for Rev 278 = $345.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,COFINITY,COFINITY,493.75,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $493.75 in Billed Charges for Rev 278 = $493.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,469.06,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $493.75 in Billed Charges for Rev 278 = $469.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,414.75,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $493.75 in Billed Charges for Rev 278 = $414.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,350.56,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $493.75 in Billed Charges for Rev 278 = $350.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,360.44,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $493.75 in Billed Charges for Rev 278 = $360.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,239.96,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $493.75 in Billed Charges for Rev 278 = $239.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,419.69,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $493.75 in Billed Charges for Rev 278 = $419.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,HUMANA,HUMANA CHOICE CARE PPO,419.69,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $493.75 in Billed Charges for Rev 278 = $419.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,360.44,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $493.75 in Billed Charges for Rev 278 = $360.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,493.75,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $493.75 in Billed Charges for Rev 278 = $493.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,246.88,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $493.75 in Billed Charges for Rev 278 = $246.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,414.75,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $493.75 in Billed Charges for Rev 278 = $414.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,370.31,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $493.75 in Billed Charges for Rev 278 = $370.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,454.25,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $493.75 in Billed Charges for Rev 278 = $454.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,315.16,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $493.75 in Billed Charges for Rev 278 = $315.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,355.50,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $493.75 in Billed Charges for Rev 278 = $355.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,355.50,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $493.75 in Billed Charges for Rev 278 = $355.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,306.13,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $493.75 in Billed Charges for Rev 278 = $306.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,355.50,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $493.75 in Billed Charges for Rev 278 = $355.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,355.50,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $493.75 in Billed Charges for Rev 278 = $355.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES 11.0 CARBON FIBER 250MM,278,RC,10041996,CDM,,,,,,both,,,493.7500,325.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,296.25,,,,,,,239.9600,493.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $493.75 in Billed Charges for Rev 278 = $296.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,AETNA,AETNA HSHS,74.70,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $115.63 in Billed Charges for Rev 278 = $74.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,AETNA,ALL COMMERCIAL AETNA,115.63,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.63 in Billed Charges for Rev 278 = $115.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,115.63,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.63 in Billed Charges for Rev 278 = $115.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,CENPATICO,ALL MEDICAID CENPATICO,115.63,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.63 in Billed Charges for Rev 278 = $115.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,98.29,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.63 in Billed Charges for Rev 278 = $98.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,CIGNA,ALL COMMERCIAL CIGNA,80.94,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $115.63 in Billed Charges for Rev 278 = $80.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,COFINITY,COFINITY,115.63,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.63 in Billed Charges for Rev 278 = $115.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,109.85,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $115.63 in Billed Charges for Rev 278 = $109.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,97.13,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $115.63 in Billed Charges for Rev 278 = $97.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,82.10,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $115.63 in Billed Charges for Rev 278 = $82.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,84.41,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $115.63 in Billed Charges for Rev 278 = $84.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,56.20,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $115.63 in Billed Charges for Rev 278 = $56.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,98.29,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.63 in Billed Charges for Rev 278 = $98.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,HUMANA,HUMANA CHOICE CARE PPO,98.29,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.63 in Billed Charges for Rev 278 = $98.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,84.41,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $115.63 in Billed Charges for Rev 278 = $84.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,115.63,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.63 in Billed Charges for Rev 278 = $115.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,57.82,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $115.63 in Billed Charges for Rev 278 = $57.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,97.13,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $115.63 in Billed Charges for Rev 278 = $97.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,86.72,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $115.63 in Billed Charges for Rev 278 = $86.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,106.38,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $115.63 in Billed Charges for Rev 278 = $106.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,73.81,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $115.63 in Billed Charges for Rev 278 = $73.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,83.25,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.63 in Billed Charges for Rev 278 = $83.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,83.25,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.63 in Billed Charges for Rev 278 = $83.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,71.69,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $115.63 in Billed Charges for Rev 278 = $71.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,83.25,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.63 in Billed Charges for Rev 278 = $83.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,83.25,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.63 in Billed Charges for Rev 278 = $83.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD SYNTHES CARBON FIBER 4 X 140MM,278,RC,10001437,CDM,,,,,,both,,,115.6300,76.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,69.38,,,,,,,56.2000,115.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $115.63 in Billed Charges for Rev 278 = $69.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,AETNA,AETNA HSHS,894.66,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,384.92 in Billed Charges for Rev 278 = $894.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,AETNA,ALL COMMERCIAL AETNA,1384.92,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,384.92 in Billed Charges for Rev 278 = $1,384.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,ANTHEM,ANTHEM POS/HMO,720.16,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,384.92 in Billed Charges for Rev 278 = $720.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,ANTHEM,ANTHEM PPO,720.16,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,384.92 in Billed Charges for Rev 278 = $720.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1384.92,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,384.92 in Billed Charges for Rev 278 = $1,384.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,CENPATICO,ALL MEDICAID CENPATICO,1384.92,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,384.92 in Billed Charges for Rev 278 = $1,384.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1177.18,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,384.92 in Billed Charges for Rev 278 = $1,177.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,CIGNA,ALL COMMERCIAL CIGNA,969.44,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,384.92 in Billed Charges for Rev 278 = $969.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,COFINITY,COFINITY,1384.92,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,384.92 in Billed Charges for Rev 278 = $1,384.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1315.67,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,384.92 in Billed Charges for Rev 278 = $1,315.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,1163.33,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,384.92 in Billed Charges for Rev 278 = $1,163.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,983.29,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,384.92 in Billed Charges for Rev 278 = $983.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1010.99,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,384.92 in Billed Charges for Rev 278 = $1,010.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,673.07,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,384.92 in Billed Charges for Rev 278 = $673.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1177.18,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,384.92 in Billed Charges for Rev 278 = $1,177.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,HUMANA,HUMANA CHOICE CARE PPO,1177.18,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,384.92 in Billed Charges for Rev 278 = $1,177.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1010.99,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,384.92 in Billed Charges for Rev 278 = $1,010.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1384.92,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,384.92 in Billed Charges for Rev 278 = $1,384.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,692.46,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,384.92 in Billed Charges for Rev 278 = $692.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1163.33,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,384.92 in Billed Charges for Rev 278 = $1,163.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1038.69,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,384.92 in Billed Charges for Rev 278 = $1,038.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1274.13,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,384.92 in Billed Charges for Rev 278 = $1,274.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,883.99,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,384.92 in Billed Charges for Rev 278 = $883.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,997.14,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,384.92 in Billed Charges for Rev 278 = $997.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,997.14,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,384.92 in Billed Charges for Rev 278 = $997.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,858.65,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,384.92 in Billed Charges for Rev 278 = $858.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,997.14,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,384.92 in Billed Charges for Rev 278 = $997.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,997.14,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,384.92 in Billed Charges for Rev 278 = $997.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
ROD TUBE STRYKER HOFFMAN 3 MRI COMPL DISTRACTION,278,RC,10080112,CDM,,,,,,both,,,1384.9200,914.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,830.95,,,,,,,673.0700,1384.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,384.92 in Billed Charges for Rev 278 = $830.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,AETNA,AETNA HSHS,724.76,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,121.92 in Billed Charges for Rev 278 = $724.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,AETNA,ALL COMMERCIAL AETNA,1121.92,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.92 in Billed Charges for Rev 278 = $1,121.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,ANTHEM,ANTHEM POS/HMO,583.40,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,121.92 in Billed Charges for Rev 278 = $583.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,ANTHEM,ANTHEM PPO,583.40,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,121.92 in Billed Charges for Rev 278 = $583.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1121.92,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.92 in Billed Charges for Rev 278 = $1,121.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,CENPATICO,ALL MEDICAID CENPATICO,1121.92,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.92 in Billed Charges for Rev 278 = $1,121.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,953.63,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.92 in Billed Charges for Rev 278 = $953.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,CIGNA,ALL COMMERCIAL CIGNA,785.34,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,121.92 in Billed Charges for Rev 278 = $785.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,COFINITY,COFINITY,1121.92,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.92 in Billed Charges for Rev 278 = $1,121.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1065.82,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,121.92 in Billed Charges for Rev 278 = $1,065.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,942.41,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,121.92 in Billed Charges for Rev 278 = $942.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,796.56,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,121.92 in Billed Charges for Rev 278 = $796.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,819.00,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,121.92 in Billed Charges for Rev 278 = $819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,545.25,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,121.92 in Billed Charges for Rev 278 = $545.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,953.63,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.92 in Billed Charges for Rev 278 = $953.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,HUMANA,HUMANA CHOICE CARE PPO,953.63,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.92 in Billed Charges for Rev 278 = $953.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,819.00,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,121.92 in Billed Charges for Rev 278 = $819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1121.92,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.92 in Billed Charges for Rev 278 = $1,121.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,560.96,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,121.92 in Billed Charges for Rev 278 = $560.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,942.41,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,121.92 in Billed Charges for Rev 278 = $942.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,841.44,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,121.92 in Billed Charges for Rev 278 = $841.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1032.17,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,121.92 in Billed Charges for Rev 278 = $1,032.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,716.12,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,121.92 in Billed Charges for Rev 278 = $716.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,807.78,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.92 in Billed Charges for Rev 278 = $807.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,807.78,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.92 in Billed Charges for Rev 278 = $807.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,695.59,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,121.92 in Billed Charges for Rev 278 = $695.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,807.78,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.92 in Billed Charges for Rev 278 = $807.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,807.78,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.92 in Billed Charges for Rev 278 = $807.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT SUNDT INTERANL CAROTID ENDARTERECTOMY 4 X 5MM,278,RC,10008828,CDM,,,,,,both,,,1121.9200,740.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,673.15,,,,,,,545.2500,1121.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,121.92 in Billed Charges for Rev 278 = $673.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,AETNA,AETNA HSHS,1858.28,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,876.60 in Billed Charges for Rev 278 = $1,858.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,AETNA,ALL COMMERCIAL AETNA,2876.60,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,876.60 in Billed Charges for Rev 278 = $2,876.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,ANTHEM,ANTHEM POS/HMO,1495.83,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,876.60 in Billed Charges for Rev 278 = $1,495.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,ANTHEM,ANTHEM PPO,1495.83,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,876.60 in Billed Charges for Rev 278 = $1,495.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2876.60,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,876.60 in Billed Charges for Rev 278 = $2,876.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,CENPATICO,ALL MEDICAID CENPATICO,2876.60,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,876.60 in Billed Charges for Rev 278 = $2,876.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2445.11,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,876.60 in Billed Charges for Rev 278 = $2,445.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,CIGNA,ALL COMMERCIAL CIGNA,2013.62,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,876.60 in Billed Charges for Rev 278 = $2,013.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,COFINITY,COFINITY,2876.60,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,876.60 in Billed Charges for Rev 278 = $2,876.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2732.77,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,876.60 in Billed Charges for Rev 278 = $2,732.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,2416.34,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,876.60 in Billed Charges for Rev 278 = $2,416.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2042.39,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,876.60 in Billed Charges for Rev 278 = $2,042.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2099.92,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,876.60 in Billed Charges for Rev 278 = $2,099.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,1398.03,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,876.60 in Billed Charges for Rev 278 = $1,398.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2445.11,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,876.60 in Billed Charges for Rev 278 = $2,445.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,HUMANA,HUMANA CHOICE CARE HMO,1438.30,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,876.60 in Billed Charges for Rev 278 = $1,438.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,HUMANA,HUMANA CHOICE CARE PPO,2445.11,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,876.60 in Billed Charges for Rev 278 = $2,445.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,HUMANA,HUMANA NATIIONAL POS HMO,1438.30,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,876.60 in Billed Charges for Rev 278 = $1,438.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2099.92,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,876.60 in Billed Charges for Rev 278 = $2,099.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2876.60,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,876.60 in Billed Charges for Rev 278 = $2,876.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1438.30,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,876.60 in Billed Charges for Rev 278 = $1,438.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2416.34,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,876.60 in Billed Charges for Rev 278 = $2,416.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2157.45,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,876.60 in Billed Charges for Rev 278 = $2,157.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2646.47,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,876.60 in Billed Charges for Rev 278 = $2,646.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1836.13,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,876.60 in Billed Charges for Rev 278 = $1,836.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2071.15,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,876.60 in Billed Charges for Rev 278 = $2,071.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2071.15,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,876.60 in Billed Charges for Rev 278 = $2,071.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1783.49,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,876.60 in Billed Charges for Rev 278 = $1,783.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2071.15,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,876.60 in Billed Charges for Rev 278 = $2,071.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2071.15,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,876.60 in Billed Charges for Rev 278 = $2,071.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SILASTIC TENDON 3 MM X 24CM,278,RC,10031978,CDM,,,,,,both,,,2876.6000,1898.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1725.96,,,,,,,1398.0300,2876.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,876.60 in Billed Charges for Rev 278 = $1,725.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,AETNA,AETNA HSHS,1350.14,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,090.00 in Billed Charges for Rev 278 = $1,350.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,AETNA,ALL COMMERCIAL AETNA,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,ANTHEM,ANTHEM POS/HMO,1086.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,090.00 in Billed Charges for Rev 278 = $1,086.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,ANTHEM,ANTHEM PPO,1086.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,090.00 in Billed Charges for Rev 278 = $1,086.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,CENPATICO,ALL MEDICAID CENPATICO,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1776.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,090.00 in Billed Charges for Rev 278 = $1,776.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,CIGNA,ALL COMMERCIAL CIGNA,1463.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,090.00 in Billed Charges for Rev 278 = $1,463.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,COFINITY,COFINITY,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1985.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,090.00 in Billed Charges for Rev 278 = $1,985.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,1755.60,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,090.00 in Billed Charges for Rev 278 = $1,755.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1483.90,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,090.00 in Billed Charges for Rev 278 = $1,483.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1525.70,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,090.00 in Billed Charges for Rev 278 = $1,525.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,1015.74,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,090.00 in Billed Charges for Rev 278 = $1,015.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1776.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,090.00 in Billed Charges for Rev 278 = $1,776.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,HUMANA,HUMANA CHOICE CARE PPO,1776.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,090.00 in Billed Charges for Rev 278 = $1,776.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1525.70,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,090.00 in Billed Charges for Rev 278 = $1,525.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1045.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,090.00 in Billed Charges for Rev 278 = $1,045.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1755.60,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,090.00 in Billed Charges for Rev 278 = $1,755.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1567.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,090.00 in Billed Charges for Rev 278 = $1,567.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1922.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,090.00 in Billed Charges for Rev 278 = $1,922.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1334.05,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,090.00 in Billed Charges for Rev 278 = $1,334.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1504.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,090.00 in Billed Charges for Rev 278 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1504.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,090.00 in Billed Charges for Rev 278 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1295.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,090.00 in Billed Charges for Rev 278 = $1,295.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1504.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,090.00 in Billed Charges for Rev 278 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1504.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,090.00 in Billed Charges for Rev 278 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPACER SPNL 14X13X8MM ACIS STD LRDTC PEEK AX LUM RADOPQ LAT,278,RC,10078615,CDM,,,,,,both,,,2090.0000,1379.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1254.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,090.00 in Billed Charges for Rev 278 = $1,254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,AETNA,AETNA HSHS,8008.79,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $12,397.50 in Billed Charges for Rev 278 = $8,008.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,AETNA,ALL COMMERCIAL AETNA,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,ANTHEM,ANTHEM POS/HMO,6446.70,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,397.50 in Billed Charges for Rev 278 = $6,446.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,ANTHEM,ANTHEM PPO,6446.70,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,397.50 in Billed Charges for Rev 278 = $6,446.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,CENPATICO,ALL MEDICAID CENPATICO,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10537.88,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,397.50 in Billed Charges for Rev 278 = $10,537.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,CIGNA,ALL COMMERCIAL CIGNA,8678.25,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $12,397.50 in Billed Charges for Rev 278 = $8,678.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,COFINITY,COFINITY,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11777.63,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $12,397.50 in Billed Charges for Rev 278 = $11,777.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,10413.90,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,397.50 in Billed Charges for Rev 278 = $10,413.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8802.23,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $12,397.50 in Billed Charges for Rev 278 = $8,802.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9050.18,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,397.50 in Billed Charges for Rev 278 = $9,050.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,6025.19,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $12,397.50 in Billed Charges for Rev 278 = $6,025.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10537.88,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,397.50 in Billed Charges for Rev 278 = $10,537.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,HUMANA,HUMANA CHOICE CARE HMO,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,HUMANA,HUMANA CHOICE CARE PPO,10537.88,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,397.50 in Billed Charges for Rev 278 = $10,537.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,HUMANA,HUMANA NATIIONAL POS HMO,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9050.18,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,397.50 in Billed Charges for Rev 278 = $9,050.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10413.90,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,397.50 in Billed Charges for Rev 278 = $10,413.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9298.13,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $12,397.50 in Billed Charges for Rev 278 = $9,298.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11405.70,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $12,397.50 in Billed Charges for Rev 278 = $11,405.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,PREVEA HEALTH NETWORK,PREVEA360,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7913.32,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $12,397.50 in Billed Charges for Rev 278 = $7,913.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8926.20,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,397.50 in Billed Charges for Rev 278 = $8,926.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5777.24,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,397.50 in Billed Charges for Rev 278 = $5,777.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,UNITED HEALTHCARE,UHC ONEIDA NATION,5777.24,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,397.50 in Billed Charges for Rev 278 = $5,777.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,UNITED HEALTHCARE,UNITED HEALTHCARE,5777.24,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,397.50 in Billed Charges for Rev 278 = $5,777.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8926.20,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,397.50 in Billed Charges for Rev 278 = $8,926.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7686.45,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $12,397.50 in Billed Charges for Rev 278 = $7,686.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8926.20,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,397.50 in Billed Charges for Rev 278 = $8,926.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8926.20,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,397.50 in Billed Charges for Rev 278 = $8,926.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT NEUROFORM ATLAS W/O TIP  4.5MMX21MM,278,RC,10075030,CDM,,,,,,both,,,12397.5000,8182.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7438.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $12,397.50 in Billed Charges for Rev 278 = $7,438.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,AETNA,AETNA HSHS,2605.23,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,032.86 in Billed Charges for Rev 278 = $2,605.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,AETNA,ALL COMMERCIAL AETNA,4032.86,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,032.86 in Billed Charges for Rev 278 = $4,032.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,ANTHEM,ANTHEM POS/HMO,2097.09,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,032.86 in Billed Charges for Rev 278 = $2,097.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,ANTHEM,ANTHEM PPO,2097.09,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,032.86 in Billed Charges for Rev 278 = $2,097.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4032.86,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,032.86 in Billed Charges for Rev 278 = $4,032.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,CENPATICO,ALL MEDICAID CENPATICO,4032.86,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,032.86 in Billed Charges for Rev 278 = $4,032.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3427.93,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,032.86 in Billed Charges for Rev 278 = $3,427.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,CIGNA,ALL COMMERCIAL CIGNA,2823.00,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,032.86 in Billed Charges for Rev 278 = $2,823.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,COFINITY,COFINITY,4032.86,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,032.86 in Billed Charges for Rev 278 = $4,032.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3831.22,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,032.86 in Billed Charges for Rev 278 = $3,831.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,3387.60,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,032.86 in Billed Charges for Rev 278 = $3,387.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2863.33,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,032.86 in Billed Charges for Rev 278 = $2,863.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2943.99,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,032.86 in Billed Charges for Rev 278 = $2,943.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,1959.97,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,032.86 in Billed Charges for Rev 278 = $1,959.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3427.93,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,032.86 in Billed Charges for Rev 278 = $3,427.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,HUMANA,HUMANA CHOICE CARE HMO,2016.43,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,032.86 in Billed Charges for Rev 278 = $2,016.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,HUMANA,HUMANA CHOICE CARE PPO,3427.93,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,032.86 in Billed Charges for Rev 278 = $3,427.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,HUMANA,HUMANA NATIIONAL POS HMO,2016.43,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,032.86 in Billed Charges for Rev 278 = $2,016.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2943.99,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,032.86 in Billed Charges for Rev 278 = $2,943.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,4032.86,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,032.86 in Billed Charges for Rev 278 = $4,032.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2016.43,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,032.86 in Billed Charges for Rev 278 = $2,016.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3387.60,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,032.86 in Billed Charges for Rev 278 = $3,387.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3024.65,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,032.86 in Billed Charges for Rev 278 = $3,024.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3710.23,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,032.86 in Billed Charges for Rev 278 = $3,710.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2574.17,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,032.86 in Billed Charges for Rev 278 = $2,574.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2903.66,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,032.86 in Billed Charges for Rev 278 = $2,903.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2903.66,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,032.86 in Billed Charges for Rev 278 = $2,903.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2500.37,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,032.86 in Billed Charges for Rev 278 = $2,500.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2903.66,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,032.86 in Billed Charges for Rev 278 = $2,903.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2903.66,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,032.86 in Billed Charges for Rev 278 = $2,903.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP MASTERGRAFT 10CM X 2.0CM X 0.6CM  (7800320),278,RC,10061871,CDM,,,,,,both,,,4032.8600,2661.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2419.72,,,,,,,1959.9700,4032.8600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,032.86 in Billed Charges for Rev 278 = $2,419.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,AETNA,AETNA HSHS,2669.09,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,131.72 in Billed Charges for Rev 278 = $2,669.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,AETNA,ALL COMMERCIAL AETNA,4131.72,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,131.72 in Billed Charges for Rev 278 = $4,131.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,ANTHEM,ANTHEM POS/HMO,2148.49,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,131.72 in Billed Charges for Rev 278 = $2,148.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,ANTHEM,ANTHEM PPO,2148.49,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,131.72 in Billed Charges for Rev 278 = $2,148.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4131.72,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,131.72 in Billed Charges for Rev 278 = $4,131.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,CENPATICO,ALL MEDICAID CENPATICO,4131.72,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,131.72 in Billed Charges for Rev 278 = $4,131.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3511.96,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,131.72 in Billed Charges for Rev 278 = $3,511.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,CIGNA,ALL COMMERCIAL CIGNA,2892.20,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,131.72 in Billed Charges for Rev 278 = $2,892.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,COFINITY,COFINITY,4131.72,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,131.72 in Billed Charges for Rev 278 = $4,131.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3925.13,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,131.72 in Billed Charges for Rev 278 = $3,925.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,3470.64,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,131.72 in Billed Charges for Rev 278 = $3,470.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2933.52,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,131.72 in Billed Charges for Rev 278 = $2,933.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3016.16,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,131.72 in Billed Charges for Rev 278 = $3,016.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,2008.02,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,131.72 in Billed Charges for Rev 278 = $2,008.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3511.96,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,131.72 in Billed Charges for Rev 278 = $3,511.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,HUMANA,HUMANA CHOICE CARE HMO,2065.86,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,131.72 in Billed Charges for Rev 278 = $2,065.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,HUMANA,HUMANA CHOICE CARE PPO,3511.96,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,131.72 in Billed Charges for Rev 278 = $3,511.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,HUMANA,HUMANA NATIIONAL POS HMO,2065.86,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,131.72 in Billed Charges for Rev 278 = $2,065.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3016.16,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,131.72 in Billed Charges for Rev 278 = $3,016.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,4131.72,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,131.72 in Billed Charges for Rev 278 = $4,131.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2065.86,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,131.72 in Billed Charges for Rev 278 = $2,065.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3470.64,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,131.72 in Billed Charges for Rev 278 = $3,470.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3098.79,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,131.72 in Billed Charges for Rev 278 = $3,098.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3801.18,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,131.72 in Billed Charges for Rev 278 = $3,801.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2637.28,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,131.72 in Billed Charges for Rev 278 = $2,637.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2974.84,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,131.72 in Billed Charges for Rev 278 = $2,974.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2974.84,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,131.72 in Billed Charges for Rev 278 = $2,974.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2561.67,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,131.72 in Billed Charges for Rev 278 = $2,561.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2974.84,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,131.72 in Billed Charges for Rev 278 = $2,974.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2974.84,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,131.72 in Billed Charges for Rev 278 = $2,974.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP OSTEOFIL 1CM MOLDABLE 90 (002390),278,RC,10012093,CDM,,,,,,both,,,4131.7200,2726.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2479.03,,,,,,,2008.0200,4131.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,131.72 in Billed Charges for Rev 278 = $2,479.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,AETNA,AETNA HSHS,2124.69,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,289.00 in Billed Charges for Rev 278 = $2,124.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,AETNA,ALL COMMERCIAL AETNA,3289.00,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,289.00 in Billed Charges for Rev 278 = $3,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,ANTHEM,ANTHEM POS/HMO,1710.28,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,289.00 in Billed Charges for Rev 278 = $1,710.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,ANTHEM,ANTHEM PPO,1710.28,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,289.00 in Billed Charges for Rev 278 = $1,710.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3289.00,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,289.00 in Billed Charges for Rev 278 = $3,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,CENPATICO,ALL MEDICAID CENPATICO,3289.00,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,289.00 in Billed Charges for Rev 278 = $3,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2795.65,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,289.00 in Billed Charges for Rev 278 = $2,795.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,CIGNA,ALL COMMERCIAL CIGNA,2302.30,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,289.00 in Billed Charges for Rev 278 = $2,302.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,COFINITY,COFINITY,3289.00,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,289.00 in Billed Charges for Rev 278 = $3,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3124.55,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,289.00 in Billed Charges for Rev 278 = $3,124.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,2762.76,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,289.00 in Billed Charges for Rev 278 = $2,762.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2335.19,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,289.00 in Billed Charges for Rev 278 = $2,335.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2400.97,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,289.00 in Billed Charges for Rev 278 = $2,400.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,1598.45,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,289.00 in Billed Charges for Rev 278 = $1,598.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2795.65,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,289.00 in Billed Charges for Rev 278 = $2,795.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,HUMANA,HUMANA CHOICE CARE HMO,1644.50,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,289.00 in Billed Charges for Rev 278 = $1,644.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,HUMANA,HUMANA CHOICE CARE PPO,2795.65,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,289.00 in Billed Charges for Rev 278 = $2,795.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,HUMANA,HUMANA NATIIONAL POS HMO,1644.50,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,289.00 in Billed Charges for Rev 278 = $1,644.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2400.97,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,289.00 in Billed Charges for Rev 278 = $2,400.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3289.00,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,289.00 in Billed Charges for Rev 278 = $3,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1644.50,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,289.00 in Billed Charges for Rev 278 = $1,644.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2762.76,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,289.00 in Billed Charges for Rev 278 = $2,762.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2466.75,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,289.00 in Billed Charges for Rev 278 = $2,466.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3025.88,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,289.00 in Billed Charges for Rev 278 = $3,025.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2099.37,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,289.00 in Billed Charges for Rev 278 = $2,099.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2368.08,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,289.00 in Billed Charges for Rev 278 = $2,368.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2368.08,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,289.00 in Billed Charges for Rev 278 = $2,368.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2039.18,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,289.00 in Billed Charges for Rev 278 = $2,039.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2368.08,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,289.00 in Billed Charges for Rev 278 = $2,368.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2368.08,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,289.00 in Billed Charges for Rev 278 = $2,368.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION TIGHTROPE XP,278,RC,10084155,CDM,,,,,,both,,,3289.0000,2170.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1973.40,,,,,,,1598.4500,3289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,289.00 in Billed Charges for Rev 278 = $1,973.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,AETNA,AETNA HSHS,2622.11,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,059.00 in Billed Charges for Rev 278 = $2,622.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,AETNA,ALL COMMERCIAL AETNA,4059.00,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,059.00 in Billed Charges for Rev 278 = $4,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,ANTHEM,ANTHEM POS/HMO,2110.68,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,059.00 in Billed Charges for Rev 278 = $2,110.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,ANTHEM,ANTHEM PPO,2110.68,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,059.00 in Billed Charges for Rev 278 = $2,110.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4059.00,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,059.00 in Billed Charges for Rev 278 = $4,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,CENPATICO,ALL MEDICAID CENPATICO,4059.00,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,059.00 in Billed Charges for Rev 278 = $4,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3450.15,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,059.00 in Billed Charges for Rev 278 = $3,450.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,CIGNA,ALL COMMERCIAL CIGNA,2841.30,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,059.00 in Billed Charges for Rev 278 = $2,841.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,COFINITY,COFINITY,4059.00,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,059.00 in Billed Charges for Rev 278 = $4,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3856.05,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,059.00 in Billed Charges for Rev 278 = $3,856.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,3409.56,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,059.00 in Billed Charges for Rev 278 = $3,409.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2881.89,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,059.00 in Billed Charges for Rev 278 = $2,881.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2963.07,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,059.00 in Billed Charges for Rev 278 = $2,963.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,1972.67,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,059.00 in Billed Charges for Rev 278 = $1,972.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3450.15,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,059.00 in Billed Charges for Rev 278 = $3,450.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,HUMANA,HUMANA CHOICE CARE HMO,2029.50,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,059.00 in Billed Charges for Rev 278 = $2,029.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,HUMANA,HUMANA CHOICE CARE PPO,3450.15,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,059.00 in Billed Charges for Rev 278 = $3,450.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,HUMANA,HUMANA NATIIONAL POS HMO,2029.50,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,059.00 in Billed Charges for Rev 278 = $2,029.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2963.07,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,059.00 in Billed Charges for Rev 278 = $2,963.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,4059.00,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,059.00 in Billed Charges for Rev 278 = $4,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2029.50,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,059.00 in Billed Charges for Rev 278 = $2,029.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3409.56,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,059.00 in Billed Charges for Rev 278 = $3,409.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3044.25,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,059.00 in Billed Charges for Rev 278 = $3,044.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3734.28,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,059.00 in Billed Charges for Rev 278 = $3,734.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2590.86,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,059.00 in Billed Charges for Rev 278 = $2,590.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2922.48,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,059.00 in Billed Charges for Rev 278 = $2,922.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2922.48,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,059.00 in Billed Charges for Rev 278 = $2,922.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2516.58,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,059.00 in Billed Charges for Rev 278 = $2,516.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2922.48,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,059.00 in Billed Charges for Rev 278 = $2,922.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2922.48,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,059.00 in Billed Charges for Rev 278 = $2,922.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM H-V LUMBAR VALUE SYSTEM MEDIUM PRESSURE,278,RC,10018935,CDM,,,,,,both,,,4059.0000,2678.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2435.40,,,,,,,1972.6700,4059.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,059.00 in Billed Charges for Rev 278 = $2,435.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,AETNA,AETNA HSHS,6395.40,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $9,900.00 in Billed Charges for Rev 278 = $6,395.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,AETNA,ALL COMMERCIAL AETNA,9900.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,900.00 in Billed Charges for Rev 278 = $9,900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,ANTHEM,ANTHEM POS/HMO,5148.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,900.00 in Billed Charges for Rev 278 = $5,148.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,ANTHEM,ANTHEM PPO,5148.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,900.00 in Billed Charges for Rev 278 = $5,148.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9900.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,900.00 in Billed Charges for Rev 278 = $9,900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,CENPATICO,ALL MEDICAID CENPATICO,9900.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,900.00 in Billed Charges for Rev 278 = $9,900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8415.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,900.00 in Billed Charges for Rev 278 = $8,415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,CIGNA,ALL COMMERCIAL CIGNA,6930.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $9,900.00 in Billed Charges for Rev 278 = $6,930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,COFINITY,COFINITY,9900.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,900.00 in Billed Charges for Rev 278 = $9,900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9405.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $9,900.00 in Billed Charges for Rev 278 = $9,405.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,8316.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,900.00 in Billed Charges for Rev 278 = $8,316.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7029.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $9,900.00 in Billed Charges for Rev 278 = $7,029.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7227.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,900.00 in Billed Charges for Rev 278 = $7,227.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,4811.40,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $9,900.00 in Billed Charges for Rev 278 = $4,811.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8415.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,900.00 in Billed Charges for Rev 278 = $8,415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,HUMANA,HUMANA CHOICE CARE HMO,4950.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,900.00 in Billed Charges for Rev 278 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,HUMANA,HUMANA CHOICE CARE PPO,8415.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,900.00 in Billed Charges for Rev 278 = $8,415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,HUMANA,HUMANA NATIIONAL POS HMO,4950.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,900.00 in Billed Charges for Rev 278 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7227.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,900.00 in Billed Charges for Rev 278 = $7,227.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,9900.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,900.00 in Billed Charges for Rev 278 = $9,900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4950.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,900.00 in Billed Charges for Rev 278 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8316.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,900.00 in Billed Charges for Rev 278 = $8,316.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7425.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $9,900.00 in Billed Charges for Rev 278 = $7,425.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9108.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $9,900.00 in Billed Charges for Rev 278 = $9,108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4950.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,900.00 in Billed Charges for Rev 278 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4950.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,900.00 in Billed Charges for Rev 278 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,PREVEA HEALTH NETWORK,PREVEA360,4950.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,900.00 in Billed Charges for Rev 278 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4950.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,900.00 in Billed Charges for Rev 278 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6319.17,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $9,900.00 in Billed Charges for Rev 278 = $6,319.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7128.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,900.00 in Billed Charges for Rev 278 = $7,128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4613.40,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,900.00 in Billed Charges for Rev 278 = $4,613.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,4613.40,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,900.00 in Billed Charges for Rev 278 = $4,613.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,4613.40,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,900.00 in Billed Charges for Rev 278 = $4,613.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7128.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,900.00 in Billed Charges for Rev 278 = $7,128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6138.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $9,900.00 in Billed Charges for Rev 278 = $6,138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7128.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,900.00 in Billed Charges for Rev 278 = $7,128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7128.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,900.00 in Billed Charges for Rev 278 = $7,128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM LINX REFLUX MANAGEMENT SZ 13,278,RC,10066140,CDM,,,,,,both,,,9900.0000,6534.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5940.00,,,,,,,4613.4000,9900.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,900.00 in Billed Charges for Rev 278 = $5,940.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,AETNA,AETNA HSHS,443.06,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $685.85 in Billed Charges for Rev 278 = $443.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,AETNA,ALL COMMERCIAL AETNA,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,CENPATICO,ALL MEDICAID CENPATICO,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,582.97,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.85 in Billed Charges for Rev 278 = $582.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,CIGNA,ALL COMMERCIAL CIGNA,480.10,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $685.85 in Billed Charges for Rev 278 = $480.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,COFINITY,COFINITY,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,651.56,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $685.85 in Billed Charges for Rev 278 = $651.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,576.11,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $685.85 in Billed Charges for Rev 278 = $576.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,486.95,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $685.85 in Billed Charges for Rev 278 = $486.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,500.67,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $685.85 in Billed Charges for Rev 278 = $500.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,333.32,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $685.85 in Billed Charges for Rev 278 = $333.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,582.97,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.85 in Billed Charges for Rev 278 = $582.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,HUMANA,HUMANA CHOICE CARE PPO,582.97,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.85 in Billed Charges for Rev 278 = $582.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,500.67,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $685.85 in Billed Charges for Rev 278 = $500.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,342.93,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $685.85 in Billed Charges for Rev 278 = $342.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,576.11,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $685.85 in Billed Charges for Rev 278 = $576.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,514.39,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $685.85 in Billed Charges for Rev 278 = $514.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,630.98,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $685.85 in Billed Charges for Rev 278 = $630.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,437.78,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $685.85 in Billed Charges for Rev 278 = $437.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,493.81,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.85 in Billed Charges for Rev 278 = $493.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,493.81,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.85 in Billed Charges for Rev 278 = $493.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,425.23,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $685.85 in Billed Charges for Rev 278 = $425.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,493.81,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.85 in Billed Charges for Rev 278 = $493.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,493.81,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.85 in Billed Charges for Rev 278 = $493.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE PERICARDIUM TUTOPLAST DEHYDRATED HUMAN 1.5 X 1.5,278,RC,10013988,CDM,,,,,,both,,,685.8500,452.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,411.51,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $685.85 in Billed Charges for Rev 278 = $411.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,AETNA,AETNA HSHS,26.87,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $41.60 in Billed Charges for Rev 278 = $26.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,AETNA,ALL COMMERCIAL AETNA,41.60,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.60 in Billed Charges for Rev 278 = $41.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,41.60,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.60 in Billed Charges for Rev 278 = $41.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,CENPATICO,ALL MEDICAID CENPATICO,41.60,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.60 in Billed Charges for Rev 278 = $41.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,35.36,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.60 in Billed Charges for Rev 278 = $35.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,CIGNA,ALL COMMERCIAL CIGNA,29.12,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $41.60 in Billed Charges for Rev 278 = $29.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,COFINITY,COFINITY,41.60,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.60 in Billed Charges for Rev 278 = $41.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,39.52,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $41.60 in Billed Charges for Rev 278 = $39.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,34.94,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.60 in Billed Charges for Rev 278 = $34.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.54,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $41.60 in Billed Charges for Rev 278 = $29.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,30.37,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.60 in Billed Charges for Rev 278 = $30.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,20.22,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $41.60 in Billed Charges for Rev 278 = $20.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,35.36,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.60 in Billed Charges for Rev 278 = $35.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,HUMANA,HUMANA CHOICE CARE PPO,35.36,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.60 in Billed Charges for Rev 278 = $35.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,30.37,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.60 in Billed Charges for Rev 278 = $30.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,41.60,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.60 in Billed Charges for Rev 278 = $41.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,20.80,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $41.60 in Billed Charges for Rev 278 = $20.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,34.94,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.60 in Billed Charges for Rev 278 = $34.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,31.20,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $41.60 in Billed Charges for Rev 278 = $31.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,38.27,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $41.60 in Billed Charges for Rev 278 = $38.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.55,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $41.60 in Billed Charges for Rev 278 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,29.95,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.60 in Billed Charges for Rev 278 = $29.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,29.95,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.60 in Billed Charges for Rev 278 = $29.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,25.79,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $41.60 in Billed Charges for Rev 278 = $25.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,29.95,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.60 in Billed Charges for Rev 278 = $29.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,29.95,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.60 in Billed Charges for Rev 278 = $29.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE POPE VENT SINGLE,278,RC,ASC143,CDM,,,,,,both,,,41.6000,27.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,24.96,,,,,,,20.2200,41.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.60 in Billed Charges for Rev 278 = $24.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,AETNA,AETNA HSHS,42.53,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $65.84 in Billed Charges for Rev 278 = $42.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,AETNA,ALL COMMERCIAL AETNA,65.84,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.84 in Billed Charges for Rev 278 = $65.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,65.84,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.84 in Billed Charges for Rev 278 = $65.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,CENPATICO,ALL MEDICAID CENPATICO,65.84,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.84 in Billed Charges for Rev 278 = $65.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,55.96,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $65.84 in Billed Charges for Rev 278 = $55.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,CIGNA,ALL COMMERCIAL CIGNA,46.09,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $65.84 in Billed Charges for Rev 278 = $46.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,COFINITY,COFINITY,65.84,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.84 in Billed Charges for Rev 278 = $65.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,62.55,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $65.84 in Billed Charges for Rev 278 = $62.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,55.31,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $65.84 in Billed Charges for Rev 278 = $55.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,46.75,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $65.84 in Billed Charges for Rev 278 = $46.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,48.06,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $65.84 in Billed Charges for Rev 278 = $48.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,32.00,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $65.84 in Billed Charges for Rev 278 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,55.96,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $65.84 in Billed Charges for Rev 278 = $55.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,HUMANA,HUMANA CHOICE CARE PPO,55.96,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $65.84 in Billed Charges for Rev 278 = $55.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,48.06,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $65.84 in Billed Charges for Rev 278 = $48.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,65.84,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.84 in Billed Charges for Rev 278 = $65.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,32.92,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $65.84 in Billed Charges for Rev 278 = $32.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,55.31,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $65.84 in Billed Charges for Rev 278 = $55.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,49.38,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $65.84 in Billed Charges for Rev 278 = $49.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,60.57,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $65.84 in Billed Charges for Rev 278 = $60.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,42.03,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $65.84 in Billed Charges for Rev 278 = $42.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,47.40,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $65.84 in Billed Charges for Rev 278 = $47.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,47.40,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $65.84 in Billed Charges for Rev 278 = $47.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,40.82,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $65.84 in Billed Charges for Rev 278 = $40.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,47.40,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $65.84 in Billed Charges for Rev 278 = $47.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,47.40,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $65.84 in Billed Charges for Rev 278 = $47.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH CUFF SIZE 6,278,RC,10014225,CDM,,,,,,both,,,65.8400,43.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,39.50,,,,,,,32.0000,65.8400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $65.84 in Billed Charges for Rev 278 = $39.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,AETNA,AETNA HSHS,52.92,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $81.92 in Billed Charges for Rev 278 = $52.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,AETNA,ALL COMMERCIAL AETNA,81.92,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.92 in Billed Charges for Rev 278 = $81.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,81.92,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.92 in Billed Charges for Rev 278 = $81.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,CENPATICO,ALL MEDICAID CENPATICO,81.92,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.92 in Billed Charges for Rev 278 = $81.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.63,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.92 in Billed Charges for Rev 278 = $69.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,CIGNA,ALL COMMERCIAL CIGNA,57.34,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $81.92 in Billed Charges for Rev 278 = $57.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,COFINITY,COFINITY,81.92,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.92 in Billed Charges for Rev 278 = $81.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.82,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $81.92 in Billed Charges for Rev 278 = $77.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,68.81,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.92 in Billed Charges for Rev 278 = $68.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,58.16,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $81.92 in Billed Charges for Rev 278 = $58.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.80,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.92 in Billed Charges for Rev 278 = $59.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,39.81,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $81.92 in Billed Charges for Rev 278 = $39.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.63,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.92 in Billed Charges for Rev 278 = $69.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,HUMANA,HUMANA CHOICE CARE PPO,69.63,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.92 in Billed Charges for Rev 278 = $69.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.80,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.92 in Billed Charges for Rev 278 = $59.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,81.92,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.92 in Billed Charges for Rev 278 = $81.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,40.96,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $81.92 in Billed Charges for Rev 278 = $40.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.81,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.92 in Billed Charges for Rev 278 = $68.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.44,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $81.92 in Billed Charges for Rev 278 = $61.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,75.37,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $81.92 in Billed Charges for Rev 278 = $75.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,52.29,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $81.92 in Billed Charges for Rev 278 = $52.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,58.98,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.92 in Billed Charges for Rev 278 = $58.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,58.98,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.92 in Billed Charges for Rev 278 = $58.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.79,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $81.92 in Billed Charges for Rev 278 = $50.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,58.98,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.92 in Billed Charges for Rev 278 = $58.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,58.98,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.92 in Billed Charges for Rev 278 = $58.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACH SHILEY CUFFED 8.5MM,278,RC,10085341,CDM,,,,,,both,,,81.9200,54.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,49.15,,,,,,,39.8100,81.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.92 in Billed Charges for Rev 278 = $49.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,AETNA,AETNA HSHS,55.27,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $85.55 in Billed Charges for Rev 278 = $55.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,AETNA,ALL COMMERCIAL AETNA,85.55,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.55 in Billed Charges for Rev 278 = $85.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,85.55,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.55 in Billed Charges for Rev 278 = $85.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,CENPATICO,ALL MEDICAID CENPATICO,85.55,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.55 in Billed Charges for Rev 278 = $85.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,72.72,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.55 in Billed Charges for Rev 278 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,CIGNA,ALL COMMERCIAL CIGNA,59.89,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $85.55 in Billed Charges for Rev 278 = $59.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,COFINITY,COFINITY,85.55,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.55 in Billed Charges for Rev 278 = $85.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,81.27,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $85.55 in Billed Charges for Rev 278 = $81.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,71.86,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.55 in Billed Charges for Rev 278 = $71.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,60.74,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $85.55 in Billed Charges for Rev 278 = $60.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,62.45,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.55 in Billed Charges for Rev 278 = $62.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,41.58,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $85.55 in Billed Charges for Rev 278 = $41.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,72.72,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.55 in Billed Charges for Rev 278 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,HUMANA,HUMANA CHOICE CARE PPO,72.72,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.55 in Billed Charges for Rev 278 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,62.45,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.55 in Billed Charges for Rev 278 = $62.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,85.55,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.55 in Billed Charges for Rev 278 = $85.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,42.78,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $85.55 in Billed Charges for Rev 278 = $42.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,71.86,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.55 in Billed Charges for Rev 278 = $71.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,64.16,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $85.55 in Billed Charges for Rev 278 = $64.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,78.71,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $85.55 in Billed Charges for Rev 278 = $78.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,54.61,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $85.55 in Billed Charges for Rev 278 = $54.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,61.60,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.55 in Billed Charges for Rev 278 = $61.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,61.60,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.55 in Billed Charges for Rev 278 = $61.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,53.04,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $85.55 in Billed Charges for Rev 278 = $53.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,61.60,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.55 in Billed Charges for Rev 278 = $61.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,61.60,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.55 in Billed Charges for Rev 278 = $61.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 4,278,RC,10015732,CDM,,,,,,both,,,85.5500,56.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,51.33,,,,,,,41.5800,85.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.55 in Billed Charges for Rev 278 = $51.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,AETNA,AETNA HSHS,55.01,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $85.16 in Billed Charges for Rev 278 = $55.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,AETNA,ALL COMMERCIAL AETNA,85.16,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.16 in Billed Charges for Rev 278 = $85.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,85.16,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.16 in Billed Charges for Rev 278 = $85.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,CENPATICO,ALL MEDICAID CENPATICO,85.16,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.16 in Billed Charges for Rev 278 = $85.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,72.39,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.16 in Billed Charges for Rev 278 = $72.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,CIGNA,ALL COMMERCIAL CIGNA,59.61,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $85.16 in Billed Charges for Rev 278 = $59.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,COFINITY,COFINITY,85.16,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.16 in Billed Charges for Rev 278 = $85.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,80.90,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $85.16 in Billed Charges for Rev 278 = $80.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,71.53,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.16 in Billed Charges for Rev 278 = $71.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,60.46,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $85.16 in Billed Charges for Rev 278 = $60.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,62.17,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.16 in Billed Charges for Rev 278 = $62.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,41.39,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $85.16 in Billed Charges for Rev 278 = $41.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,72.39,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.16 in Billed Charges for Rev 278 = $72.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,HUMANA,HUMANA CHOICE CARE PPO,72.39,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.16 in Billed Charges for Rev 278 = $72.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,62.17,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.16 in Billed Charges for Rev 278 = $62.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,85.16,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.16 in Billed Charges for Rev 278 = $85.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,42.58,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $85.16 in Billed Charges for Rev 278 = $42.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,71.53,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.16 in Billed Charges for Rev 278 = $71.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,63.87,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $85.16 in Billed Charges for Rev 278 = $63.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,78.35,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $85.16 in Billed Charges for Rev 278 = $78.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,54.36,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $85.16 in Billed Charges for Rev 278 = $54.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,61.32,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.16 in Billed Charges for Rev 278 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,61.32,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.16 in Billed Charges for Rev 278 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,52.80,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $85.16 in Billed Charges for Rev 278 = $52.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,61.32,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.16 in Billed Charges for Rev 278 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,61.32,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.16 in Billed Charges for Rev 278 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE TRACHEOSTOMY FENESTRATED SHILEY 8,278,RC,10014613,CDM,,,,,,both,,,85.1600,56.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,51.10,,,,,,,41.3900,85.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.16 in Billed Charges for Rev 278 = $51.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,AETNA,AETNA HSHS,622.23,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $963.20 in Billed Charges for Rev 278 = $622.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,AETNA,ALL COMMERCIAL AETNA,963.20,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $963.20 in Billed Charges for Rev 278 = $963.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,963.20,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $963.20 in Billed Charges for Rev 278 = $963.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,CENPATICO,ALL MEDICAID CENPATICO,963.20,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $963.20 in Billed Charges for Rev 278 = $963.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,818.72,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $963.20 in Billed Charges for Rev 278 = $818.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,CIGNA,ALL COMMERCIAL CIGNA,674.24,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $963.20 in Billed Charges for Rev 278 = $674.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,COFINITY,COFINITY,963.20,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $963.20 in Billed Charges for Rev 278 = $963.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,915.04,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $963.20 in Billed Charges for Rev 278 = $915.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,HEALTH CARE ALLIANCE,THE ALLIANCE,809.09,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $963.20 in Billed Charges for Rev 278 = $809.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,683.87,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $963.20 in Billed Charges for Rev 278 = $683.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,703.14,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $963.20 in Billed Charges for Rev 278 = $703.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,HSHS EMPLOYEES,HSHS EMPLOYEES,468.12,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $963.20 in Billed Charges for Rev 278 = $468.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,818.72,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $963.20 in Billed Charges for Rev 278 = $818.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,HUMANA,HUMANA CHOICE CARE PPO,818.72,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $963.20 in Billed Charges for Rev 278 = $818.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,703.14,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $963.20 in Billed Charges for Rev 278 = $703.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,LIVE360,LIVE360 HSHS HEALTHY PLAN,963.20,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $963.20 in Billed Charges for Rev 278 = $963.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,481.60,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $963.20 in Billed Charges for Rev 278 = $481.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,809.09,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $963.20 in Billed Charges for Rev 278 = $809.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,722.40,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $963.20 in Billed Charges for Rev 278 = $722.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,886.14,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $963.20 in Billed Charges for Rev 278 = $886.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,614.81,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $963.20 in Billed Charges for Rev 278 = $614.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,693.50,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $963.20 in Billed Charges for Rev 278 = $693.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,693.50,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $963.20 in Billed Charges for Rev 278 = $693.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,597.18,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $963.20 in Billed Charges for Rev 278 = $597.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,693.50,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $963.20 in Billed Charges for Rev 278 = $693.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,693.50,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $963.20 in Billed Charges for Rev 278 = $693.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT 3MM .2MM CLIP EAR TITAN PART,278,RC,10083827,CDM,,,,,,both,,,963.2000,635.7100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,577.92,,,,,,,468.1200,963.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $963.20 in Billed Charges for Rev 278 = $577.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,AETNA,AETNA HSHS,13.27,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.54 in Billed Charges for Rev 278 = $13.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,AETNA,ALL COMMERCIAL AETNA,20.54,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.54 in Billed Charges for Rev 278 = $20.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.54,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.54 in Billed Charges for Rev 278 = $20.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,CENPATICO,ALL MEDICAID CENPATICO,20.54,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.54 in Billed Charges for Rev 278 = $20.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.46,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.54 in Billed Charges for Rev 278 = $17.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,CIGNA,ALL COMMERCIAL CIGNA,14.38,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.54 in Billed Charges for Rev 278 = $14.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,COFINITY,COFINITY,20.54,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.54 in Billed Charges for Rev 278 = $20.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.51,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.54 in Billed Charges for Rev 278 = $19.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,17.25,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.54 in Billed Charges for Rev 278 = $17.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.58,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.54 in Billed Charges for Rev 278 = $14.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.99,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.54 in Billed Charges for Rev 278 = $14.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,9.98,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.54 in Billed Charges for Rev 278 = $9.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.46,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.54 in Billed Charges for Rev 278 = $17.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,HUMANA,HUMANA CHOICE CARE PPO,17.46,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.54 in Billed Charges for Rev 278 = $17.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.99,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.54 in Billed Charges for Rev 278 = $14.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.54,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.54 in Billed Charges for Rev 278 = $20.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.27,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.54 in Billed Charges for Rev 278 = $10.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.25,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.54 in Billed Charges for Rev 278 = $17.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.41,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.54 in Billed Charges for Rev 278 = $15.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.90,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.54 in Billed Charges for Rev 278 = $18.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.11,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.54 in Billed Charges for Rev 278 = $13.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.79,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.54 in Billed Charges for Rev 278 = $14.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.79,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.54 in Billed Charges for Rev 278 = $14.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.73,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.54 in Billed Charges for Rev 278 = $12.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.79,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.54 in Billed Charges for Rev 278 = $14.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.79,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.54 in Billed Charges for Rev 278 = $14.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENT CLR 7MM .86MM STRT POLYETH SM FLNG MYRNGTM STER,278,RC,10000217,CDM,,,,,,both,,,20.5400,13.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.32,,,,,,,9.9800,20.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.54 in Billed Charges for Rev 278 = $12.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,AETNA,AETNA HSHS,8953.56,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $13,860.00 in Billed Charges for Rev 278 = $8,953.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,AETNA,ALL COMMERCIAL AETNA,13860.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,860.00 in Billed Charges for Rev 278 = $13,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,ANTHEM,ANTHEM POS/HMO,7207.20,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $13,860.00 in Billed Charges for Rev 278 = $7,207.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,ANTHEM,ANTHEM PPO,7207.20,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $13,860.00 in Billed Charges for Rev 278 = $7,207.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13860.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,860.00 in Billed Charges for Rev 278 = $13,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,CENPATICO,ALL MEDICAID CENPATICO,13860.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,860.00 in Billed Charges for Rev 278 = $13,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11781.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,860.00 in Billed Charges for Rev 278 = $11,781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,CIGNA,ALL COMMERCIAL CIGNA,9702.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $13,860.00 in Billed Charges for Rev 278 = $9,702.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,COFINITY,COFINITY,13860.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,860.00 in Billed Charges for Rev 278 = $13,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13167.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $13,860.00 in Billed Charges for Rev 278 = $13,167.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,11642.40,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $13,860.00 in Billed Charges for Rev 278 = $11,642.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9840.60,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $13,860.00 in Billed Charges for Rev 278 = $9,840.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10117.80,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $13,860.00 in Billed Charges for Rev 278 = $10,117.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,6735.96,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $13,860.00 in Billed Charges for Rev 278 = $6,735.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11781.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,860.00 in Billed Charges for Rev 278 = $11,781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,HUMANA,HUMANA CHOICE CARE HMO,6930.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,860.00 in Billed Charges for Rev 278 = $6,930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,HUMANA,HUMANA CHOICE CARE PPO,11781.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,860.00 in Billed Charges for Rev 278 = $11,781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,HUMANA,HUMANA NATIIONAL POS HMO,6930.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,860.00 in Billed Charges for Rev 278 = $6,930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10117.80,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $13,860.00 in Billed Charges for Rev 278 = $10,117.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,13860.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,860.00 in Billed Charges for Rev 278 = $13,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6930.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,860.00 in Billed Charges for Rev 278 = $6,930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11642.40,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $13,860.00 in Billed Charges for Rev 278 = $11,642.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10395.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $13,860.00 in Billed Charges for Rev 278 = $10,395.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12751.20,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $13,860.00 in Billed Charges for Rev 278 = $12,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6930.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,860.00 in Billed Charges for Rev 278 = $6,930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6930.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,860.00 in Billed Charges for Rev 278 = $6,930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,PREVEA HEALTH NETWORK,PREVEA360,6930.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,860.00 in Billed Charges for Rev 278 = $6,930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6930.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,860.00 in Billed Charges for Rev 278 = $6,930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8846.84,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $13,860.00 in Billed Charges for Rev 278 = $8,846.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9979.20,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,860.00 in Billed Charges for Rev 278 = $9,979.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6458.76,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $13,860.00 in Billed Charges for Rev 278 = $6,458.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,6458.76,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $13,860.00 in Billed Charges for Rev 278 = $6,458.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,6458.76,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $13,860.00 in Billed Charges for Rev 278 = $6,458.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9979.20,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,860.00 in Billed Charges for Rev 278 = $9,979.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8593.20,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $13,860.00 in Billed Charges for Rev 278 = $8,593.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9979.20,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,860.00 in Billed Charges for Rev 278 = $9,979.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9979.20,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,860.00 in Billed Charges for Rev 278 = $9,979.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL C-E 25MM,278,RC,10046564,CDM,,,,,,both,,,13860.0000,9147.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8316.00,,,,,,,6458.7600,13860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $13,860.00 in Billed Charges for Rev 278 = $8,316.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,AETNA,AETNA HSHS,1746.71,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,746.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,AETNA,ALL COMMERCIAL AETNA,2703.89,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,703.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,ANTHEM,ANTHEM POS/HMO,1406.02,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,406.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,ANTHEM,ANTHEM PPO,1406.02,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,406.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2703.89,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,703.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,CENPATICO,ALL MEDICAID CENPATICO,2703.89,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,703.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2298.31,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,298.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,CIGNA,ALL COMMERCIAL CIGNA,1892.72,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,892.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,COFINITY,COFINITY,2703.89,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,703.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2568.70,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,568.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,2271.27,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,271.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1919.76,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,919.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1973.84,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,973.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,1314.09,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,314.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2298.31,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,298.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,HUMANA,HUMANA CHOICE CARE HMO,1351.95,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,351.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,HUMANA,HUMANA CHOICE CARE PPO,2298.31,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,298.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,HUMANA,HUMANA NATIIONAL POS HMO,1351.95,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,351.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1973.84,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,973.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,2703.89,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,703.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1351.95,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,351.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2271.27,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,271.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2027.92,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,027.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2487.58,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $2,487.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1725.89,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,725.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1946.80,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,946.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1946.80,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,946.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1676.41,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,676.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1946.80,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,946.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1946.80,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,946.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409750,CDM,,,,both,,,2703.8900,1784.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1622.33,,,,,,,1314.0900,2703.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,703.89 in Billed Charges for Rev 278 Proc C1713 = $1,622.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,AETNA,AETNA HSHS,1708.91,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,708.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,AETNA,ALL COMMERCIAL AETNA,2645.37,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,645.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,ANTHEM,ANTHEM POS/HMO,1375.59,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,375.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,ANTHEM,ANTHEM PPO,1375.59,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,375.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2645.37,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,645.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,CENPATICO,ALL MEDICAID CENPATICO,2645.37,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,645.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2248.56,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,248.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,CIGNA,ALL COMMERCIAL CIGNA,1851.76,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,851.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,COFINITY,COFINITY,2645.37,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,645.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2513.10,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,513.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,2222.11,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,222.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1878.21,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,878.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1931.12,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,931.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,1285.65,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,285.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2248.56,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,248.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,HUMANA,HUMANA CHOICE CARE HMO,1322.69,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,322.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,HUMANA,HUMANA CHOICE CARE PPO,2248.56,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,248.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,HUMANA,HUMANA NATIIONAL POS HMO,1322.69,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,322.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1931.12,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,931.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2645.37,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,645.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1322.69,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,322.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2222.11,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,222.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1984.03,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,984.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2433.74,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $2,433.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1688.54,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,688.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1904.67,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,904.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1904.67,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,904.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1640.13,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,640.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1904.67,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,904.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1904.67,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,904.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/LEFT,C1713,HCPCS,278,RC,70409752,CDM,,,,both,,,2645.3700,1745.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1587.22,,,,,,,1285.6500,2645.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,645.37 in Billed Charges for Rev 278 Proc C1713 = $1,587.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,AETNA,AETNA HSHS,1649.72,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,649.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,AETNA,ALL COMMERCIAL AETNA,2553.75,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,553.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,ANTHEM,ANTHEM POS/HMO,1327.95,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,327.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,ANTHEM,ANTHEM PPO,1327.95,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,327.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2553.75,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,553.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,CENPATICO,ALL MEDICAID CENPATICO,2553.75,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,553.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2170.69,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,170.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,CIGNA,ALL COMMERCIAL CIGNA,1787.63,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,787.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,COFINITY,COFINITY,2553.75,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,553.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2426.06,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,426.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,2145.15,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,145.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1813.16,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,813.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1864.24,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,864.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,1241.12,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,241.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2170.69,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,170.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,HUMANA,HUMANA CHOICE CARE HMO,1276.88,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,276.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,HUMANA,HUMANA CHOICE CARE PPO,2170.69,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,170.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,HUMANA,HUMANA NATIIONAL POS HMO,1276.88,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,276.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1864.24,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,864.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2553.75,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,553.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1276.88,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,276.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2145.15,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,145.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1915.31,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,915.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2349.45,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $2,349.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1630.06,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,630.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1838.70,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,838.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1838.70,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,838.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1583.33,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,583.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1838.70,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,838.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1838.70,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,838.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 7 HOLES/RIGHT,C1713,HCPCS,278,RC,10021435,CDM,,,,both,,,2553.7500,1685.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1532.25,,,,,,,1241.1200,2553.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,553.75 in Billed Charges for Rev 278 Proc C1713 = $1,532.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,AETNA,AETNA HSHS,1666.29,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,666.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,AETNA,ALL COMMERCIAL AETNA,2579.40,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,579.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,ANTHEM,ANTHEM POS/HMO,1341.29,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,341.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,ANTHEM,ANTHEM PPO,1341.29,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,341.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2579.40,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,579.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,CENPATICO,ALL MEDICAID CENPATICO,2579.40,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,579.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2192.49,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,192.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,CIGNA,ALL COMMERCIAL CIGNA,1805.58,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,805.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,COFINITY,COFINITY,2579.40,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,579.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2450.43,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,450.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,2166.70,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,166.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1831.37,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,831.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1882.96,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,882.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,1253.59,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,253.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2192.49,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,192.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,HUMANA,HUMANA CHOICE CARE HMO,1289.70,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,289.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,HUMANA,HUMANA CHOICE CARE PPO,2192.49,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,192.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,HUMANA,HUMANA NATIIONAL POS HMO,1289.70,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,289.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1882.96,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,882.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2579.40,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,579.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1289.70,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,289.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2166.70,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,166.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1934.55,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,934.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2373.05,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $2,373.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1646.43,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,646.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1857.17,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,857.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1857.17,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,857.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1599.23,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,599.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1857.17,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,857.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1857.17,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,857.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/LEFT,C1713,HCPCS,278,RC,10020893,CDM,,,,both,,,2579.4000,1702.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1547.64,,,,,,,1253.5900,2579.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,579.40 in Billed Charges for Rev 278 Proc C1713 = $1,547.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,AETNA,AETNA HSHS,1726.09,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,726.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,AETNA,ALL COMMERCIAL AETNA,2671.97,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,671.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,ANTHEM,ANTHEM POS/HMO,1389.42,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,389.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,ANTHEM,ANTHEM PPO,1389.42,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,389.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2671.97,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,671.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,CENPATICO,ALL MEDICAID CENPATICO,2671.97,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,671.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2271.17,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,271.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,CIGNA,ALL COMMERCIAL CIGNA,1870.38,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,870.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,COFINITY,COFINITY,2671.97,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,671.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2538.37,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,538.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,2244.45,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,244.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1897.10,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,897.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1950.54,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,950.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,1298.58,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,298.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2271.17,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,271.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,HUMANA,HUMANA CHOICE CARE HMO,1335.99,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,335.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,HUMANA,HUMANA CHOICE CARE PPO,2271.17,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,271.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,HUMANA,HUMANA NATIIONAL POS HMO,1335.99,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,335.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1950.54,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,950.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2671.97,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,671.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1335.99,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,335.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2244.45,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,244.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2003.98,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,003.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2458.21,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $2,458.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1705.52,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,705.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1923.82,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,923.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1923.82,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,923.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1656.62,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,656.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1923.82,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,923.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1923.82,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,923.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 ANTEROLATERAL DISTAL TIBIA PL 9 HOLES/RIGHT,C1713,HCPCS,278,RC,70409753,CDM,,,,both,,,2671.9700,1763.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1603.18,,,,,,,1298.5800,2671.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,671.97 in Billed Charges for Rev 278 Proc C1713 = $1,603.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,AETNA,AETNA HSHS,1603.23,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,603.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,AETNA,ALL COMMERCIAL AETNA,2481.78,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,481.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,ANTHEM,ANTHEM POS/HMO,1290.53,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,290.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,ANTHEM,ANTHEM PPO,1290.53,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,290.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2481.78,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,481.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,CENPATICO,ALL MEDICAID CENPATICO,2481.78,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,481.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2109.51,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,109.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,CIGNA,ALL COMMERCIAL CIGNA,1737.25,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,737.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,COFINITY,COFINITY,2481.78,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,481.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2357.69,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,357.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,2084.70,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,084.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1762.06,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,762.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1811.70,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,811.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,1206.15,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,206.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2109.51,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,109.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,HUMANA,HUMANA CHOICE CARE PPO,2109.51,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,109.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1811.70,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,811.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,2481.78,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,481.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1240.89,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,240.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2084.70,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,084.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1861.34,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,861.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2283.24,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $2,283.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1584.12,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,584.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1786.88,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,786.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1786.88,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,786.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1538.70,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,538.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1786.88,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,786.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1786.88,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,786.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10022648,CDM,,,,both,,,2481.7800,1637.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1489.07,,,,,,,1206.1500,2481.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,481.78 in Billed Charges for Rev 278 Proc C1713 = $1,489.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,AETNA,AETNA HSHS,226.89,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $226.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,AETNA,ALL COMMERCIAL AETNA,351.23,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $351.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,351.23,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $351.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,CENPATICO,ALL MEDICAID CENPATICO,351.23,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $351.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,298.55,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $298.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,CIGNA,ALL COMMERCIAL CIGNA,245.86,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $245.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,COFINITY,COFINITY,351.23,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $351.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,333.67,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $333.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,295.03,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $295.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,249.37,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $249.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,256.40,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $256.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,170.70,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $170.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,298.55,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $298.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,HUMANA,HUMANA CHOICE CARE PPO,298.55,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $298.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,256.40,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $256.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,351.23,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $351.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,175.62,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $175.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,295.03,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $295.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,263.42,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $263.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,323.13,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $323.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,224.19,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $224.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,252.89,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $252.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,252.89,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $252.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,217.76,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $217.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,252.89,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $252.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,252.89,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $252.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026009,CDM,,,,both,,,351.2300,231.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,210.74,,,,,,,170.7000,351.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.23 in Billed Charges for Rev 278 Proc C1713 = $210.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,AETNA,AETNA HSHS,1817.17,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,817.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,AETNA,ALL COMMERCIAL AETNA,2812.95,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,812.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,ANTHEM,ANTHEM POS/HMO,1462.73,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,462.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,ANTHEM,ANTHEM PPO,1462.73,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,462.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2812.95,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,812.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,CENPATICO,ALL MEDICAID CENPATICO,2812.95,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,812.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2391.01,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,391.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,CIGNA,ALL COMMERCIAL CIGNA,1969.07,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,969.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,COFINITY,COFINITY,2812.95,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,812.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2672.30,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,672.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,2362.88,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,362.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1997.19,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,997.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2053.45,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,053.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,1367.09,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,367.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2391.01,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,391.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,HUMANA,HUMANA CHOICE CARE HMO,1406.48,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,406.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,HUMANA,HUMANA CHOICE CARE PPO,2391.01,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,391.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,HUMANA,HUMANA NATIIONAL POS HMO,1406.48,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,406.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2053.45,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,053.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,2812.95,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,812.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1406.48,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,406.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2362.88,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,362.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2109.71,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,109.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2587.91,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,587.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1795.51,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,795.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2025.32,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,025.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2025.32,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,025.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1744.03,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,744.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2025.32,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,025.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2025.32,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $2,025.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM LEFT,C1713,HCPCS,278,RC,70409769,CDM,,,,both,,,2812.9500,1856.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1687.77,,,,,,,1367.0900,2812.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,812.95 in Billed Charges for Rev 278 Proc C1713 = $1,687.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,AETNA,AETNA HSHS,2340.96,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,340.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,AETNA,ALL COMMERCIAL AETNA,3623.78,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,623.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,ANTHEM,ANTHEM POS/HMO,1884.37,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $1,884.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,ANTHEM,ANTHEM PPO,1884.37,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $1,884.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3623.78,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,623.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,CENPATICO,ALL MEDICAID CENPATICO,3623.78,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,623.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3080.21,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,080.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,CIGNA,ALL COMMERCIAL CIGNA,2536.65,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,536.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,COFINITY,COFINITY,3623.78,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,623.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3442.59,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,442.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,3043.98,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,043.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2572.88,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,572.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2645.36,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,645.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,1761.16,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $1,761.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3080.21,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,080.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,HUMANA,HUMANA CHOICE CARE HMO,1811.89,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $1,811.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,HUMANA,HUMANA CHOICE CARE PPO,3080.21,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,080.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,HUMANA,HUMANA NATIIONAL POS HMO,1811.89,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $1,811.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2645.36,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,645.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,3623.78,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,623.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1811.89,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $1,811.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3043.98,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,043.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2717.84,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,717.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3333.88,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $3,333.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2313.06,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,313.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2609.12,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,609.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2609.12,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,609.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2246.74,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,246.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2609.12,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,609.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2609.12,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,609.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 14H 246MM RIGHT,C1713,HCPCS,278,RC,10070978,CDM,,,,both,,,3623.7800,2391.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2174.27,,,,,,,1761.1600,3623.7800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,623.78 in Billed Charges for Rev 278 Proc C1713 = $2,174.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,AETNA,AETNA HSHS,2217.61,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,217.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,AETNA,ALL COMMERCIAL AETNA,3432.83,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $3,432.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,ANTHEM,ANTHEM POS/HMO,1785.07,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $1,785.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,ANTHEM,ANTHEM PPO,1785.07,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $1,785.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3432.83,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $3,432.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,CENPATICO,ALL MEDICAID CENPATICO,3432.83,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $3,432.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2917.91,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,917.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,CIGNA,ALL COMMERCIAL CIGNA,2402.98,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,402.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,COFINITY,COFINITY,3432.83,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $3,432.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3261.19,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $3,261.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,2883.58,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,883.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2437.31,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,437.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2505.97,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,505.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,1668.36,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $1,668.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2917.91,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,917.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,HUMANA,HUMANA CHOICE CARE HMO,1716.42,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $1,716.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,HUMANA,HUMANA CHOICE CARE PPO,2917.91,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,917.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,HUMANA,HUMANA NATIIONAL POS HMO,1716.42,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $1,716.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2505.97,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,505.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,3432.83,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $3,432.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1716.42,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $1,716.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2883.58,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,883.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2574.62,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,574.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3158.20,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $3,158.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2191.18,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,191.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2471.64,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,471.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2471.64,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,471.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2128.35,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2471.64,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,471.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2471.64,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,471.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006942,CDM,,,,both,,,3432.8300,2265.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2059.70,,,,,,,1668.3600,3432.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,432.83 in Billed Charges for Rev 278 Proc C1713 = $2,059.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,AETNA,AETNA HSHS,2240.62,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,240.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,AETNA,ALL COMMERCIAL AETNA,3468.45,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $3,468.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,ANTHEM,ANTHEM POS/HMO,1803.59,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $1,803.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,ANTHEM,ANTHEM PPO,1803.59,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $1,803.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3468.45,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $3,468.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,CENPATICO,ALL MEDICAID CENPATICO,3468.45,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $3,468.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2948.18,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,948.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,CIGNA,ALL COMMERCIAL CIGNA,2427.92,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,427.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,COFINITY,COFINITY,3468.45,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $3,468.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3295.03,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $3,295.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,2913.50,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,913.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2462.60,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,462.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2531.97,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,531.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,1685.67,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $1,685.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2948.18,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,948.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,HUMANA,HUMANA CHOICE CARE HMO,1734.23,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $1,734.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,HUMANA,HUMANA CHOICE CARE PPO,2948.18,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,948.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,HUMANA,HUMANA NATIIONAL POS HMO,1734.23,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $1,734.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2531.97,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,531.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3468.45,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $3,468.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1734.23,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $1,734.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2913.50,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,913.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2601.34,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,601.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3190.97,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $3,190.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2213.91,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,213.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2497.28,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,497.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2497.28,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,497.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2150.44,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,150.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2497.28,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,497.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2497.28,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,497.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10005598,CDM,,,,both,,,3468.4500,2289.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2081.07,,,,,,,1685.6700,3468.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,468.45 in Billed Charges for Rev 278 Proc C1713 = $2,081.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,AETNA,AETNA HSHS,701.34,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $701.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,AETNA,ALL COMMERCIAL AETNA,1085.66,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $1,085.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,ANTHEM,ANTHEM POS/HMO,564.54,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $564.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,ANTHEM,ANTHEM PPO,564.54,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $564.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1085.66,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $1,085.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,CENPATICO,ALL MEDICAID CENPATICO,1085.66,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $1,085.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,922.81,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $922.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,CIGNA,ALL COMMERCIAL CIGNA,759.96,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $759.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,COFINITY,COFINITY,1085.66,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $1,085.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1031.38,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $1,031.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,911.95,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $911.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,770.82,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $770.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,792.53,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $792.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,527.63,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $527.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,922.81,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $922.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,HUMANA,HUMANA CHOICE CARE PPO,922.81,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $922.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,792.53,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $792.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1085.66,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $1,085.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,542.83,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $542.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,911.95,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $911.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,814.25,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $814.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,998.81,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $998.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,692.98,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $692.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,781.68,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $781.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,781.68,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $781.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,673.11,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $673.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,781.68,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $781.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,781.68,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $781.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP HOOK 3H,C1713,HCPCS,278,RC,10036859,CDM,,,,both,,,1085.6600,716.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,651.40,,,,,,,527.6300,1085.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,085.66 in Billed Charges for Rev 278 Proc C1713 = $651.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,AETNA,AETNA HSHS,1771.63,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,771.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,AETNA,ALL COMMERCIAL AETNA,2742.46,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,ANTHEM,ANTHEM POS/HMO,1426.08,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,426.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,ANTHEM,ANTHEM PPO,1426.08,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,426.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2742.46,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,CENPATICO,ALL MEDICAID CENPATICO,2742.46,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2331.09,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,CIGNA,ALL COMMERCIAL CIGNA,1919.72,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,919.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,COFINITY,COFINITY,2742.46,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2605.34,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,605.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,2303.67,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,303.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1947.15,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,947.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2002.00,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,002.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,1332.84,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,332.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2331.09,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,HUMANA,HUMANA CHOICE CARE HMO,1371.23,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,371.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,HUMANA,HUMANA CHOICE CARE PPO,2331.09,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,HUMANA,HUMANA NATIIONAL POS HMO,1371.23,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,371.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2002.00,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,002.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2742.46,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1371.23,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,371.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2303.67,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,303.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2056.85,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,056.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2523.06,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $2,523.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1750.51,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,750.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1974.57,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,974.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1974.57,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,974.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1700.33,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,700.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1974.57,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,974.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1974.57,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,974.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045651,CDM,,,,both,,,2742.4600,1810.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1645.48,,,,,,,1332.8400,2742.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,742.46 in Billed Charges for Rev 278 Proc C1713 = $1,645.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,AETNA,AETNA HSHS,1843.80,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,843.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,AETNA,ALL COMMERCIAL AETNA,2854.18,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,854.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,ANTHEM,ANTHEM POS/HMO,1484.17,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,484.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,ANTHEM,ANTHEM PPO,1484.17,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,484.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2854.18,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,854.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,CENPATICO,ALL MEDICAID CENPATICO,2854.18,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,854.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2426.05,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,426.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,CIGNA,ALL COMMERCIAL CIGNA,1997.93,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,997.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,COFINITY,COFINITY,2854.18,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,854.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2711.47,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,711.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,2397.51,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,397.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2026.47,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,026.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2083.55,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,083.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,1387.13,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,387.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2426.05,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,426.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,HUMANA,HUMANA CHOICE CARE HMO,1427.09,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,427.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,HUMANA,HUMANA CHOICE CARE PPO,2426.05,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,426.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,HUMANA,HUMANA NATIIONAL POS HMO,1427.09,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,427.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2083.55,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,083.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2854.18,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,854.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1427.09,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,427.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2397.51,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,397.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2140.64,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,140.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2625.85,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,625.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1821.82,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,821.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2055.01,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,055.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2055.01,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,055.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1769.59,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,769.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2055.01,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,055.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2055.01,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $2,055.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409748,CDM,,,,both,,,2854.1800,1883.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1712.51,,,,,,,1387.1300,2854.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,854.18 in Billed Charges for Rev 278 Proc C1713 = $1,712.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,AETNA,AETNA HSHS,1801.70,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,801.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,AETNA,ALL COMMERCIAL AETNA,2789.01,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,789.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,ANTHEM,ANTHEM POS/HMO,1450.29,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,450.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,ANTHEM,ANTHEM PPO,1450.29,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,450.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2789.01,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,789.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,CENPATICO,ALL MEDICAID CENPATICO,2789.01,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,789.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2370.66,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,370.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,CIGNA,ALL COMMERCIAL CIGNA,1952.31,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,952.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,COFINITY,COFINITY,2789.01,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,789.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2649.56,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,649.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,2342.77,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,342.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1980.20,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,980.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2035.98,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,035.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,1355.46,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,355.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2370.66,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,370.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,HUMANA,HUMANA CHOICE CARE HMO,1394.51,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,394.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,HUMANA,HUMANA CHOICE CARE PPO,2370.66,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,370.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,HUMANA,HUMANA NATIIONAL POS HMO,1394.51,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,394.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2035.98,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,035.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,2789.01,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,789.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1394.51,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,394.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2342.77,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,342.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2091.76,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,091.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2565.89,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,565.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1780.23,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,780.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2008.09,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,008.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2008.09,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,008.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1729.19,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,729.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2008.09,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,008.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2008.09,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $2,008.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROX HUMERUS 6H HEAD 5H SHAFT,C1713,HCPCS,278,RC,10026083,CDM,,,,both,,,2789.0100,1840.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1673.41,,,,,,,1355.4600,2789.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,789.01 in Billed Charges for Rev 278 Proc C1713 = $1,673.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,AETNA,AETNA HSHS,2037.12,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,037.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,AETNA,ALL COMMERCIAL AETNA,3153.43,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $3,153.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,ANTHEM,ANTHEM POS/HMO,1639.78,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $1,639.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,ANTHEM,ANTHEM PPO,1639.78,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $1,639.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3153.43,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $3,153.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,CENPATICO,ALL MEDICAID CENPATICO,3153.43,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $3,153.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2680.42,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,680.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,CIGNA,ALL COMMERCIAL CIGNA,2207.40,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,207.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,COFINITY,COFINITY,3153.43,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $3,153.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2995.76,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,995.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,2648.88,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,648.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2238.94,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,238.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2302.00,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,1532.57,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $1,532.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2680.42,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,680.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,HUMANA,HUMANA CHOICE CARE HMO,1576.72,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $1,576.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,HUMANA,HUMANA CHOICE CARE PPO,2680.42,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,680.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,HUMANA,HUMANA NATIIONAL POS HMO,1576.72,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $1,576.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2302.00,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,3153.43,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $3,153.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1576.72,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $1,576.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2648.88,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,648.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2365.07,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,365.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2901.16,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,901.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2012.83,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,012.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2270.47,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,270.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2270.47,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,270.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1955.13,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $1,955.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2270.47,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,270.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2270.47,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $2,270.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 10H 232MM,C1713,HCPCS,278,RC,10012859,CDM,,,,both,,,3153.4300,2081.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1892.06,,,,,,,1532.5700,3153.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,153.43 in Billed Charges for Rev 278 Proc C1713 = $1,892.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,AETNA,AETNA HSHS,2107.57,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,107.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,AETNA,ALL COMMERCIAL AETNA,3262.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $3,262.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,ANTHEM,ANTHEM POS/HMO,1696.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $1,696.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,ANTHEM,ANTHEM PPO,1696.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $1,696.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3262.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $3,262.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,CENPATICO,ALL MEDICAID CENPATICO,3262.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $3,262.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2773.12,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,773.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,CIGNA,ALL COMMERCIAL CIGNA,2283.74,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,283.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,COFINITY,COFINITY,3262.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $3,262.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3099.37,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $3,099.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,2740.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,740.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2316.37,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,316.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2381.62,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,381.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,1585.57,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $1,585.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2773.12,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,773.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,HUMANA,HUMANA CHOICE CARE HMO,1631.25,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $1,631.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,HUMANA,HUMANA CHOICE CARE PPO,2773.12,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,773.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,HUMANA,HUMANA NATIIONAL POS HMO,1631.25,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $1,631.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2381.62,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,381.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3262.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $3,262.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1631.25,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $1,631.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2740.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,740.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2446.87,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,446.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3001.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $3,001.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2082.45,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,082.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2348.99,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,348.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2348.99,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,348.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2022.74,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,022.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2348.99,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,348.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2348.99,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $2,348.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 12H 268MM,C1713,HCPCS,278,RC,10012860,CDM,,,,both,,,3262.4900,2153.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1957.49,,,,,,,1585.5700,3262.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,262.49 in Billed Charges for Rev 278 Proc C1713 = $1,957.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,AETNA,AETNA HSHS,540.28,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $540.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,AETNA,ALL COMMERCIAL AETNA,836.35,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $836.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,836.35,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $836.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,CENPATICO,ALL MEDICAID CENPATICO,836.35,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $836.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,710.90,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $710.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,CIGNA,ALL COMMERCIAL CIGNA,585.45,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $585.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,COFINITY,COFINITY,836.35,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $836.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,794.53,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $794.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,702.53,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $702.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,593.81,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $593.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,610.54,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $610.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,406.47,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $406.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,710.90,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $710.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,HUMANA,HUMANA CHOICE CARE PPO,710.90,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $710.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,610.54,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $610.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,836.35,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $836.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,418.18,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $418.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,702.53,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $702.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,627.26,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $627.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,769.44,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $769.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,533.84,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $533.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,602.17,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $602.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,602.17,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $602.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,518.54,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $518.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,602.17,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $602.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,602.17,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $602.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  5 HOLE,C1713,HCPCS,278,RC,10003445,CDM,,,,both,,,836.3500,551.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,501.81,,,,,,,406.4700,836.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $836.35 in Billed Charges for Rev 278 Proc C1713 = $501.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,AETNA,AETNA HSHS,624.71,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $624.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,AETNA,ALL COMMERCIAL AETNA,967.05,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $967.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,967.05,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $967.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,CENPATICO,ALL MEDICAID CENPATICO,967.05,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $967.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,821.99,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $821.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,CIGNA,ALL COMMERCIAL CIGNA,676.94,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $676.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,COFINITY,COFINITY,967.05,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $967.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,918.70,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $918.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,HEALTH CARE ALLIANCE,THE ALLIANCE,812.32,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $812.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,686.61,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $686.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,705.95,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $705.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,HSHS EMPLOYEES,HSHS EMPLOYEES,469.99,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $469.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,821.99,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $821.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,HUMANA,HUMANA CHOICE CARE PPO,821.99,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $821.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,705.95,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $705.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,LIVE360,LIVE360 HSHS HEALTHY PLAN,967.05,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $967.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,483.53,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $483.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,812.32,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $812.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,725.29,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $725.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,889.69,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $889.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,617.27,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $617.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,696.28,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $696.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,696.28,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $696.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,599.57,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $599.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,696.28,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $696.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,696.28,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $696.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP RECON  6 HOLE,C1713,HCPCS,278,RC,10026084,CDM,,,,both,,,967.0500,638.2500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,580.23,,,,,,,469.9900,967.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $967.05 in Billed Charges for Rev 278 Proc C1713 = $580.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,AETNA,AETNA HSHS,683.80,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $683.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,AETNA,ALL COMMERCIAL AETNA,1058.51,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $1,058.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,ANTHEM,ANTHEM POS/HMO,550.43,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $550.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,ANTHEM,ANTHEM PPO,550.43,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $550.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1058.51,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $1,058.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,CENPATICO,ALL MEDICAID CENPATICO,1058.51,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $1,058.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,899.73,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $899.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,CIGNA,ALL COMMERCIAL CIGNA,740.96,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $740.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,COFINITY,COFINITY,1058.51,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $1,058.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1005.58,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $1,005.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,889.15,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $889.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,751.54,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $751.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,772.71,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $772.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,514.44,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $514.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,899.73,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $899.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,HUMANA,HUMANA CHOICE CARE PPO,899.73,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $899.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,772.71,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $772.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1058.51,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $1,058.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,529.26,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $529.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,889.15,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $889.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,793.88,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $793.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,973.83,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $973.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,675.65,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $675.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,762.13,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $762.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,762.13,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $762.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,656.28,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $656.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,762.13,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $762.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,762.13,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $762.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003446,CDM,,,,both,,,1058.5100,698.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,635.11,,,,,,,514.4400,1058.5100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,058.51 in Billed Charges for Rev 278 Proc C1713 = $635.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,AETNA,AETNA HSHS,748.60,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $748.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,AETNA,ALL COMMERCIAL AETNA,1158.82,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $1,158.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,ANTHEM,ANTHEM POS/HMO,602.59,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $602.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,ANTHEM,ANTHEM PPO,602.59,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $602.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1158.82,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $1,158.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,CENPATICO,ALL MEDICAID CENPATICO,1158.82,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $1,158.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,985.00,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $985.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,CIGNA,ALL COMMERCIAL CIGNA,811.17,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $811.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,COFINITY,COFINITY,1158.82,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $1,158.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1100.88,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $1,100.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,973.41,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $973.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,822.76,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $822.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,845.94,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $845.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,563.19,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $563.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,985.00,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $985.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,HUMANA,HUMANA CHOICE CARE PPO,985.00,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $985.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,845.94,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $845.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1158.82,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $1,158.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,579.41,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $579.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,973.41,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $973.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,869.12,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $869.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1066.11,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $1,066.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,739.67,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $739.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,834.35,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $834.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,834.35,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $834.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,718.47,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $718.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,834.35,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $834.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,834.35,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $834.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 12 HOLE,C1713,HCPCS,278,RC,10003466,CDM,,,,both,,,1158.8200,764.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,695.29,,,,,,,563.1900,1158.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,158.82 in Billed Charges for Rev 278 Proc C1713 = $695.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,AETNA,AETNA HSHS,1043.72,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,043.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,AETNA,ALL COMMERCIAL AETNA,1615.67,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,615.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,ANTHEM,ANTHEM POS/HMO,840.15,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $840.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,ANTHEM,ANTHEM PPO,840.15,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $840.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1615.67,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,615.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,CENPATICO,ALL MEDICAID CENPATICO,1615.67,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,615.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1373.32,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,373.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,CIGNA,ALL COMMERCIAL CIGNA,1130.97,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,130.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,COFINITY,COFINITY,1615.67,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,615.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1534.89,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,534.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,1357.16,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,357.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1147.13,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,147.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1179.44,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,179.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,785.22,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $785.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1373.32,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,373.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,HUMANA,HUMANA CHOICE CARE PPO,1373.32,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,373.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1179.44,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,179.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1615.67,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,615.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,807.84,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $807.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1357.16,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,357.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1211.75,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,211.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1486.42,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,486.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1031.28,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,031.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1163.28,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,163.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1163.28,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,163.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1001.72,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,001.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1163.28,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,163.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1163.28,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $1,163.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070591,CDM,,,,both,,,1615.6700,1066.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,969.40,,,,,,,785.2200,1615.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,615.67 in Billed Charges for Rev 278 Proc C1713 = $969.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,AETNA,AETNA HSHS,1061.51,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,061.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,AETNA,ALL COMMERCIAL AETNA,1643.20,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,ANTHEM,ANTHEM POS/HMO,854.46,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $854.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,ANTHEM,ANTHEM PPO,854.46,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $854.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1643.20,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,CENPATICO,ALL MEDICAID CENPATICO,1643.20,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1396.72,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,396.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,CIGNA,ALL COMMERCIAL CIGNA,1150.24,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,150.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,COFINITY,COFINITY,1643.20,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1561.04,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,561.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,1380.29,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,380.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1166.67,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,166.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1199.54,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,199.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,798.60,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $798.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1396.72,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,396.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,HUMANA,HUMANA CHOICE CARE PPO,1396.72,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,396.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1199.54,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,199.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1643.20,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,821.60,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $821.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1380.29,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,380.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1232.40,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,232.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1511.74,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,511.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1048.85,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,048.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1183.10,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,183.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1183.10,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,183.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1018.78,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,018.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1183.10,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,183.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1183.10,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $1,183.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070594,CDM,,,,both,,,1643.2000,1084.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,985.92,,,,,,,798.6000,1643.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,643.20 in Billed Charges for Rev 278 Proc C1713 = $985.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,AETNA,AETNA HSHS,1073.06,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,073.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,AETNA,ALL COMMERCIAL AETNA,1661.09,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,661.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,ANTHEM,ANTHEM POS/HMO,863.77,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $863.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,ANTHEM,ANTHEM PPO,863.77,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $863.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1661.09,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,661.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,CENPATICO,ALL MEDICAID CENPATICO,1661.09,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,661.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1411.93,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,411.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,CIGNA,ALL COMMERCIAL CIGNA,1162.76,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,162.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,COFINITY,COFINITY,1661.09,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,661.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1578.04,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,578.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,1395.32,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,395.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1179.37,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,179.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1212.60,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,212.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,807.29,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $807.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1411.93,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,411.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,HUMANA,HUMANA CHOICE CARE PPO,1411.93,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,411.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1212.60,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,212.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1661.09,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,661.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,830.55,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $830.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1395.32,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,395.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1245.82,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,245.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1528.20,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,528.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1060.27,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,060.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1195.98,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,195.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1195.98,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,195.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1029.88,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,029.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1195.98,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,195.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1195.98,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $1,195.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063113,CDM,,,,both,,,1661.0900,1096.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,996.65,,,,,,,807.2900,1661.0900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,661.09 in Billed Charges for Rev 278 Proc C1713 = $996.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,AETNA,AETNA HSHS,1169.98,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,169.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,AETNA,ALL COMMERCIAL AETNA,1811.11,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,811.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,ANTHEM,ANTHEM POS/HMO,941.78,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $941.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,ANTHEM,ANTHEM PPO,941.78,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $941.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1811.11,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,811.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,CENPATICO,ALL MEDICAID CENPATICO,1811.11,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,811.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1539.44,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,539.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,CIGNA,ALL COMMERCIAL CIGNA,1267.78,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,267.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,COFINITY,COFINITY,1811.11,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,811.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1720.55,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,720.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,1521.33,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,521.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1285.89,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,285.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1322.11,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,322.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,880.20,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $880.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1539.44,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,539.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,HUMANA,HUMANA CHOICE CARE PPO,1539.44,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,539.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1322.11,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,322.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1811.11,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,811.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,905.56,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $905.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1521.33,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,521.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1358.33,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,358.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1666.22,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,666.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1156.03,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,156.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1304.00,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,304.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1304.00,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,304.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1122.89,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,122.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1304.00,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,304.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1304.00,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,304.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP SUPERIOR ANT CLAVICLE W/EXT 6H 105MM RT,C1713,HCPCS,278,RC,10070580,CDM,,,,both,,,1811.1100,1195.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1086.67,,,,,,,880.2000,1811.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,811.11 in Billed Charges for Rev 278 Proc C1713 = $1,086.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,AETNA,AETNA HSHS,1101.58,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,101.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,AETNA,ALL COMMERCIAL AETNA,1705.23,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,705.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,ANTHEM,ANTHEM POS/HMO,886.72,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $886.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,ANTHEM,ANTHEM PPO,886.72,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $886.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1705.23,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,705.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,CENPATICO,ALL MEDICAID CENPATICO,1705.23,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,705.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1449.45,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,449.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,CIGNA,ALL COMMERCIAL CIGNA,1193.66,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,193.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,COFINITY,COFINITY,1705.23,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,705.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1619.97,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,619.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,1432.39,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,432.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1210.71,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,210.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1244.82,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,244.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,828.74,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $828.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1449.45,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,449.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,HUMANA,HUMANA CHOICE CARE PPO,1449.45,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,449.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1244.82,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,244.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1705.23,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,705.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,852.62,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $852.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1432.39,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,432.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1278.92,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,278.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1568.81,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,568.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1088.45,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,088.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1227.77,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,227.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1227.77,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,227.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1057.24,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,057.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1227.77,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,227.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1227.77,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,227.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10041458,CDM,,,,both,,,1705.2300,1125.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1023.14,,,,,,,828.7400,1705.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,705.23 in Billed Charges for Rev 278 Proc C1713 = $1,023.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,AETNA,AETNA HSHS,442.71,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $442.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,AETNA,ALL COMMERCIAL AETNA,685.31,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $685.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,685.31,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $685.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,CENPATICO,ALL MEDICAID CENPATICO,685.31,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $685.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,582.51,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $582.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,CIGNA,ALL COMMERCIAL CIGNA,479.72,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $479.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,COFINITY,COFINITY,685.31,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $685.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,651.04,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $651.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,575.66,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $575.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,486.57,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $486.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,500.28,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $500.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,333.06,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $333.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,582.51,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $582.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,HUMANA,HUMANA CHOICE CARE PPO,582.51,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $582.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,500.28,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $500.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,685.31,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $685.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,342.66,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $342.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,575.66,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $575.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,513.98,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $513.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,630.49,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $630.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,437.43,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $437.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,493.42,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $493.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,493.42,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $493.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,424.89,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $424.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,493.42,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $493.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,493.42,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $493.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10044984,CDM,,,,both,,,685.3100,452.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,411.19,,,,,,,333.0600,685.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $685.31 in Billed Charges for Rev 278 Proc C1713 = $411.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,AETNA,AETNA HSHS,464.29,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $464.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,AETNA,ALL COMMERCIAL AETNA,718.72,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $718.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,718.72,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $718.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,CENPATICO,ALL MEDICAID CENPATICO,718.72,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $718.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,610.91,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $610.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,CIGNA,ALL COMMERCIAL CIGNA,503.10,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $503.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,COFINITY,COFINITY,718.72,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $718.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,682.78,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $682.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,603.72,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $603.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,510.29,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $510.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,524.67,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $524.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,349.30,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $349.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,610.91,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $610.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,HUMANA,HUMANA CHOICE CARE PPO,610.91,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $610.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,524.67,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $524.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,718.72,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $718.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,359.36,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $359.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,603.72,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $603.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,539.04,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $539.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,661.22,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $661.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,458.76,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $458.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,517.48,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $517.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,517.48,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $517.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,445.61,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $445.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,517.48,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $517.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,517.48,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $517.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003457,CDM,,,,both,,,718.7200,474.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,431.23,,,,,,,349.3000,718.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $718.72 in Billed Charges for Rev 278 Proc C1713 = $431.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,AETNA,AETNA HSHS,484.93,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $484.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,AETNA,ALL COMMERCIAL AETNA,750.67,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $750.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,750.67,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $750.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,CENPATICO,ALL MEDICAID CENPATICO,750.67,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $750.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,638.07,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $638.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,CIGNA,ALL COMMERCIAL CIGNA,525.47,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $525.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,COFINITY,COFINITY,750.67,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $750.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,713.14,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $713.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,630.56,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $630.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,532.98,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $532.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,547.99,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $547.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,364.83,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $364.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,638.07,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $638.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,HUMANA,HUMANA CHOICE CARE PPO,638.07,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $638.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,547.99,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $547.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,750.67,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $750.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,375.34,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $375.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,630.56,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $630.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,563.00,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $563.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,690.62,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $690.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,479.15,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $479.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,540.48,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $540.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,540.48,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $540.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,465.42,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $465.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,540.48,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $540.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,540.48,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $540.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003468,CDM,,,,both,,,750.6700,495.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,450.40,,,,,,,364.8300,750.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $750.67 in Billed Charges for Rev 278 Proc C1713 = $450.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,AETNA,AETNA HSHS,448.40,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $448.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,AETNA,ALL COMMERCIAL AETNA,694.11,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $694.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,694.11,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $694.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,CENPATICO,ALL MEDICAID CENPATICO,694.11,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $694.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,589.99,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $589.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,CIGNA,ALL COMMERCIAL CIGNA,485.88,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $485.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,COFINITY,COFINITY,694.11,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $694.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,659.40,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $659.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,583.05,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $583.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,492.82,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $492.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,506.70,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $506.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,337.34,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $337.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,589.99,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $589.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,HUMANA,HUMANA CHOICE CARE PPO,589.99,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $589.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,506.70,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $506.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,694.11,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $694.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,347.06,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $347.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,583.05,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $583.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,520.58,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $520.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,638.58,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $638.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,443.05,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $443.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,499.76,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $499.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,499.76,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $499.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,430.35,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $430.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,499.76,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $499.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,499.76,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $499.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026087,CDM,,,,both,,,694.1100,458.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,416.47,,,,,,,337.3400,694.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $694.11 in Billed Charges for Rev 278 Proc C1713 = $416.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,AETNA,AETNA HSHS,524.31,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $524.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,AETNA,ALL COMMERCIAL AETNA,811.63,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $811.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,811.63,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $811.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,CENPATICO,ALL MEDICAID CENPATICO,811.63,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $811.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,689.89,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $689.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,CIGNA,ALL COMMERCIAL CIGNA,568.14,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $568.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,COFINITY,COFINITY,811.63,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $811.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,771.05,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $771.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,681.77,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $681.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,576.26,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $576.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,592.49,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $592.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,394.45,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $394.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,689.89,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $689.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,HUMANA,HUMANA CHOICE CARE PPO,689.89,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $689.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,592.49,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $592.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,811.63,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $811.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,405.82,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $405.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,681.77,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $681.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,608.72,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $608.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,746.70,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $746.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,518.06,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $518.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,584.37,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $584.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,584.37,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $584.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,503.21,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $503.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,584.37,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $584.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,584.37,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $584.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7H SHAFT OBL RT,C1713,HCPCS,278,RC,10040478,CDM,,,,both,,,811.6300,535.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,486.98,,,,,,,394.4500,811.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $811.63 in Billed Charges for Rev 278 Proc C1713 = $486.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,AETNA,AETNA HSHS,522.45,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $522.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,AETNA,ALL COMMERCIAL AETNA,808.74,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $808.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,808.74,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $808.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,CENPATICO,ALL MEDICAID CENPATICO,808.74,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $808.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,687.43,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $687.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,CIGNA,ALL COMMERCIAL CIGNA,566.12,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $566.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,COFINITY,COFINITY,808.74,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $808.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,768.30,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $768.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,679.34,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $679.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,574.21,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $574.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,590.38,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $590.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,393.05,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $393.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,687.43,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $687.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,HUMANA,HUMANA CHOICE CARE PPO,687.43,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $687.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,590.38,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $590.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,808.74,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $808.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,404.37,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $404.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,679.34,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $679.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,606.56,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $606.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,744.04,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $744.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,516.22,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $516.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,582.29,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $582.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,582.29,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $582.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,501.42,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $501.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,582.29,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $582.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,582.29,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $582.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 6 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10040479,CDM,,,,both,,,808.7400,533.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,485.24,,,,,,,393.0500,808.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $808.74 in Billed Charges for Rev 278 Proc C1713 = $485.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,AETNA,AETNA HSHS,457.41,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $457.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,AETNA,ALL COMMERCIAL AETNA,708.06,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $708.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,708.06,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $708.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,CENPATICO,ALL MEDICAID CENPATICO,708.06,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $708.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,601.85,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $601.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,CIGNA,ALL COMMERCIAL CIGNA,495.64,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $495.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,COFINITY,COFINITY,708.06,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $708.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,672.66,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $672.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,594.77,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $594.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,502.72,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $502.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,516.88,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $516.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,344.12,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $344.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,601.85,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $601.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,HUMANA,HUMANA CHOICE CARE PPO,601.85,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $601.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,516.88,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $516.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,708.06,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $708.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,354.03,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $354.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,594.77,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $594.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,531.05,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $531.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,651.42,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $651.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,451.95,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $451.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,509.80,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $509.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,509.80,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $509.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,439.00,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $439.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,509.80,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $509.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,509.80,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $509.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 10 HOLE,C1713,HCPCS,278,RC,10040475,CDM,,,,both,,,708.0600,467.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,424.84,,,,,,,344.1200,708.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $708.06 in Billed Charges for Rev 278 Proc C1713 = $424.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,AETNA,AETNA HSHS,721.04,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $721.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,AETNA,ALL COMMERCIAL AETNA,1116.16,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $1,116.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,ANTHEM,ANTHEM POS/HMO,580.40,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $580.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,ANTHEM,ANTHEM PPO,580.40,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $580.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1116.16,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $1,116.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,CENPATICO,ALL MEDICAID CENPATICO,1116.16,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $1,116.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,948.74,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $948.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,CIGNA,ALL COMMERCIAL CIGNA,781.31,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $781.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,COFINITY,COFINITY,1116.16,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $1,116.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1060.35,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $1,060.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,937.57,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $937.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,792.47,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $792.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,814.80,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $814.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,542.45,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $542.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,948.74,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $948.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,HUMANA,HUMANA CHOICE CARE PPO,948.74,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $948.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,814.80,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $814.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1116.16,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $1,116.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,558.08,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $558.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,937.57,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $937.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,837.12,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $837.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1026.87,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $1,026.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,712.44,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $712.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,803.64,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $803.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,803.64,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $803.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,692.02,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $692.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,803.64,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $803.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,803.64,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $803.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 14 HOLE,C1713,HCPCS,278,RC,10040476,CDM,,,,both,,,1116.1600,736.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,669.70,,,,,,,542.4500,1116.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,116.16 in Billed Charges for Rev 278 Proc C1713 = $669.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,AETNA,AETNA HSHS,390.16,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $390.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,AETNA,ALL COMMERCIAL AETNA,603.96,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $603.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,603.96,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $603.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,CENPATICO,ALL MEDICAID CENPATICO,603.96,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $603.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,513.37,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $513.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,CIGNA,ALL COMMERCIAL CIGNA,422.77,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $422.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,COFINITY,COFINITY,603.96,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $603.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,573.76,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $573.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,507.33,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $507.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,428.81,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $428.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,440.89,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $440.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,293.52,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $293.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,513.37,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $513.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,HUMANA,HUMANA CHOICE CARE PPO,513.37,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $513.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,440.89,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $440.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,603.96,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $603.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,301.98,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $301.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,507.33,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $507.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,452.97,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $452.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,555.64,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $555.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,385.51,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $385.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,434.85,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $434.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,434.85,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $434.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,374.46,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $374.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,434.85,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $434.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,434.85,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $434.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 6 HOLE,C1713,HCPCS,278,RC,10046451,CDM,,,,both,,,603.9600,398.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,362.38,,,,,,,293.5200,603.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $603.96 in Billed Charges for Rev 278 Proc C1713 = $362.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,AETNA,AETNA HSHS,406.09,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $406.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,AETNA,ALL COMMERCIAL AETNA,628.62,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $628.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,628.62,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $628.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,CENPATICO,ALL MEDICAID CENPATICO,628.62,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $628.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,534.33,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $534.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,CIGNA,ALL COMMERCIAL CIGNA,440.03,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $440.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,COFINITY,COFINITY,628.62,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $628.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,597.19,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $597.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,HEALTH CARE ALLIANCE,THE ALLIANCE,528.04,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $528.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,446.32,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $446.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,458.89,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $458.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,HSHS EMPLOYEES,HSHS EMPLOYEES,305.51,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $305.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,534.33,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $534.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,HUMANA,HUMANA CHOICE CARE PPO,534.33,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $534.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,458.89,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $458.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,LIVE360,LIVE360 HSHS HEALTHY PLAN,628.62,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $628.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,314.31,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $314.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,528.04,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $528.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,471.47,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $471.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,578.33,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $578.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,401.25,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $401.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,452.61,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $452.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,452.61,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $452.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,389.74,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $389.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,452.61,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $452.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,452.61,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $452.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 7 HOLE,C1713,HCPCS,278,RC,10039961,CDM,,,,both,,,628.6200,414.8900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,377.17,,,,,,,305.5100,628.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $628.62 in Billed Charges for Rev 278 Proc C1713 = $377.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,AETNA,AETNA HSHS,426.81,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $426.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,AETNA,ALL COMMERCIAL AETNA,660.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $660.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,660.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $660.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,CENPATICO,ALL MEDICAID CENPATICO,660.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $660.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,561.60,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $561.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,CIGNA,ALL COMMERCIAL CIGNA,462.49,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $462.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,COFINITY,COFINITY,660.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $660.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,627.67,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $627.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,554.99,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $554.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,469.10,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $469.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,482.31,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $482.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,321.10,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $321.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,561.60,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $561.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,HUMANA,HUMANA CHOICE CARE PPO,561.60,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $561.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,482.31,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $482.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,660.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $660.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,330.35,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $330.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,554.99,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $554.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,495.53,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $495.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,607.84,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $607.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,421.72,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $421.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,475.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $475.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,475.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $475.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,409.63,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $409.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,475.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $475.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,475.70,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $475.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 8 HOLE,C1713,HCPCS,278,RC,10028660,CDM,,,,both,,,660.7000,436.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,396.42,,,,,,,321.1000,660.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $660.70 in Billed Charges for Rev 278 Proc C1713 = $396.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,AETNA,AETNA HSHS,400.96,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $400.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,AETNA,ALL COMMERCIAL AETNA,620.68,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $620.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,620.68,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $620.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,CENPATICO,ALL MEDICAID CENPATICO,620.68,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $620.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,527.58,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $527.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,CIGNA,ALL COMMERCIAL CIGNA,434.48,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $434.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,COFINITY,COFINITY,620.68,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $620.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,589.65,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $589.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,521.37,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $521.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,440.68,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $440.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,453.10,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $453.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,301.65,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $301.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,527.58,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $527.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,HUMANA,HUMANA CHOICE CARE PPO,527.58,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $527.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,453.10,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $453.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,620.68,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $620.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,310.34,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $310.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,521.37,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $521.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,465.51,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $465.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,571.03,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $571.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,396.18,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $396.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,446.89,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $446.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,446.89,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $446.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,384.82,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $384.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,446.89,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $446.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,446.89,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $446.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  3H 39MM,C1713,HCPCS,278,RC,10003371,CDM,,,,both,,,620.6800,409.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,372.41,,,,,,,301.6500,620.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $620.68 in Billed Charges for Rev 278 Proc C1713 = $372.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,AETNA,AETNA HSHS,437.12,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $437.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,AETNA,ALL COMMERCIAL AETNA,676.65,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $676.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,676.65,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $676.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,CENPATICO,ALL MEDICAID CENPATICO,676.65,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $676.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,575.15,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $575.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,CIGNA,ALL COMMERCIAL CIGNA,473.66,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $473.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,COFINITY,COFINITY,676.65,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $676.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,642.82,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $642.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,HEALTH CARE ALLIANCE,THE ALLIANCE,568.39,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $568.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,480.42,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $480.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,493.95,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $493.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,HSHS EMPLOYEES,HSHS EMPLOYEES,328.85,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $328.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,575.15,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $575.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,HUMANA,HUMANA CHOICE CARE PPO,575.15,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $575.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,493.95,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $493.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,LIVE360,LIVE360 HSHS HEALTHY PLAN,676.65,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $676.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,338.33,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $338.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,568.39,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $568.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,507.49,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $507.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,622.52,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $622.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,431.91,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $431.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,487.19,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $487.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,487.19,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $487.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,419.52,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $419.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,487.19,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $487.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,487.19,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $487.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  5H 65MM,C1713,HCPCS,278,RC,10028792,CDM,,,,both,,,676.6500,446.5900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,405.99,,,,,,,328.8500,676.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $676.65 in Billed Charges for Rev 278 Proc C1713 = $405.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,AETNA,AETNA HSHS,598.71,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $598.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,AETNA,ALL COMMERCIAL AETNA,926.80,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $926.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,926.80,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $926.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,CENPATICO,ALL MEDICAID CENPATICO,926.80,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $926.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,787.78,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $787.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,CIGNA,ALL COMMERCIAL CIGNA,648.76,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $648.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,COFINITY,COFINITY,926.80,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $926.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,880.46,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $880.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,778.51,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $778.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,658.03,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $658.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,676.56,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $676.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,450.42,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $450.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,787.78,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $787.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,HUMANA,HUMANA CHOICE CARE PPO,787.78,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $787.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,676.56,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $676.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,926.80,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $926.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,463.40,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $463.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,778.51,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $778.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,695.10,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $695.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,852.66,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $852.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,591.58,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $591.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,667.30,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $667.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,667.30,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $667.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,574.62,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $574.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,667.30,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $667.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,667.30,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $667.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 12H 156MM,C1713,HCPCS,278,RC,10003373,CDM,,,,both,,,926.8000,611.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,556.08,,,,,,,450.4200,926.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $926.80 in Billed Charges for Rev 278 Proc C1713 = $556.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,AETNA,AETNA HSHS,683.17,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $683.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,AETNA,ALL COMMERCIAL AETNA,1057.54,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $1,057.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,ANTHEM,ANTHEM POS/HMO,549.92,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $549.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,ANTHEM,ANTHEM PPO,549.92,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $549.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1057.54,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $1,057.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,CENPATICO,ALL MEDICAID CENPATICO,1057.54,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $1,057.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,898.91,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $898.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,CIGNA,ALL COMMERCIAL CIGNA,740.28,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $740.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,COFINITY,COFINITY,1057.54,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $1,057.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1004.66,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $1,004.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,888.33,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $888.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,750.85,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $750.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,772.00,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $772.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,513.96,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $513.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,898.91,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $898.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,HUMANA,HUMANA CHOICE CARE PPO,898.91,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $898.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,772.00,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $772.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1057.54,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $1,057.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,528.77,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $528.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,888.33,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $888.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,793.16,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $793.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,972.94,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $972.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,675.03,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $675.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,761.43,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $761.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,761.43,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $761.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,655.67,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $655.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,761.43,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $761.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,761.43,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $761.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 15 HOLE,C1713,HCPCS,278,RC,10017354,CDM,,,,both,,,1057.5400,697.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,634.52,,,,,,,513.9600,1057.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,057.54 in Billed Charges for Rev 278 Proc C1713 = $634.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,AETNA,AETNA HSHS,685.94,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $685.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,AETNA,ALL COMMERCIAL AETNA,1061.82,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $1,061.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,ANTHEM,ANTHEM POS/HMO,552.15,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $552.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,ANTHEM,ANTHEM PPO,552.15,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $552.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1061.82,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $1,061.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,CENPATICO,ALL MEDICAID CENPATICO,1061.82,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $1,061.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,902.55,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $902.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,CIGNA,ALL COMMERCIAL CIGNA,743.27,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $743.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,COFINITY,COFINITY,1061.82,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $1,061.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1008.73,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $1,008.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,891.93,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $891.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,753.89,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $753.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,775.13,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $775.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,516.04,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $516.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,902.55,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $902.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,HUMANA,HUMANA CHOICE CARE PPO,902.55,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $902.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,775.13,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $775.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1061.82,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $1,061.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,530.91,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $530.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,891.93,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $891.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,796.37,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $796.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,976.87,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $976.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,677.76,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $677.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,764.51,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $764.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,764.51,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $764.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,658.33,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $658.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,764.51,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $764.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,764.51,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $764.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 14H 182MM,C1713,HCPCS,278,RC,10017360,CDM,,,,both,,,1061.8200,700.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,637.09,,,,,,,516.0400,1061.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,061.82 in Billed Charges for Rev 278 Proc C1713 = $637.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,AETNA,AETNA HSHS,733.84,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $733.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,AETNA,ALL COMMERCIAL AETNA,1135.97,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $1,135.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,ANTHEM,ANTHEM POS/HMO,590.70,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $590.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,ANTHEM,ANTHEM PPO,590.70,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $590.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1135.97,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $1,135.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,CENPATICO,ALL MEDICAID CENPATICO,1135.97,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $1,135.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,965.57,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $965.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,CIGNA,ALL COMMERCIAL CIGNA,795.18,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $795.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,COFINITY,COFINITY,1135.97,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $1,135.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1079.17,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $1,079.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,954.21,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $954.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,806.54,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $806.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,829.26,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $829.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,552.08,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $552.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,965.57,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $965.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,HUMANA,HUMANA CHOICE CARE PPO,965.57,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $965.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,829.26,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $829.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1135.97,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $1,135.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,567.99,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $567.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,954.21,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $954.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,851.98,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $851.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1045.09,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $1,045.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,725.09,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $725.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,817.90,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $817.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,817.90,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $817.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,704.30,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $704.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,817.90,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $817.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,817.90,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $817.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 16H 208MM,C1713,HCPCS,278,RC,10017361,CDM,,,,both,,,1135.9700,749.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,681.58,,,,,,,552.0800,1135.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,135.97 in Billed Charges for Rev 278 Proc C1713 = $681.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,AETNA,AETNA HSHS,1142.08,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,142.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,AETNA,ALL COMMERCIAL AETNA,1767.92,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,767.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,ANTHEM,ANTHEM POS/HMO,919.32,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $919.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,ANTHEM,ANTHEM PPO,919.32,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $919.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1767.92,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,767.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,CENPATICO,ALL MEDICAID CENPATICO,1767.92,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,767.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1502.73,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,502.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,CIGNA,ALL COMMERCIAL CIGNA,1237.54,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,237.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,COFINITY,COFINITY,1767.92,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,767.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1679.52,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,679.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,1485.05,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,485.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1255.22,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,255.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1290.58,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,290.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,859.21,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $859.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1502.73,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,502.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,HUMANA,HUMANA CHOICE CARE PPO,1502.73,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,502.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1290.58,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,290.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1767.92,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,767.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,883.96,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $883.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1485.05,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,485.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1325.94,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,325.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1626.49,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,626.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1128.46,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,128.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1272.90,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,272.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1272.90,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,272.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1096.11,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,096.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1272.90,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,272.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1272.90,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,272.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040289,CDM,,,,both,,,1767.9200,1166.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1060.75,,,,,,,859.2100,1767.9200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,767.92 in Billed Charges for Rev 278 Proc C1713 = $1,060.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,AETNA,AETNA HSHS,833.21,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $833.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,AETNA,ALL COMMERCIAL AETNA,1289.80,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,ANTHEM,ANTHEM POS/HMO,670.70,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $670.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,ANTHEM,ANTHEM PPO,670.70,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $670.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1289.80,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,CENPATICO,ALL MEDICAID CENPATICO,1289.80,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1096.33,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,096.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,CIGNA,ALL COMMERCIAL CIGNA,902.86,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $902.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,COFINITY,COFINITY,1289.80,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1225.31,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,225.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,1083.43,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,083.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,915.76,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $915.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,941.55,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,626.84,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $626.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1096.33,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,096.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,HUMANA,HUMANA CHOICE CARE PPO,1096.33,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,096.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,941.55,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1289.80,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,644.90,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $644.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1083.43,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,083.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,967.35,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $967.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1186.62,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $1,186.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,823.28,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $823.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,928.66,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $928.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,928.66,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $928.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,799.68,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $799.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,928.66,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $928.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,928.66,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $928.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028644,CDM,,,,both,,,1289.8000,851.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,773.88,,,,,,,626.8400,1289.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,289.80 in Billed Charges for Rev 278 Proc C1713 = $773.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,AETNA,AETNA HSHS,658.04,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $658.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,AETNA,ALL COMMERCIAL AETNA,1018.63,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $1,018.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,ANTHEM,ANTHEM POS/HMO,529.69,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $529.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,ANTHEM,ANTHEM PPO,529.69,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $529.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1018.63,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $1,018.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,CENPATICO,ALL MEDICAID CENPATICO,1018.63,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $1,018.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,865.84,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $865.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,CIGNA,ALL COMMERCIAL CIGNA,713.04,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $713.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,COFINITY,COFINITY,1018.63,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $1,018.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,967.70,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $967.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,855.65,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $855.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,723.23,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $723.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,743.60,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $743.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,495.05,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $495.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,865.84,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $865.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,HUMANA,HUMANA CHOICE CARE PPO,865.84,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $865.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,743.60,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $743.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1018.63,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $1,018.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,509.32,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $509.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,855.65,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $855.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,763.97,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $763.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,937.14,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $937.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,650.19,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $650.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,733.41,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $733.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,733.41,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $733.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,631.55,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $631.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,733.41,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $733.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,733.41,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $733.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002686,CDM,,,,both,,,1018.6300,672.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,611.18,,,,,,,495.0500,1018.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,018.63 in Billed Charges for Rev 278 Proc C1713 = $611.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,AETNA,AETNA HSHS,1084.60,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,084.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,AETNA,ALL COMMERCIAL AETNA,1678.95,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,678.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,ANTHEM,ANTHEM POS/HMO,873.05,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $873.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,ANTHEM,ANTHEM PPO,873.05,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $873.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1678.95,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,678.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,CENPATICO,ALL MEDICAID CENPATICO,1678.95,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,678.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1427.11,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,427.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,CIGNA,ALL COMMERCIAL CIGNA,1175.27,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,175.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,COFINITY,COFINITY,1678.95,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,678.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1595.00,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,595.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,1410.32,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,410.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1192.05,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,192.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1225.63,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,225.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,815.97,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $815.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1427.11,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,427.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,HUMANA,HUMANA CHOICE CARE PPO,1427.11,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,427.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1225.63,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,225.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1678.95,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,678.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,839.48,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $839.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1410.32,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,410.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1259.21,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,259.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1544.63,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,544.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1071.67,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,071.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1208.84,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,208.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1208.84,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,208.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1040.95,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,040.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1208.84,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,208.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1208.84,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,208.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027964,CDM,,,,both,,,1678.9500,1108.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1007.37,,,,,,,815.9700,1678.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,678.95 in Billed Charges for Rev 278 Proc C1713 = $1,007.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,AETNA,AETNA HSHS,1131.88,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,131.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,AETNA,ALL COMMERCIAL AETNA,1752.14,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,752.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,ANTHEM,ANTHEM POS/HMO,911.11,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $911.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,ANTHEM,ANTHEM PPO,911.11,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $911.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1752.14,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,752.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,CENPATICO,ALL MEDICAID CENPATICO,1752.14,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,752.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1489.32,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,489.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,CIGNA,ALL COMMERCIAL CIGNA,1226.50,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,226.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,COFINITY,COFINITY,1752.14,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,752.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1664.53,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,664.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,1471.80,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,471.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1244.02,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,244.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1279.06,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,279.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,851.54,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $851.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1489.32,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,489.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,HUMANA,HUMANA CHOICE CARE PPO,1489.32,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,489.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1279.06,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,279.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1752.14,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,752.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,876.07,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $876.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1471.80,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,471.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1314.11,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,314.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1611.97,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,611.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1118.39,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,118.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1261.54,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,261.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1261.54,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,261.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1086.33,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,086.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1261.54,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,261.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1261.54,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,261.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040559,CDM,,,,both,,,1752.1400,1156.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1051.28,,,,,,,851.5400,1752.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,752.14 in Billed Charges for Rev 278 Proc C1713 = $1,051.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,AETNA,AETNA HSHS,5304.69,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,211.60 in Billed Charges for Rev 278 = $5,304.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,AETNA,ALL COMMERCIAL AETNA,8211.60,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,211.60 in Billed Charges for Rev 278 = $8,211.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,ANTHEM,ANTHEM POS/HMO,4270.03,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,211.60 in Billed Charges for Rev 278 = $4,270.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,ANTHEM,ANTHEM PPO,4270.03,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,211.60 in Billed Charges for Rev 278 = $4,270.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8211.60,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,211.60 in Billed Charges for Rev 278 = $8,211.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,CENPATICO,ALL MEDICAID CENPATICO,8211.60,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,211.60 in Billed Charges for Rev 278 = $8,211.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6979.86,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,211.60 in Billed Charges for Rev 278 = $6,979.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,CIGNA,ALL COMMERCIAL CIGNA,5748.12,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,211.60 in Billed Charges for Rev 278 = $5,748.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,COFINITY,COFINITY,8211.60,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,211.60 in Billed Charges for Rev 278 = $8,211.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7801.02,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,211.60 in Billed Charges for Rev 278 = $7,801.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,6897.74,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,211.60 in Billed Charges for Rev 278 = $6,897.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5830.24,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,211.60 in Billed Charges for Rev 278 = $5,830.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5994.47,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,211.60 in Billed Charges for Rev 278 = $5,994.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,3990.84,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,211.60 in Billed Charges for Rev 278 = $3,990.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6979.86,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,211.60 in Billed Charges for Rev 278 = $6,979.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,HUMANA,HUMANA CHOICE CARE HMO,4105.80,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,211.60 in Billed Charges for Rev 278 = $4,105.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,HUMANA,HUMANA CHOICE CARE PPO,6979.86,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,211.60 in Billed Charges for Rev 278 = $6,979.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,HUMANA,HUMANA NATIIONAL POS HMO,4105.80,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,211.60 in Billed Charges for Rev 278 = $4,105.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5994.47,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,211.60 in Billed Charges for Rev 278 = $5,994.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,8211.60,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,211.60 in Billed Charges for Rev 278 = $8,211.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4105.80,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,211.60 in Billed Charges for Rev 278 = $4,105.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6897.74,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,211.60 in Billed Charges for Rev 278 = $6,897.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6158.70,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,211.60 in Billed Charges for Rev 278 = $6,158.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7554.67,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,211.60 in Billed Charges for Rev 278 = $7,554.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4105.80,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,211.60 in Billed Charges for Rev 278 = $4,105.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4105.80,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,211.60 in Billed Charges for Rev 278 = $4,105.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,PREVEA HEALTH NETWORK,PREVEA360,4105.80,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,211.60 in Billed Charges for Rev 278 = $4,105.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4105.80,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,211.60 in Billed Charges for Rev 278 = $4,105.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5241.46,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,211.60 in Billed Charges for Rev 278 = $5,241.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5912.35,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,211.60 in Billed Charges for Rev 278 = $5,912.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3826.61,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,211.60 in Billed Charges for Rev 278 = $3,826.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,3826.61,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,211.60 in Billed Charges for Rev 278 = $3,826.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,3826.61,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,211.60 in Billed Charges for Rev 278 = $3,826.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5912.35,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,211.60 in Billed Charges for Rev 278 = $5,912.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5091.19,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,211.60 in Billed Charges for Rev 278 = $5,091.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5912.35,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,211.60 in Billed Charges for Rev 278 = $5,912.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5912.35,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,211.60 in Billed Charges for Rev 278 = $5,912.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE MITRAL MOSAIC 25MM,278,RC,10034565,CDM,,,,,,both,,,8211.6000,5419.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4926.96,,,,,,,3826.6100,8211.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,211.60 in Billed Charges for Rev 278 = $4,926.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,AETNA,AETNA HSHS,1070.59,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,657.26 in Billed Charges for Rev 278 = $1,070.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,AETNA,ALL COMMERCIAL AETNA,1657.26,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,657.26 in Billed Charges for Rev 278 = $1,657.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,ANTHEM,ANTHEM POS/HMO,861.78,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,657.26 in Billed Charges for Rev 278 = $861.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,ANTHEM,ANTHEM PPO,861.78,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,657.26 in Billed Charges for Rev 278 = $861.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1657.26,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,657.26 in Billed Charges for Rev 278 = $1,657.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,CENPATICO,ALL MEDICAID CENPATICO,1657.26,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,657.26 in Billed Charges for Rev 278 = $1,657.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1408.67,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,657.26 in Billed Charges for Rev 278 = $1,408.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,CIGNA,ALL COMMERCIAL CIGNA,1160.08,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,657.26 in Billed Charges for Rev 278 = $1,160.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,COFINITY,COFINITY,1657.26,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,657.26 in Billed Charges for Rev 278 = $1,657.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1574.40,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,657.26 in Billed Charges for Rev 278 = $1,574.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,1392.10,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,657.26 in Billed Charges for Rev 278 = $1,392.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1176.65,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,657.26 in Billed Charges for Rev 278 = $1,176.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1209.80,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,657.26 in Billed Charges for Rev 278 = $1,209.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,805.43,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,657.26 in Billed Charges for Rev 278 = $805.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1408.67,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,657.26 in Billed Charges for Rev 278 = $1,408.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,HUMANA,HUMANA CHOICE CARE PPO,1408.67,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,657.26 in Billed Charges for Rev 278 = $1,408.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1209.80,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,657.26 in Billed Charges for Rev 278 = $1,209.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1657.26,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,657.26 in Billed Charges for Rev 278 = $1,657.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,828.63,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,657.26 in Billed Charges for Rev 278 = $828.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1392.10,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,657.26 in Billed Charges for Rev 278 = $1,392.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1242.95,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,657.26 in Billed Charges for Rev 278 = $1,242.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1524.68,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,657.26 in Billed Charges for Rev 278 = $1,524.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1057.83,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,657.26 in Billed Charges for Rev 278 = $1,057.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1193.23,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,657.26 in Billed Charges for Rev 278 = $1,193.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1193.23,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,657.26 in Billed Charges for Rev 278 = $1,193.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1027.50,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,657.26 in Billed Charges for Rev 278 = $1,027.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1193.23,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,657.26 in Billed Charges for Rev 278 = $1,193.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1193.23,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,657.26 in Billed Charges for Rev 278 = $1,193.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT DELT PS MDCL REG CONTR CSF FLW CNTRL MED PRESS,278,RC,10004887,CDM,,,,,,both,,,1657.2600,1093.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,994.36,,,,,,,805.4300,1657.2600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,657.26 in Billed Charges for Rev 278 = $994.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,AETNA,AETNA HSHS,6686.10,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $10,350.00 in Billed Charges for Rev 278 = $6,686.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,AETNA,ALL COMMERCIAL AETNA,10350.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,350.00 in Billed Charges for Rev 278 = $10,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,ANTHEM,ANTHEM POS/HMO,5382.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,350.00 in Billed Charges for Rev 278 = $5,382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,ANTHEM,ANTHEM PPO,5382.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,350.00 in Billed Charges for Rev 278 = $5,382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10350.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,350.00 in Billed Charges for Rev 278 = $10,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,CENPATICO,ALL MEDICAID CENPATICO,10350.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,350.00 in Billed Charges for Rev 278 = $10,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8797.50,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,350.00 in Billed Charges for Rev 278 = $8,797.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,CIGNA,ALL COMMERCIAL CIGNA,7245.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $10,350.00 in Billed Charges for Rev 278 = $7,245.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,COFINITY,COFINITY,10350.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,350.00 in Billed Charges for Rev 278 = $10,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9832.50,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $10,350.00 in Billed Charges for Rev 278 = $9,832.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,8694.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,350.00 in Billed Charges for Rev 278 = $8,694.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7348.50,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $10,350.00 in Billed Charges for Rev 278 = $7,348.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7555.50,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,350.00 in Billed Charges for Rev 278 = $7,555.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,5030.10,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $10,350.00 in Billed Charges for Rev 278 = $5,030.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8797.50,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,350.00 in Billed Charges for Rev 278 = $8,797.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,HUMANA,HUMANA CHOICE CARE HMO,5175.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,350.00 in Billed Charges for Rev 278 = $5,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,HUMANA,HUMANA CHOICE CARE PPO,8797.50,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,350.00 in Billed Charges for Rev 278 = $8,797.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,HUMANA,HUMANA NATIIONAL POS HMO,5175.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,350.00 in Billed Charges for Rev 278 = $5,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7555.50,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,350.00 in Billed Charges for Rev 278 = $7,555.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,10350.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,350.00 in Billed Charges for Rev 278 = $10,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5175.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,350.00 in Billed Charges for Rev 278 = $5,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8694.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,350.00 in Billed Charges for Rev 278 = $8,694.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7762.50,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $10,350.00 in Billed Charges for Rev 278 = $7,762.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9522.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $10,350.00 in Billed Charges for Rev 278 = $9,522.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5175.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,350.00 in Billed Charges for Rev 278 = $5,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5175.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,350.00 in Billed Charges for Rev 278 = $5,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,PREVEA HEALTH NETWORK,PREVEA360,5175.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,350.00 in Billed Charges for Rev 278 = $5,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5175.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,350.00 in Billed Charges for Rev 278 = $5,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6606.41,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $10,350.00 in Billed Charges for Rev 278 = $6,606.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7452.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,350.00 in Billed Charges for Rev 278 = $7,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4823.10,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,350.00 in Billed Charges for Rev 278 = $4,823.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,4823.10,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,350.00 in Billed Charges for Rev 278 = $4,823.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,4823.10,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,350.00 in Billed Charges for Rev 278 = $4,823.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7452.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,350.00 in Billed Charges for Rev 278 = $7,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6417.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $10,350.00 in Billed Charges for Rev 278 = $6,417.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7452.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,350.00 in Billed Charges for Rev 278 = $7,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7452.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,350.00 in Billed Charges for Rev 278 = $7,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE TRIFECTA AORTIC TISSUE  19MM  (TF-19A),278,RC,10053381,CDM,,,,,,both,,,10350.0000,6831.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6210.00,,,,,,,4823.1000,10350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $10,350.00 in Billed Charges for Rev 278 = $6,210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,AETNA,AETNA HSHS,1229.16,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,229.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,AETNA,ALL COMMERCIAL AETNA,1902.73,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,902.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,ANTHEM,ANTHEM POS/HMO,989.42,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $989.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,ANTHEM,ANTHEM PPO,989.42,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $989.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1902.73,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,902.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,CENPATICO,ALL MEDICAID CENPATICO,1902.73,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,902.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1617.32,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,617.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,CIGNA,ALL COMMERCIAL CIGNA,1331.91,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,331.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,COFINITY,COFINITY,1902.73,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,902.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1807.59,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,807.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,1598.29,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,598.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1350.94,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,350.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1388.99,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,388.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,924.73,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $924.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1617.32,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,617.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,HUMANA,HUMANA CHOICE CARE PPO,1617.32,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,617.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1388.99,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,388.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1902.73,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,902.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,951.37,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $951.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1598.29,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,598.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1427.05,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,427.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1750.51,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,750.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1214.51,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,214.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1369.97,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,369.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1369.97,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,369.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1179.69,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,179.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1369.97,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,369.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1369.97,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,369.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040509,CDM,,,,both,,,1902.7300,1255.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1141.64,,,,,,,924.7300,1902.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,902.73 in Billed Charges for Rev 278 Proc C1713 = $1,141.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,AETNA,AETNA HSHS,1139.06,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,139.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,AETNA,ALL COMMERCIAL AETNA,1763.25,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,ANTHEM,ANTHEM POS/HMO,916.89,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $916.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,ANTHEM,ANTHEM PPO,916.89,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $916.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1763.25,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,CENPATICO,ALL MEDICAID CENPATICO,1763.25,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1498.76,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,498.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,CIGNA,ALL COMMERCIAL CIGNA,1234.28,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,234.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,COFINITY,COFINITY,1763.25,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1675.09,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,675.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,1481.13,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,481.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1251.91,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,251.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1287.17,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,287.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,856.94,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $856.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1498.76,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,498.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,HUMANA,HUMANA CHOICE CARE PPO,1498.76,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,498.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1287.17,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,287.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1763.25,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,881.63,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $881.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1481.13,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,481.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1322.44,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,322.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1622.19,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,622.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1125.48,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,125.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1269.54,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,269.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1269.54,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,269.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1093.22,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,093.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1269.54,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,269.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1269.54,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,269.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084043,CDM,,,,both,,,1763.2500,1163.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1057.95,,,,,,,856.9400,1763.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,763.25 in Billed Charges for Rev 278 Proc C1713 = $1,057.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,AETNA,AETNA HSHS,1170.64,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,170.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,AETNA,ALL COMMERCIAL AETNA,1812.14,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,812.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,ANTHEM,ANTHEM POS/HMO,942.31,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $942.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,ANTHEM,ANTHEM PPO,942.31,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $942.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1812.14,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,812.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,CENPATICO,ALL MEDICAID CENPATICO,1812.14,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,812.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1540.32,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,540.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,CIGNA,ALL COMMERCIAL CIGNA,1268.50,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,268.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,COFINITY,COFINITY,1812.14,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,812.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1721.53,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,721.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,1522.20,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,522.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1286.62,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,286.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1322.86,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,322.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,880.70,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $880.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1540.32,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,540.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,HUMANA,HUMANA CHOICE CARE PPO,1540.32,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,540.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1322.86,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,322.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1812.14,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,812.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,906.07,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $906.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1522.20,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,522.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1359.11,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,359.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1667.17,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,667.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1156.69,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,156.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1304.74,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,304.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1304.74,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,304.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1123.53,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,123.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1304.74,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,304.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1304.74,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,304.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA LOCKING X-PLATE LARGE,C1713,HCPCS,278,RC,10084045,CDM,,,,both,,,1812.1400,1196.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1087.28,,,,,,,880.7000,1812.1400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,812.14 in Billed Charges for Rev 278 Proc C1713 = $1,087.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,AETNA,AETNA HSHS,922.26,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $922.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,AETNA,ALL COMMERCIAL AETNA,1427.64,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,427.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,ANTHEM,ANTHEM POS/HMO,742.37,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $742.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,ANTHEM,ANTHEM PPO,742.37,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $742.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1427.64,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,427.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,CENPATICO,ALL MEDICAID CENPATICO,1427.64,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,427.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1213.49,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,213.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,CIGNA,ALL COMMERCIAL CIGNA,999.35,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $999.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,COFINITY,COFINITY,1427.64,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,427.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1356.26,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,356.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,1199.22,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,199.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1013.62,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,013.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1042.18,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,042.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,693.83,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $693.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1213.49,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,213.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,HUMANA,HUMANA CHOICE CARE PPO,1213.49,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,213.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1042.18,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,042.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1427.64,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,427.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,713.82,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $713.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1199.22,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,199.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1070.73,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,070.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1313.43,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,313.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,911.26,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $911.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1027.90,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,027.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1027.90,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,027.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,885.14,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $885.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1027.90,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,027.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1027.90,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $1,027.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/2H,C1713,HCPCS,278,RC,10084075,CDM,,,,both,,,1427.6400,942.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,856.58,,,,,,,693.8300,1427.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,427.64 in Billed Charges for Rev 278 Proc C1713 = $856.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,AETNA,AETNA HSHS,975.54,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $975.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,AETNA,ALL COMMERCIAL AETNA,1510.13,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,510.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,ANTHEM,ANTHEM POS/HMO,785.27,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $785.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,ANTHEM,ANTHEM PPO,785.27,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $785.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1510.13,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,510.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,CENPATICO,ALL MEDICAID CENPATICO,1510.13,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,510.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1283.61,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,283.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,CIGNA,ALL COMMERCIAL CIGNA,1057.09,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,057.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,COFINITY,COFINITY,1510.13,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,510.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1434.62,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,434.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,1268.51,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,268.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1072.19,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,072.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1102.39,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,102.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,733.92,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $733.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1283.61,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,283.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,HUMANA,HUMANA CHOICE CARE PPO,1283.61,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,283.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1102.39,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,102.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1510.13,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,510.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,755.07,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $755.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1268.51,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,268.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1132.60,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,132.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1389.32,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,389.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,963.92,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $963.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1087.29,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,087.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1087.29,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,087.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,936.28,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $936.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1087.29,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,087.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1087.29,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $1,087.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA STRAIGHT FUSION PLATE/4H,C1713,HCPCS,278,RC,10068978,CDM,,,,both,,,1510.1300,996.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,906.08,,,,,,,733.9200,1510.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,510.13 in Billed Charges for Rev 278 Proc C1713 = $906.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,AETNA,AETNA HSHS,1192.34,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,192.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,AETNA,ALL COMMERCIAL AETNA,1845.72,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,845.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,ANTHEM,ANTHEM POS/HMO,959.77,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $959.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,ANTHEM,ANTHEM PPO,959.77,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $959.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1845.72,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,845.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,CENPATICO,ALL MEDICAID CENPATICO,1845.72,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,845.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1568.86,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,568.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,CIGNA,ALL COMMERCIAL CIGNA,1292.00,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,292.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,COFINITY,COFINITY,1845.72,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,845.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1753.43,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,753.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,1550.40,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,550.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1310.46,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,310.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1347.38,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,347.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,897.02,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $897.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1568.86,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,568.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,HUMANA,HUMANA CHOICE CARE PPO,1568.86,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,568.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1347.38,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,347.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1845.72,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,845.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,922.86,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $922.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1550.40,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,550.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1384.29,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,384.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1698.06,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,698.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1178.12,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,178.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1328.92,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,328.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1328.92,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,328.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1144.35,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,144.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1328.92,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,328.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1328.92,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,328.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084061,CDM,,,,both,,,1845.7200,1218.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1107.43,,,,,,,897.0200,1845.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,845.72 in Billed Charges for Rev 278 Proc C1713 = $1,107.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,AETNA,AETNA HSHS,1087.57,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,087.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,AETNA,ALL COMMERCIAL AETNA,1683.54,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,683.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,ANTHEM,ANTHEM POS/HMO,875.44,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $875.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,ANTHEM,ANTHEM PPO,875.44,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $875.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1683.54,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,683.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,CENPATICO,ALL MEDICAID CENPATICO,1683.54,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,683.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1431.01,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,431.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,CIGNA,ALL COMMERCIAL CIGNA,1178.48,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,178.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,COFINITY,COFINITY,1683.54,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,683.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1599.36,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,599.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,1414.17,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,414.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1195.31,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,195.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1228.98,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,228.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,818.20,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $818.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1431.01,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,431.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,HUMANA,HUMANA CHOICE CARE PPO,1431.01,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,431.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1228.98,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,228.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1683.54,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,683.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,841.77,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $841.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1414.17,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,414.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1262.66,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,262.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1548.86,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,548.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1074.60,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,074.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1212.15,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,212.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1212.15,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,212.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1043.79,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,043.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1212.15,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,212.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1212.15,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,212.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084072,CDM,,,,both,,,1683.5400,1111.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1010.12,,,,,,,818.2000,1683.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,683.54 in Billed Charges for Rev 278 Proc C1713 = $1,010.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,AETNA,AETNA HSHS,1769.84,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,769.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,AETNA,ALL COMMERCIAL AETNA,2739.69,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,739.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,ANTHEM,ANTHEM POS/HMO,1424.64,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,424.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,ANTHEM,ANTHEM PPO,1424.64,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,424.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2739.69,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,739.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,CENPATICO,ALL MEDICAID CENPATICO,2739.69,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,739.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2328.74,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,328.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,CIGNA,ALL COMMERCIAL CIGNA,1917.78,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,917.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,COFINITY,COFINITY,2739.69,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,739.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2602.71,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,602.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,2301.34,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,301.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1945.18,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,945.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1999.97,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,999.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,1331.49,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,331.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2328.74,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,328.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,HUMANA,HUMANA CHOICE CARE HMO,1369.85,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,369.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,HUMANA,HUMANA CHOICE CARE PPO,2328.74,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,328.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,HUMANA,HUMANA NATIIONAL POS HMO,1369.85,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,369.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1999.97,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,999.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2739.69,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,739.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1369.85,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,369.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2301.34,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,301.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2054.77,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,054.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2520.51,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $2,520.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1748.74,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,748.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1972.58,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,972.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1972.58,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,972.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1698.61,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,698.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1972.58,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,972.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1972.58,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,972.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4/2.7 VA-LOCKING MESH 5 X 12H,C1713,HCPCS,278,RC,10084055,CDM,,,,both,,,2739.6900,1808.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1643.81,,,,,,,1331.4900,2739.6900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,739.69 in Billed Charges for Rev 278 Proc C1713 = $1,643.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,AETNA,AETNA HSHS,920.52,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $920.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,AETNA,ALL COMMERCIAL AETNA,1424.96,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,424.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,ANTHEM,ANTHEM POS/HMO,740.98,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $740.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,ANTHEM,ANTHEM PPO,740.98,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $740.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1424.96,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,424.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,CENPATICO,ALL MEDICAID CENPATICO,1424.96,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,424.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1211.22,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,211.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,CIGNA,ALL COMMERCIAL CIGNA,997.47,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $997.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,COFINITY,COFINITY,1424.96,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,424.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1353.71,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,353.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,1196.97,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,196.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1011.72,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,011.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1040.22,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,040.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,692.53,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $692.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1211.22,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,211.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,HUMANA,HUMANA CHOICE CARE PPO,1211.22,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,211.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1040.22,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,040.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1424.96,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,424.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,712.48,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $712.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1196.97,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,196.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1068.72,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,068.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1310.96,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,310.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,909.55,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $909.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1025.97,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,025.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1025.97,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,025.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,883.48,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $883.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1025.97,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,025.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1025.97,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $1,025.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM LCP VOLAR COLUMN DISTAL RADIUS MODULE,C1713,HCPCS,278,RC,70901145,CDM,,,,both,,,1424.9600,940.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,854.98,,,,,,,692.5300,1424.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,424.96 in Billed Charges for Rev 278 Proc C1713 = $854.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,AETNA,AETNA HSHS,460.80,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $460.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,AETNA,ALL COMMERCIAL AETNA,713.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $713.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,713.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $713.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,CENPATICO,ALL MEDICAID CENPATICO,713.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $713.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,606.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $606.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,CIGNA,ALL COMMERCIAL CIGNA,499.32,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $499.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,COFINITY,COFINITY,713.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $713.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,677.64,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $677.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,599.18,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $599.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,506.45,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $506.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,520.72,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $520.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,346.67,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $346.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,606.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $606.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,HUMANA,HUMANA CHOICE CARE PPO,606.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $606.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,520.72,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $520.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,713.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $713.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,356.66,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $356.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,599.18,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $599.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,534.98,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $534.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,656.25,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $656.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,455.31,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $455.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,513.58,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $513.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,513.58,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $513.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,442.25,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $442.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,513.58,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $513.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,513.58,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $513.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 6 HOLES/47MM,C1713,HCPCS,278,RC,10040304,CDM,,,,both,,,713.3100,470.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,427.99,,,,,,,346.6700,713.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $713.31 in Billed Charges for Rev 278 Proc C1713 = $427.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,AETNA,AETNA HSHS,497.06,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $497.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,AETNA,ALL COMMERCIAL AETNA,769.44,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $769.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,769.44,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $769.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,CENPATICO,ALL MEDICAID CENPATICO,769.44,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $769.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,654.02,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $654.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,CIGNA,ALL COMMERCIAL CIGNA,538.61,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $538.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,COFINITY,COFINITY,769.44,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $769.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,730.97,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $730.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,646.33,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $646.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,546.30,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $546.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,561.69,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $561.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,373.95,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $373.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,654.02,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $654.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,HUMANA,HUMANA CHOICE CARE PPO,654.02,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $654.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,561.69,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $561.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,769.44,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $769.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,384.72,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $384.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,646.33,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $646.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,577.08,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $577.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,707.88,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $707.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,491.13,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $491.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,554.00,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,554.00,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,477.05,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $477.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,554.00,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,554.00,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI LC-DCP 8 HOLES/63MM,C1713,HCPCS,278,RC,10026121,CDM,,,,both,,,769.4400,507.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,461.66,,,,,,,373.9500,769.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $769.44 in Billed Charges for Rev 278 Proc C1713 = $461.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,AETNA,AETNA HSHS,322.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $322.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,AETNA,ALL COMMERCIAL AETNA,499.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $499.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,499.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $499.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,CENPATICO,ALL MEDICAID CENPATICO,499.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $499.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,424.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $424.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,CIGNA,ALL COMMERCIAL CIGNA,349.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $349.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,COFINITY,COFINITY,499.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $499.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,474.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $474.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,419.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $419.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,354.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $354.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,364.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $364.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,242.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $242.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,424.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $424.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,HUMANA,HUMANA CHOICE CARE PPO,424.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $424.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,364.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $364.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,499.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $499.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,249.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $249.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,419.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $419.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,374.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $374.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,459.98,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $459.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,319.14,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $319.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,359.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $359.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,359.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $359.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,309.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $309.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,359.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $359.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,359.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $359.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 2 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10040305,CDM,,,,both,,,499.9800,329.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,299.99,,,,,,,242.9900,499.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $499.98 in Billed Charges for Rev 278 Proc C1713 = $299.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,AETNA,AETNA HSHS,346.32,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,AETNA,ALL COMMERCIAL AETNA,536.10,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $536.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,536.10,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $536.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,CENPATICO,ALL MEDICAID CENPATICO,536.10,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $536.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,455.69,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $455.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,CIGNA,ALL COMMERCIAL CIGNA,375.27,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $375.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,COFINITY,COFINITY,536.10,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $536.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,509.30,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $509.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,450.32,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $450.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,380.63,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $380.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,391.35,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $391.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,260.54,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $260.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,455.69,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $455.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,HUMANA,HUMANA CHOICE CARE PPO,455.69,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $455.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,391.35,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $391.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,536.10,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $536.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,268.05,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $268.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,450.32,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $450.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,402.08,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $402.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,493.21,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $493.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,342.19,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $342.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,385.99,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $385.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,385.99,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $385.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,332.38,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $332.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,385.99,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $385.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,385.99,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $385.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI T 3 HOLES HEAD/ 8 HOLES SHAFT/54MM,C1713,HCPCS,278,RC,10026120,CDM,,,,both,,,536.1000,353.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,321.66,,,,,,,260.5400,536.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $536.10 in Billed Charges for Rev 278 Proc C1713 = $321.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,AETNA,AETNA HSHS,334.65,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $334.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,AETNA,ALL COMMERCIAL AETNA,518.04,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $518.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,518.04,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $518.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,CENPATICO,ALL MEDICAID CENPATICO,518.04,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $518.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,440.33,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $440.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,CIGNA,ALL COMMERCIAL CIGNA,362.63,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $362.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,COFINITY,COFINITY,518.04,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $518.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,492.14,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $492.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,HEALTH CARE ALLIANCE,THE ALLIANCE,435.15,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $435.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,367.81,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $367.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,378.17,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $378.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,HSHS EMPLOYEES,HSHS EMPLOYEES,251.77,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $251.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,440.33,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $440.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,HUMANA,HUMANA CHOICE CARE PPO,440.33,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $440.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,378.17,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $378.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,LIVE360,LIVE360 HSHS HEALTHY PLAN,518.04,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $518.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,259.02,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $259.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,435.15,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $435.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,388.53,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $388.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,476.60,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $476.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,330.66,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $330.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,372.99,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $372.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,372.99,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $372.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,321.18,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $321.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,372.99,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $372.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,372.99,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $372.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.4MM TI Y PLATE,C1713,HCPCS,278,RC,10001238,CDM,,,,both,,,518.0400,341.9100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,310.82,,,,,,,251.7700,518.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $518.04 in Billed Charges for Rev 278 Proc C1713 = $310.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,AETNA,AETNA HSHS,1185.57,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,185.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,AETNA,ALL COMMERCIAL AETNA,1835.24,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,835.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,ANTHEM,ANTHEM POS/HMO,954.32,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $954.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,ANTHEM,ANTHEM PPO,954.32,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $954.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1835.24,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,835.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,CENPATICO,ALL MEDICAID CENPATICO,1835.24,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,835.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1559.95,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,559.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,CIGNA,ALL COMMERCIAL CIGNA,1284.67,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,284.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,COFINITY,COFINITY,1835.24,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,835.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1743.48,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,743.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,1541.60,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,541.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1303.02,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,303.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1339.73,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,339.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,891.93,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $891.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1559.95,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,559.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,HUMANA,HUMANA CHOICE CARE PPO,1559.95,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,559.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1339.73,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,339.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1835.24,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,835.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,917.62,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $917.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1541.60,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,541.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1376.43,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,376.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1688.42,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,688.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1171.43,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,171.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1321.37,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,321.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1321.37,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,321.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1137.85,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,137.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1321.37,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,321.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1321.37,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,321.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10069931,CDM,,,,both,,,1835.2400,1211.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1101.14,,,,,,,891.9300,1835.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,835.24 in Billed Charges for Rev 278 Proc C1713 = $1,101.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,AETNA,AETNA HSHS,381.42,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $381.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,AETNA,ALL COMMERCIAL AETNA,590.43,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $590.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,590.43,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $590.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,CENPATICO,ALL MEDICAID CENPATICO,590.43,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $590.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,501.87,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $501.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,CIGNA,ALL COMMERCIAL CIGNA,413.30,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $413.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,COFINITY,COFINITY,590.43,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $590.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,560.91,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $560.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,495.96,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $495.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,419.21,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $419.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,431.01,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $431.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,286.95,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $286.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,501.87,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $501.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,HUMANA,HUMANA CHOICE CARE PPO,501.87,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $501.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,431.01,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $431.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,590.43,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $590.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,295.22,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $295.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,495.96,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $495.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,442.82,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $442.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,543.20,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $543.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,376.87,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $376.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,425.11,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $425.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,425.11,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $425.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,366.07,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $366.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,425.11,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $425.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,425.11,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $425.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7  6H 48MM,C1713,HCPCS,278,RC,10001566,CDM,,,,both,,,590.4300,389.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,354.26,,,,,,,286.9500,590.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $590.43 in Billed Charges for Rev 278 Proc C1713 = $354.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,AETNA,AETNA HSHS,422.39,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $422.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,AETNA,ALL COMMERCIAL AETNA,653.86,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $653.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,653.86,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $653.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,CENPATICO,ALL MEDICAID CENPATICO,653.86,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $653.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,555.78,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $555.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,CIGNA,ALL COMMERCIAL CIGNA,457.70,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $457.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,COFINITY,COFINITY,653.86,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $653.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,621.17,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $621.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,549.24,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $549.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,464.24,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $464.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,477.32,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $477.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,317.78,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $317.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,555.78,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $555.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,HUMANA,HUMANA CHOICE CARE PPO,555.78,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $555.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,477.32,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $477.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,653.86,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $653.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,326.93,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $326.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,549.24,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $549.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,490.40,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $490.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,601.55,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $601.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,417.36,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $417.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,470.78,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $470.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,470.78,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $470.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,405.39,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $405.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,470.78,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $470.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,470.78,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $470.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 10H 80MM,C1713,HCPCS,278,RC,10032964,CDM,,,,both,,,653.8600,431.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,392.32,,,,,,,317.7800,653.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $653.86 in Billed Charges for Rev 278 Proc C1713 = $392.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,AETNA,AETNA HSHS,1856.69,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,856.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,AETNA,ALL COMMERCIAL AETNA,2874.13,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,874.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,ANTHEM,ANTHEM POS/HMO,1494.55,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,494.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,ANTHEM,ANTHEM PPO,1494.55,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,494.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2874.13,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,874.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,CENPATICO,ALL MEDICAID CENPATICO,2874.13,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,874.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2443.01,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,443.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,CIGNA,ALL COMMERCIAL CIGNA,2011.89,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,011.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,COFINITY,COFINITY,2874.13,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,874.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2730.42,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,730.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,2414.27,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,414.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2040.63,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,040.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2098.11,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,098.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,1396.83,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,396.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2443.01,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,443.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,HUMANA,HUMANA CHOICE CARE HMO,1437.07,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,437.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,HUMANA,HUMANA CHOICE CARE PPO,2443.01,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,443.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,HUMANA,HUMANA NATIIONAL POS HMO,1437.07,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,437.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2098.11,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,098.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,2874.13,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,874.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1437.07,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,437.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2414.27,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,414.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2155.60,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,155.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2644.20,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,644.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1834.56,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,834.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2069.37,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,069.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2069.37,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,069.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1781.96,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,781.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2069.37,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,069.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2069.37,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $2,069.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083965,CDM,,,,both,,,2874.1300,1896.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1724.48,,,,,,,1396.8300,2874.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,874.13 in Billed Charges for Rev 278 Proc C1713 = $1,724.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,AETNA,AETNA HSHS,2350.72,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,350.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,AETNA,ALL COMMERCIAL AETNA,3638.88,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,638.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,ANTHEM,ANTHEM POS/HMO,1892.22,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $1,892.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,ANTHEM,ANTHEM PPO,1892.22,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $1,892.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3638.88,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,638.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,CENPATICO,ALL MEDICAID CENPATICO,3638.88,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,638.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3093.05,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,093.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,CIGNA,ALL COMMERCIAL CIGNA,2547.22,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,547.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,COFINITY,COFINITY,3638.88,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,638.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3456.94,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,456.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,3056.66,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,056.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2583.60,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,583.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2656.38,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,656.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,1768.50,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $1,768.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3093.05,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,093.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,HUMANA,HUMANA CHOICE CARE HMO,1819.44,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $1,819.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,HUMANA,HUMANA CHOICE CARE PPO,3093.05,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,093.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,HUMANA,HUMANA NATIIONAL POS HMO,1819.44,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $1,819.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2656.38,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,656.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,3638.88,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,638.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1819.44,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $1,819.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3056.66,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,056.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2729.16,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,729.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3347.77,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $3,347.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2322.70,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,322.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2619.99,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,619.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2619.99,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,619.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2256.11,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,256.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2619.99,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,619.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2619.99,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,619.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083969,CDM,,,,both,,,3638.8800,2401.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2183.33,,,,,,,1768.5000,3638.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,638.88 in Billed Charges for Rev 278 Proc C1713 = $2,183.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,AETNA,AETNA HSHS,1799.12,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,799.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,AETNA,ALL COMMERCIAL AETNA,2785.02,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,785.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,ANTHEM,ANTHEM POS/HMO,1448.21,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,448.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,ANTHEM,ANTHEM PPO,1448.21,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,448.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2785.02,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,785.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,CENPATICO,ALL MEDICAID CENPATICO,2785.02,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,785.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2367.27,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,367.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,CIGNA,ALL COMMERCIAL CIGNA,1949.51,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,949.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,COFINITY,COFINITY,2785.02,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,785.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2645.77,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,645.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,2339.42,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,339.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1977.36,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,977.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2033.06,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,033.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,1353.52,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,353.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2367.27,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,367.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,HUMANA,HUMANA CHOICE CARE HMO,1392.51,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,392.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,HUMANA,HUMANA CHOICE CARE PPO,2367.27,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,367.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,HUMANA,HUMANA NATIIONAL POS HMO,1392.51,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,392.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2033.06,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,033.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,2785.02,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,785.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1392.51,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,392.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2339.42,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,339.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2088.77,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,088.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2562.22,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,562.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1777.68,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,777.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2005.21,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,005.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2005.21,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,005.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1726.71,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,726.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2005.21,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,005.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2005.21,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $2,005.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083959,CDM,,,,both,,,2785.0200,1838.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1671.01,,,,,,,1353.5200,2785.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,785.02 in Billed Charges for Rev 278 Proc C1713 = $1,671.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,AETNA,AETNA HSHS,1744.99,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,744.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,AETNA,ALL COMMERCIAL AETNA,2701.23,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,701.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,ANTHEM,ANTHEM POS/HMO,1404.64,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,404.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,ANTHEM,ANTHEM PPO,1404.64,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,404.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2701.23,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,701.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,CENPATICO,ALL MEDICAID CENPATICO,2701.23,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,701.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2296.05,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,296.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,CIGNA,ALL COMMERCIAL CIGNA,1890.86,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,890.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,COFINITY,COFINITY,2701.23,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,701.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2566.17,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,566.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,2269.03,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,269.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1917.87,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,917.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1971.90,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,971.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,1312.80,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,312.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2296.05,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,296.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,HUMANA,HUMANA CHOICE CARE HMO,1350.62,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,350.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,HUMANA,HUMANA CHOICE CARE PPO,2296.05,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,296.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,HUMANA,HUMANA NATIIONAL POS HMO,1350.62,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,350.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1971.90,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,971.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,2701.23,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,701.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1350.62,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,350.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2269.03,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,269.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2025.92,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,025.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2485.13,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $2,485.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1724.20,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,724.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1944.89,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,944.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1944.89,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,944.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1674.76,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,674.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1944.89,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,944.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1944.89,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,944.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083953,CDM,,,,both,,,2701.2300,1782.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1620.74,,,,,,,1312.8000,2701.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,701.23 in Billed Charges for Rev 278 Proc C1713 = $1,620.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,AETNA,AETNA HSHS,2036.26,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,036.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,AETNA,ALL COMMERCIAL AETNA,3152.10,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $3,152.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,ANTHEM,ANTHEM POS/HMO,1639.09,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $1,639.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,ANTHEM,ANTHEM PPO,1639.09,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $1,639.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3152.10,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $3,152.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,CENPATICO,ALL MEDICAID CENPATICO,3152.10,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $3,152.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2679.29,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,679.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,CIGNA,ALL COMMERCIAL CIGNA,2206.47,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,206.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,COFINITY,COFINITY,3152.10,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $3,152.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2994.50,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,994.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,2647.76,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,647.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2237.99,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,237.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2301.03,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,301.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,1531.92,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $1,531.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2679.29,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,679.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,HUMANA,HUMANA CHOICE CARE HMO,1576.05,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $1,576.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,HUMANA,HUMANA CHOICE CARE PPO,2679.29,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,679.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,HUMANA,HUMANA NATIIONAL POS HMO,1576.05,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $1,576.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2301.03,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,301.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,3152.10,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $3,152.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1576.05,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $1,576.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2647.76,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,647.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2364.08,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,364.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2899.93,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,899.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2011.99,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,011.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2269.51,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,269.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2269.51,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,269.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1954.30,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $1,954.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2269.51,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,269.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2269.51,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $2,269.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083955,CDM,,,,both,,,3152.1000,2080.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1891.26,,,,,,,1531.9200,3152.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,152.10 in Billed Charges for Rev 278 Proc C1713 = $1,891.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,AETNA,AETNA HSHS,1709.77,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,709.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,AETNA,ALL COMMERCIAL AETNA,2646.70,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,646.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,ANTHEM,ANTHEM POS/HMO,1376.28,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,376.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,ANTHEM,ANTHEM PPO,1376.28,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,376.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2646.70,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,646.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,CENPATICO,ALL MEDICAID CENPATICO,2646.70,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,646.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2249.70,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,249.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,CIGNA,ALL COMMERCIAL CIGNA,1852.69,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,852.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,COFINITY,COFINITY,2646.70,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,646.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2514.37,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,514.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,2223.23,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,223.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1879.16,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,879.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1932.09,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,932.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,1286.30,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,286.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2249.70,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,249.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,HUMANA,HUMANA CHOICE CARE HMO,1323.35,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,323.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,HUMANA,HUMANA CHOICE CARE PPO,2249.70,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,249.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,HUMANA,HUMANA NATIIONAL POS HMO,1323.35,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,323.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1932.09,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,932.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2646.70,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,646.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1323.35,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,323.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2223.23,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,223.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1985.03,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,985.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2434.96,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $2,434.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1689.39,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,689.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1905.62,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,905.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1905.62,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,905.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1640.95,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,640.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1905.62,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,905.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1905.62,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,905.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083949,CDM,,,,both,,,2646.7000,1746.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1588.02,,,,,,,1286.3000,2646.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,646.70 in Billed Charges for Rev 278 Proc C1713 = $1,588.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,AETNA,AETNA HSHS,536.67,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $536.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,AETNA,ALL COMMERCIAL AETNA,830.76,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $830.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,830.76,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $830.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,CENPATICO,ALL MEDICAID CENPATICO,830.76,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $830.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,706.15,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $706.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,CIGNA,ALL COMMERCIAL CIGNA,581.53,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $581.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,COFINITY,COFINITY,830.76,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $830.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,789.22,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $789.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,697.84,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $697.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,589.84,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $589.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,606.45,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $606.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,403.75,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $403.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,706.15,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $706.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,HUMANA,HUMANA CHOICE CARE PPO,706.15,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $706.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,606.45,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $606.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,830.76,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $830.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,415.38,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $415.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,697.84,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $697.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,623.07,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $623.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,764.30,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $764.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,530.27,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $530.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,598.15,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $598.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,598.15,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $598.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,515.07,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $515.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,598.15,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $598.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,598.15,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $598.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10027970,CDM,,,,both,,,830.7600,548.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,498.46,,,,,,,403.7500,830.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $830.76 in Billed Charges for Rev 278 Proc C1713 = $498.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,AETNA,AETNA HSHS,517.78,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $517.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,AETNA,ALL COMMERCIAL AETNA,801.52,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $801.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,801.52,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $801.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,CENPATICO,ALL MEDICAID CENPATICO,801.52,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $801.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,681.29,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $681.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,CIGNA,ALL COMMERCIAL CIGNA,561.06,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $561.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,COFINITY,COFINITY,801.52,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $801.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,761.44,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $761.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,673.28,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $673.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,569.08,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $569.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,585.11,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $585.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,389.54,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $389.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,681.29,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $681.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,HUMANA,HUMANA CHOICE CARE PPO,681.29,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $681.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,585.11,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $585.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,801.52,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $801.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,400.76,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $400.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,673.28,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $673.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,601.14,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $601.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,737.40,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $737.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,511.61,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $511.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,577.09,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $577.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,577.09,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $577.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,496.94,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $496.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,577.09,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $577.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,577.09,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $577.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 LCP 4H/40MM,C1713,HCPCS,278,RC,10064041,CDM,,,,both,,,801.5200,529.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,480.91,,,,,,,389.5400,801.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $801.52 in Billed Charges for Rev 278 Proc C1713 = $480.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,AETNA,AETNA HSHS,1168.03,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,168.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,AETNA,ALL COMMERCIAL AETNA,1808.10,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,808.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,ANTHEM,ANTHEM POS/HMO,940.21,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $940.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,ANTHEM,ANTHEM PPO,940.21,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $940.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1808.10,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,808.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,CENPATICO,ALL MEDICAID CENPATICO,1808.10,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,808.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1536.89,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,536.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,CIGNA,ALL COMMERCIAL CIGNA,1265.67,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,265.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,COFINITY,COFINITY,1808.10,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,808.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1717.70,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,717.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,1518.80,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,518.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1283.75,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,283.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1319.91,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,319.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,878.74,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $878.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1536.89,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,536.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,HUMANA,HUMANA CHOICE CARE PPO,1536.89,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,536.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1319.91,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,319.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1808.10,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,808.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,904.05,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $904.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1518.80,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,518.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1356.08,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,356.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1663.45,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,663.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1154.11,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,154.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1301.83,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1301.83,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1121.02,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,121.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1301.83,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1301.83,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040609,CDM,,,,both,,,1808.1000,1193.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1084.86,,,,,,,878.7400,1808.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,808.10 in Billed Charges for Rev 278 Proc C1713 = $1,084.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,AETNA,AETNA HSHS,1324.01,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,324.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,AETNA,ALL COMMERCIAL AETNA,2049.55,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $2,049.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,ANTHEM,ANTHEM POS/HMO,1065.77,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,065.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,ANTHEM,ANTHEM PPO,1065.77,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,065.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2049.55,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $2,049.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,CENPATICO,ALL MEDICAID CENPATICO,2049.55,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $2,049.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1742.12,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,742.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,CIGNA,ALL COMMERCIAL CIGNA,1434.69,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,434.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,COFINITY,COFINITY,2049.55,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $2,049.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1947.07,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,947.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,1721.62,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,721.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1455.18,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,455.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1496.17,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,496.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,996.08,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $996.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1742.12,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,742.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,HUMANA,HUMANA CHOICE CARE PPO,1742.12,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,742.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1496.17,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,496.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2049.55,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $2,049.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1024.78,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,024.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1721.62,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,721.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1537.16,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1885.59,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,885.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1308.23,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,308.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1475.68,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,475.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1475.68,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,475.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1270.72,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,270.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1475.68,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,475.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1475.68,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,475.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H LFT,C1713,HCPCS,278,RC,70902393,CDM,,,,both,,,2049.5500,1352.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1229.73,,,,,,,996.0800,2049.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,049.55 in Billed Charges for Rev 278 Proc C1713 = $1,229.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,AETNA,AETNA HSHS,567.80,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $567.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,AETNA,ALL COMMERCIAL AETNA,878.94,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $878.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,878.94,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $878.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,CENPATICO,ALL MEDICAID CENPATICO,878.94,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $878.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,747.10,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $747.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,CIGNA,ALL COMMERCIAL CIGNA,615.26,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $615.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,COFINITY,COFINITY,878.94,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $878.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,834.99,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $834.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,738.31,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $738.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,624.05,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $624.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,641.63,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $641.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,427.16,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $427.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,747.10,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $747.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,HUMANA,HUMANA CHOICE CARE PPO,747.10,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $747.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,641.63,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $641.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,878.94,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $878.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,439.47,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $439.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,738.31,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $738.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,659.21,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $659.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,808.62,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $808.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,561.03,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $561.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,632.84,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $632.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,632.84,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $632.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,544.94,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $544.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,632.84,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $632.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,632.84,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $632.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 18 HOLE,C1713,HCPCS,278,RC,10001569,CDM,,,,both,,,878.9400,580.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,527.36,,,,,,,427.1600,878.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $878.94 in Billed Charges for Rev 278 Proc C1713 = $527.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,AETNA,AETNA HSHS,82.18,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $82.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,AETNA,ALL COMMERCIAL AETNA,127.22,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $127.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,127.22,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $127.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,CENPATICO,ALL MEDICAID CENPATICO,127.22,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $127.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,108.14,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $108.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,CIGNA,ALL COMMERCIAL CIGNA,89.05,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $89.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,COFINITY,COFINITY,127.22,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $127.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,120.86,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $120.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,106.86,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $106.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,90.33,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $90.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,92.87,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $92.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,61.83,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $61.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,108.14,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $108.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,HUMANA,HUMANA CHOICE CARE PPO,108.14,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $108.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,92.87,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $92.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,127.22,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $127.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,63.61,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $63.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,106.86,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $106.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,95.42,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $95.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,117.04,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $117.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,81.20,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $81.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,91.60,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $91.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,91.60,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $91.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,78.88,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $78.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,91.60,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $91.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,91.60,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $91.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 CORTEX SELF TAP  9MM,C1713,HCPCS,278,RC,10067565,CDM,,,,both,,,127.2200,83.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,76.33,,,,,,,61.8300,127.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $127.22 in Billed Charges for Rev 278 Proc C1713 = $76.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,AETNA,AETNA HSHS,154.70,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $154.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,AETNA,ALL COMMERCIAL AETNA,239.47,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $239.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,239.47,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $239.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,CENPATICO,ALL MEDICAID CENPATICO,239.47,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $239.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,203.55,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $203.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,CIGNA,ALL COMMERCIAL CIGNA,167.63,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $167.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,COFINITY,COFINITY,239.47,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $239.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,227.50,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $227.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,201.15,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $201.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,170.02,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $170.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,174.81,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $174.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,116.38,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $116.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,203.55,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $203.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,HUMANA,HUMANA CHOICE CARE PPO,203.55,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $203.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,174.81,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $174.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,239.47,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $239.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,119.74,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $119.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,201.15,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $201.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,179.60,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $179.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,220.31,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $220.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,152.85,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $152.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,172.42,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $172.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,172.42,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $172.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,148.47,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $148.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,172.42,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $172.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,172.42,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $172.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10063954,CDM,,,,both,,,239.4700,158.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,143.68,,,,,,,116.3800,239.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $239.47 in Billed Charges for Rev 278 Proc C1713 = $143.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,AETNA,AETNA HSHS,105.87,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $105.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,AETNA,ALL COMMERCIAL AETNA,163.89,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $163.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,163.89,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $163.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,CENPATICO,ALL MEDICAID CENPATICO,163.89,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $163.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,139.31,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $139.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,CIGNA,ALL COMMERCIAL CIGNA,114.72,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $114.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,COFINITY,COFINITY,163.89,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $163.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,155.70,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $155.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,137.67,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $137.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,116.36,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $116.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,119.64,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $119.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,79.65,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $79.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,139.31,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $139.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,HUMANA,HUMANA CHOICE CARE PPO,139.31,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $139.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,119.64,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $119.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,163.89,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $163.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,81.95,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $81.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,137.67,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $137.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,122.92,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $122.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,150.78,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $150.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,104.61,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $104.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,118.00,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,118.00,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,101.61,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $101.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,118.00,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,118.00,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026148,CDM,,,,both,,,163.8900,108.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,98.33,,,,,,,79.6500,163.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $163.89 in Billed Charges for Rev 278 Proc C1713 = $98.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,AETNA,AETNA HSHS,134.90,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $134.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,AETNA,ALL COMMERCIAL AETNA,208.82,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $208.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,208.82,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $208.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,CENPATICO,ALL MEDICAID CENPATICO,208.82,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $208.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,177.50,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $177.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,CIGNA,ALL COMMERCIAL CIGNA,146.17,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $146.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,COFINITY,COFINITY,208.82,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $208.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,198.38,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $198.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,175.41,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $175.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,148.26,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $148.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,152.44,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $152.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,101.49,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $101.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,177.50,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $177.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,HUMANA,HUMANA CHOICE CARE PPO,177.50,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $177.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,152.44,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $152.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,208.82,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $208.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,104.41,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $104.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,175.41,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $175.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,156.62,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $156.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,192.11,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $192.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,133.29,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $133.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,150.35,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $150.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,150.35,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $150.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,129.47,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $129.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,150.35,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $150.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,150.35,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $150.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 40MM,C1713,HCPCS,278,RC,10016038,CDM,,,,both,,,208.8200,137.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,125.29,,,,,,,101.4900,208.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $208.82 in Billed Charges for Rev 278 Proc C1713 = $125.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,AETNA,AETNA HSHS,66.87,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $66.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,AETNA,ALL COMMERCIAL AETNA,103.52,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $103.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,103.52,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $103.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,CENPATICO,ALL MEDICAID CENPATICO,103.52,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $103.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,87.99,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $87.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,CIGNA,ALL COMMERCIAL CIGNA,72.46,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $72.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,COFINITY,COFINITY,103.52,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $103.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,98.34,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $98.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,86.96,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $86.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,73.50,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $73.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,75.57,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $75.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,50.31,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $50.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,87.99,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $87.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,HUMANA,HUMANA CHOICE CARE PPO,87.99,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $87.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,75.57,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $75.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,103.52,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $103.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,51.76,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $51.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,86.96,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $86.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,77.64,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $77.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,95.24,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $95.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,66.08,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $66.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,74.53,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $74.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,74.53,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $74.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,64.18,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $64.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,74.53,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $74.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,74.53,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $74.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE BENDING INSERT,C1713,HCPCS,278,RC,10003244,CDM,,,,both,,,103.5200,68.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,62.11,,,,,,,50.3100,103.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $103.52 in Billed Charges for Rev 278 Proc C1713 = $62.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,AETNA,AETNA HSHS,227.22,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $227.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,AETNA,ALL COMMERCIAL AETNA,351.74,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $351.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,351.74,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $351.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,CENPATICO,ALL MEDICAID CENPATICO,351.74,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $351.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,298.98,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $298.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,CIGNA,ALL COMMERCIAL CIGNA,246.22,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $246.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,COFINITY,COFINITY,351.74,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $351.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,334.15,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $334.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,295.46,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $295.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,249.74,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $249.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,256.77,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $256.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,170.95,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $170.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,298.98,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $298.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,HUMANA,HUMANA CHOICE CARE PPO,298.98,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $298.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,256.77,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $256.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,351.74,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $351.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,175.87,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $175.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,295.46,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $295.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,263.81,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $263.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,323.60,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $323.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,224.52,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $224.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,253.25,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $253.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,253.25,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $253.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,218.08,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $218.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,253.25,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $253.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,253.25,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $253.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008666,CDM,,,,both,,,351.7400,232.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,211.04,,,,,,,170.9500,351.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.74 in Billed Charges for Rev 278 Proc C1713 = $211.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,AETNA,AETNA HSHS,253.81,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $253.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,AETNA,ALL COMMERCIAL AETNA,392.90,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $392.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,392.90,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $392.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,CENPATICO,ALL MEDICAID CENPATICO,392.90,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $392.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,333.97,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $333.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,CIGNA,ALL COMMERCIAL CIGNA,275.03,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $275.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,COFINITY,COFINITY,392.90,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $392.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,373.26,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $373.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,HEALTH CARE ALLIANCE,THE ALLIANCE,330.04,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $330.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,278.96,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $278.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,286.82,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $286.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,HSHS EMPLOYEES,HSHS EMPLOYEES,190.95,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $190.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,333.97,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $333.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,HUMANA,HUMANA CHOICE CARE PPO,333.97,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $333.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,286.82,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $286.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,LIVE360,LIVE360 HSHS HEALTHY PLAN,392.90,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $392.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,196.45,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $196.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,330.04,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $330.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,294.68,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $294.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,361.47,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $361.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,250.79,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $250.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,282.89,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $282.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,282.89,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $282.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,243.60,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $243.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,282.89,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $282.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,282.89,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $282.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009292,CDM,,,,both,,,392.9000,259.3100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,235.74,,,,,,,190.9500,392.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $392.90 in Billed Charges for Rev 278 Proc C1713 = $235.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,AETNA,AETNA HSHS,509.45,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $509.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,AETNA,ALL COMMERCIAL AETNA,788.62,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $788.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,788.62,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $788.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,CENPATICO,ALL MEDICAID CENPATICO,788.62,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $788.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,670.33,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $670.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,CIGNA,ALL COMMERCIAL CIGNA,552.03,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $552.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,COFINITY,COFINITY,788.62,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $788.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,749.19,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $749.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,HEALTH CARE ALLIANCE,THE ALLIANCE,662.44,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $662.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,559.92,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $559.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,575.69,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $575.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,HSHS EMPLOYEES,HSHS EMPLOYEES,383.27,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $383.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,670.33,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $670.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,HUMANA,HUMANA CHOICE CARE PPO,670.33,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $670.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,575.69,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $575.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,LIVE360,LIVE360 HSHS HEALTHY PLAN,788.62,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $788.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,394.31,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $394.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,662.44,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $662.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,591.47,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $591.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,725.53,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $725.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,503.38,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $503.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,567.81,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $567.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,567.81,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $567.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,488.94,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $488.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,567.81,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $567.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,567.81,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $567.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10064047,CDM,,,,both,,,788.6200,520.4900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,473.17,,,,,,,383.2700,788.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $788.62 in Billed Charges for Rev 278 Proc C1713 = $473.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,AETNA,AETNA HSHS,105.81,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $105.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,AETNA,ALL COMMERCIAL AETNA,163.80,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,163.80,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,CENPATICO,ALL MEDICAID CENPATICO,163.80,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,139.23,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $139.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,CIGNA,ALL COMMERCIAL CIGNA,114.66,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $114.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,COFINITY,COFINITY,163.80,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,155.61,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $155.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,137.59,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $137.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,116.30,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $116.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,119.57,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $119.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,79.61,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $79.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,139.23,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $139.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,HUMANA,HUMANA CHOICE CARE PPO,139.23,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $139.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,119.57,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $119.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,163.80,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,81.90,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $81.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,137.59,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $137.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,122.85,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $122.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,150.70,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $150.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,104.55,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,117.94,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $117.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,117.94,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $117.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,101.56,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $101.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,117.94,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $117.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,117.94,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $117.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  3 HOLE 23MM,C1713,HCPCS,278,RC,10039987,CDM,,,,both,,,163.8000,108.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,98.28,,,,,,,79.6100,163.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $163.80 in Billed Charges for Rev 278 Proc C1713 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,AETNA,AETNA HSHS,112.94,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $112.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,AETNA,ALL COMMERCIAL AETNA,174.83,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $174.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,174.83,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $174.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,CENPATICO,ALL MEDICAID CENPATICO,174.83,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $174.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,148.61,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $148.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,CIGNA,ALL COMMERCIAL CIGNA,122.38,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $122.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,COFINITY,COFINITY,174.83,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $174.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,166.09,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $166.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,146.86,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $146.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,124.13,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $124.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,127.63,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $127.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,84.97,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $84.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,148.61,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $148.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,HUMANA,HUMANA CHOICE CARE PPO,148.61,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $148.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,127.63,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $127.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,174.83,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $174.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,87.42,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $87.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,146.86,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $146.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,131.12,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $131.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,160.84,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $160.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,111.59,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $111.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,125.88,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $125.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,125.88,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $125.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,108.39,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $108.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,125.88,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $125.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,125.88,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $125.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053162,CDM,,,,both,,,174.8300,115.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,104.90,,,,,,,84.9700,174.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $174.83 in Billed Charges for Rev 278 Proc C1713 = $104.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,AETNA,AETNA HSHS,130.23,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $130.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,AETNA,ALL COMMERCIAL AETNA,201.60,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,201.60,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,CENPATICO,ALL MEDICAID CENPATICO,201.60,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,171.36,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $171.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,CIGNA,ALL COMMERCIAL CIGNA,141.12,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,COFINITY,COFINITY,201.60,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,191.52,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $191.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,169.34,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $169.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,143.14,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $143.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,147.17,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $147.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,97.98,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $97.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,171.36,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $171.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,HUMANA,HUMANA CHOICE CARE PPO,171.36,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $171.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,147.17,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $147.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,201.60,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,100.80,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,169.34,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $169.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,151.20,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,185.47,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $185.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,128.68,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $128.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,145.15,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $145.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,145.15,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $145.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,124.99,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $124.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,145.15,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $145.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,145.15,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $145.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053161,CDM,,,,both,,,201.6000,133.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,120.96,,,,,,,97.9800,201.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $201.60 in Billed Charges for Rev 278 Proc C1713 = $120.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,AETNA,AETNA HSHS,142.44,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $142.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,AETNA,ALL COMMERCIAL AETNA,220.50,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $220.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,220.50,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $220.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,CENPATICO,ALL MEDICAID CENPATICO,220.50,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $220.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,187.43,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $187.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,CIGNA,ALL COMMERCIAL CIGNA,154.35,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $154.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,COFINITY,COFINITY,220.50,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $220.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,209.48,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $209.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,HEALTH CARE ALLIANCE,THE ALLIANCE,185.22,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $185.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,156.56,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $156.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,160.97,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $160.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,HSHS EMPLOYEES,HSHS EMPLOYEES,107.16,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $107.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,187.43,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $187.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,HUMANA,HUMANA CHOICE CARE PPO,187.43,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $187.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,160.97,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $160.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,LIVE360,LIVE360 HSHS HEALTHY PLAN,220.50,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $220.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,110.25,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $110.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,185.22,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $185.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,165.38,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $165.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,202.86,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $202.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,140.75,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $140.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,158.76,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,158.76,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,136.71,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $136.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,158.76,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,158.76,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 2.7 QRTR-TUBE  8 HOLE 63MM,C1713,HCPCS,278,RC,10053164,CDM,,,,both,,,220.5000,145.5300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,132.30,,,,,,,107.1600,220.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $220.50 in Billed Charges for Rev 278 Proc C1713 = $132.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,AETNA,AETNA HSHS,996.54,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $996.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,AETNA,ALL COMMERCIAL AETNA,1542.63,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,542.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,ANTHEM,ANTHEM POS/HMO,802.17,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $802.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,ANTHEM,ANTHEM PPO,802.17,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $802.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1542.63,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,542.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,CENPATICO,ALL MEDICAID CENPATICO,1542.63,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,542.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1311.24,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,311.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,CIGNA,ALL COMMERCIAL CIGNA,1079.84,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,079.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,COFINITY,COFINITY,1542.63,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,542.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1465.50,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,465.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,1295.81,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,295.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1095.27,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,095.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1126.12,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,126.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,749.72,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $749.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1311.24,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,311.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,HUMANA,HUMANA CHOICE CARE PPO,1311.24,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,311.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1126.12,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,126.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1542.63,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,542.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,771.32,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $771.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1295.81,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,295.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1156.97,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,156.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1419.22,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,419.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,984.66,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $984.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1110.69,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,110.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1110.69,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,110.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,956.43,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $956.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1110.69,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,110.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1110.69,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $1,110.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080565,CDM,,,,both,,,1542.6300,1018.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,925.58,,,,,,,749.7200,1542.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,542.63 in Billed Charges for Rev 278 Proc C1713 = $925.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,AETNA,AETNA HSHS,1041.96,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,041.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,AETNA,ALL COMMERCIAL AETNA,1612.94,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,612.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,ANTHEM,ANTHEM POS/HMO,838.73,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $838.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,ANTHEM,ANTHEM PPO,838.73,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $838.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1612.94,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,612.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,CENPATICO,ALL MEDICAID CENPATICO,1612.94,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,612.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1371.00,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,CIGNA,ALL COMMERCIAL CIGNA,1129.06,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,129.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,COFINITY,COFINITY,1612.94,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,612.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1532.29,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,532.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,1354.87,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,354.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1145.19,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,145.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1177.45,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,177.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,783.89,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $783.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1371.00,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,HUMANA,HUMANA CHOICE CARE PPO,1371.00,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1177.45,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,177.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1612.94,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,612.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,806.47,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $806.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1354.87,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,354.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1209.71,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,209.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1483.90,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,483.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1029.54,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,029.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1161.32,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,161.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1161.32,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,161.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1000.02,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,000.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1161.32,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,161.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1161.32,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $1,161.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060239,CDM,,,,both,,,1612.9400,1064.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,967.76,,,,,,,783.8900,1612.9400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,612.94 in Billed Charges for Rev 278 Proc C1713 = $967.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,AETNA,AETNA HSHS,1093.87,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,093.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,AETNA,ALL COMMERCIAL AETNA,1693.30,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,693.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,ANTHEM,ANTHEM POS/HMO,880.52,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $880.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,ANTHEM,ANTHEM PPO,880.52,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $880.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1693.30,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,693.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,CENPATICO,ALL MEDICAID CENPATICO,1693.30,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,693.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1439.31,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,439.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,CIGNA,ALL COMMERCIAL CIGNA,1185.31,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,185.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,COFINITY,COFINITY,1693.30,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,693.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1608.64,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,608.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,1422.37,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,422.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1202.24,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,202.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1236.11,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,236.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,822.94,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $822.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1439.31,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,439.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,HUMANA,HUMANA CHOICE CARE PPO,1439.31,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,439.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1236.11,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,236.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1693.30,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,693.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,846.65,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $846.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1422.37,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,422.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1269.98,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,269.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1557.84,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,557.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1080.83,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,080.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1219.18,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,219.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1219.18,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,219.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1049.85,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,049.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1219.18,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,219.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1219.18,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,219.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080599,CDM,,,,both,,,1693.3000,1117.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1015.98,,,,,,,822.9400,1693.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,693.30 in Billed Charges for Rev 278 Proc C1713 = $1,015.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,AETNA,AETNA HSHS,1149.49,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,149.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,AETNA,ALL COMMERCIAL AETNA,1779.40,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,779.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,ANTHEM,ANTHEM POS/HMO,925.29,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $925.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,ANTHEM,ANTHEM PPO,925.29,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $925.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1779.40,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,779.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,CENPATICO,ALL MEDICAID CENPATICO,1779.40,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,779.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1512.49,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,512.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,CIGNA,ALL COMMERCIAL CIGNA,1245.58,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,245.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,COFINITY,COFINITY,1779.40,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,779.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1690.43,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,690.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,1494.70,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,494.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1263.37,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,263.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1298.96,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,298.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,864.79,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $864.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1512.49,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,512.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,HUMANA,HUMANA CHOICE CARE PPO,1512.49,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,512.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1298.96,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,298.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1779.40,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,779.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,889.70,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $889.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1494.70,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,494.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1334.55,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,334.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1637.05,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,637.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1135.79,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,135.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1281.17,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,281.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1281.17,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,281.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1103.23,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,103.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1281.17,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,281.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1281.17,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,281.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10060247,CDM,,,,both,,,1779.4000,1174.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1067.64,,,,,,,864.7900,1779.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,779.40 in Billed Charges for Rev 278 Proc C1713 = $1,067.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,AETNA,AETNA HSHS,1259.81,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,259.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,AETNA,ALL COMMERCIAL AETNA,1950.17,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,950.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,ANTHEM,ANTHEM POS/HMO,1014.09,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,014.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,ANTHEM,ANTHEM PPO,1014.09,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,014.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1950.17,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,950.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,CENPATICO,ALL MEDICAID CENPATICO,1950.17,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,950.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1657.64,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,657.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,CIGNA,ALL COMMERCIAL CIGNA,1365.12,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,365.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,COFINITY,COFINITY,1950.17,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,950.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1852.66,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,852.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,1638.14,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,638.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1384.62,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,384.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1423.62,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,423.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,947.78,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $947.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1657.64,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,657.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,HUMANA,HUMANA CHOICE CARE PPO,1657.64,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,657.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1423.62,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,423.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1950.17,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,950.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,975.09,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $975.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1638.14,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,638.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1462.63,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,462.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1794.16,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,794.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1244.79,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,244.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1404.12,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,404.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1404.12,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,404.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1209.11,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,209.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1404.12,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,404.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1404.12,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,404.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083978,CDM,,,,both,,,1950.1700,1287.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1170.10,,,,,,,947.7800,1950.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,950.17 in Billed Charges for Rev 278 Proc C1713 = $1,170.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,AETNA,AETNA HSHS,1054.01,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,054.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,AETNA,ALL COMMERCIAL AETNA,1631.60,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,631.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,ANTHEM,ANTHEM POS/HMO,848.43,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $848.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,ANTHEM,ANTHEM PPO,848.43,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $848.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1631.60,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,631.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,CENPATICO,ALL MEDICAID CENPATICO,1631.60,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,631.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1386.86,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,386.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,CIGNA,ALL COMMERCIAL CIGNA,1142.12,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,142.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,COFINITY,COFINITY,1631.60,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,631.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1550.02,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,550.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,1370.54,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,370.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1158.44,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,158.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1191.07,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,191.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,792.96,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $792.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1386.86,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,386.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,HUMANA,HUMANA CHOICE CARE PPO,1386.86,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,386.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1191.07,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,191.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1631.60,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,631.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,815.80,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $815.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1370.54,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,370.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1223.70,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,223.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1501.07,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,501.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1041.45,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,041.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1174.75,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,174.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1174.75,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,174.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1011.59,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,011.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1174.75,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,174.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1174.75,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $1,174.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10083971,CDM,,,,both,,,1631.6000,1076.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,978.96,,,,,,,792.9600,1631.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,631.60 in Billed Charges for Rev 278 Proc C1713 = $978.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,AETNA,AETNA HSHS,1314.58,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,314.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,AETNA,ALL COMMERCIAL AETNA,2034.96,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $2,034.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,ANTHEM,ANTHEM POS/HMO,1058.18,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,058.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,ANTHEM,ANTHEM PPO,1058.18,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,058.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2034.96,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $2,034.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,CENPATICO,ALL MEDICAID CENPATICO,2034.96,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $2,034.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1729.72,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,729.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,CIGNA,ALL COMMERCIAL CIGNA,1424.47,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,424.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,COFINITY,COFINITY,2034.96,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $2,034.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1933.21,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,933.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,1709.37,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,709.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1444.82,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,444.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1485.52,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,485.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,988.99,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $988.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1729.72,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,729.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,HUMANA,HUMANA CHOICE CARE PPO,1729.72,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,729.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1485.52,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,485.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,2034.96,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $2,034.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1017.48,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,017.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1709.37,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,709.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1526.22,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,526.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1872.16,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,872.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1298.92,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,298.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1465.17,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,465.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1465.17,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,465.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1261.68,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,261.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1465.17,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,465.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1465.17,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,465.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080576,CDM,,,,both,,,2034.9600,1343.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1220.98,,,,,,,988.9900,2034.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,034.96 in Billed Charges for Rev 278 Proc C1713 = $1,220.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,AETNA,AETNA HSHS,776.20,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $776.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,AETNA,ALL COMMERCIAL AETNA,1201.55,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,201.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,ANTHEM,ANTHEM POS/HMO,624.81,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $624.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,ANTHEM,ANTHEM PPO,624.81,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $624.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1201.55,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,201.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,CENPATICO,ALL MEDICAID CENPATICO,1201.55,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,201.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1021.32,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,021.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,CIGNA,ALL COMMERCIAL CIGNA,841.09,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $841.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,COFINITY,COFINITY,1201.55,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,201.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1141.47,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,141.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,1009.30,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,009.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,853.10,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $853.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,877.13,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $877.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,583.95,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $583.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1021.32,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,021.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,HUMANA,HUMANA CHOICE CARE PPO,1021.32,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,021.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,877.13,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $877.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1201.55,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,201.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,600.78,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $600.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1009.30,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,009.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,901.16,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $901.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1105.43,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $1,105.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,766.95,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $766.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,865.12,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $865.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,865.12,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $865.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,744.96,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $744.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,865.12,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $865.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,865.12,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $865.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037077,CDM,,,,both,,,1201.5500,793.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,720.93,,,,,,,583.9500,1201.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,201.55 in Billed Charges for Rev 278 Proc C1713 = $720.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,AETNA,AETNA HSHS,813.71,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $813.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,AETNA,ALL COMMERCIAL AETNA,1259.62,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,259.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,ANTHEM,ANTHEM POS/HMO,655.00,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $655.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,ANTHEM,ANTHEM PPO,655.00,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $655.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1259.62,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,259.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,CENPATICO,ALL MEDICAID CENPATICO,1259.62,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,259.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1070.68,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,070.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,CIGNA,ALL COMMERCIAL CIGNA,881.73,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $881.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,COFINITY,COFINITY,1259.62,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,259.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1196.64,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,196.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,1058.08,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,058.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,894.33,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $894.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,919.52,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $919.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,612.18,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $612.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1070.68,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,070.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,HUMANA,HUMANA CHOICE CARE PPO,1070.68,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,070.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,919.52,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $919.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1259.62,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,259.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,629.81,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $629.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1058.08,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,058.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,944.72,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $944.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1158.85,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $1,158.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,804.02,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $804.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,906.93,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $906.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,906.93,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $906.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,780.96,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $780.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,906.93,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $906.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,906.93,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $906.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10037057,CDM,,,,both,,,1259.6200,831.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,755.77,,,,,,,612.1800,1259.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,259.62 in Billed Charges for Rev 278 Proc C1713 = $755.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,AETNA,AETNA HSHS,84.45,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $84.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,AETNA,ALL COMMERCIAL AETNA,130.73,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $130.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,130.73,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $130.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,CENPATICO,ALL MEDICAID CENPATICO,130.73,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $130.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,111.12,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $111.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,CIGNA,ALL COMMERCIAL CIGNA,91.51,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $91.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,COFINITY,COFINITY,130.73,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $130.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,124.19,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $124.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,109.81,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $109.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,92.82,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $92.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,95.43,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $95.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,63.53,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $63.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,111.12,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $111.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,HUMANA,HUMANA CHOICE CARE PPO,111.12,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $111.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,95.43,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $95.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,130.73,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $130.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.37,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $65.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,109.81,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $109.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,98.05,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $98.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,120.27,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $120.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,83.45,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $83.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,94.13,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $94.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,94.13,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $94.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,81.05,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $81.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,94.13,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $94.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,94.13,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $94.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001317,CDM,,,,both,,,130.7300,86.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,78.44,,,,,,,63.5300,130.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.73 in Billed Charges for Rev 278 Proc C1713 = $78.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,AETNA,AETNA HSHS,1575.64,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,575.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,AETNA,ALL COMMERCIAL AETNA,2439.07,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,439.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,ANTHEM,ANTHEM POS/HMO,1268.32,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,268.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,ANTHEM,ANTHEM PPO,1268.32,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,268.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2439.07,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,439.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,CENPATICO,ALL MEDICAID CENPATICO,2439.07,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,439.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2073.21,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,073.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,CIGNA,ALL COMMERCIAL CIGNA,1707.35,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,707.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,COFINITY,COFINITY,2439.07,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,439.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2317.12,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,317.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,2048.82,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,048.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1731.74,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,731.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1780.52,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,780.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,1185.39,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,185.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2073.21,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,073.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,HUMANA,HUMANA CHOICE CARE PPO,2073.21,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,073.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1780.52,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,780.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,2439.07,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,439.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1219.54,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,219.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2048.82,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,048.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1829.30,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,829.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2243.94,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $2,243.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1556.86,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,556.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1756.13,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,756.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1756.13,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,756.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1512.22,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,512.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1756.13,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,756.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1756.13,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,756.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 20 HOLE STRAIGHT,C1713,HCPCS,278,RC,10007501,CDM,,,,both,,,2439.0700,1609.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1463.44,,,,,,,1185.3900,2439.0700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,439.07 in Billed Charges for Rev 278 Proc C1713 = $1,463.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,AETNA,AETNA HSHS,1762.18,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,762.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,AETNA,ALL COMMERCIAL AETNA,2727.83,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,727.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,ANTHEM,ANTHEM POS/HMO,1418.47,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,418.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,ANTHEM,ANTHEM PPO,1418.47,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,418.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2727.83,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,727.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,CENPATICO,ALL MEDICAID CENPATICO,2727.83,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,727.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2318.66,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,318.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,CIGNA,ALL COMMERCIAL CIGNA,1909.48,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,909.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,COFINITY,COFINITY,2727.83,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,727.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2591.44,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,591.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,2291.38,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,291.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1936.76,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,936.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1991.32,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,991.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,1325.73,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,325.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2318.66,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,318.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,HUMANA,HUMANA CHOICE CARE HMO,1363.92,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,363.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,HUMANA,HUMANA CHOICE CARE PPO,2318.66,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,318.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,HUMANA,HUMANA NATIIONAL POS HMO,1363.92,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,363.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1991.32,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,991.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,2727.83,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,727.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1363.92,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,363.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2291.38,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,291.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2045.87,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,045.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2509.60,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $2,509.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1741.17,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,741.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1964.04,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,964.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1964.04,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,964.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1691.25,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,691.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1964.04,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,964.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1964.04,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,964.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70409758,CDM,,,,both,,,2727.8300,1800.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1636.70,,,,,,,1325.7300,2727.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,727.83 in Billed Charges for Rev 278 Proc C1713 = $1,636.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,AETNA,AETNA HSHS,1701.18,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,701.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,AETNA,ALL COMMERCIAL AETNA,2633.40,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,633.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,ANTHEM,ANTHEM POS/HMO,1369.37,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,369.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,ANTHEM,ANTHEM PPO,1369.37,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,369.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2633.40,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,633.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,CENPATICO,ALL MEDICAID CENPATICO,2633.40,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,633.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2238.39,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,238.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,CIGNA,ALL COMMERCIAL CIGNA,1843.38,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,843.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,COFINITY,COFINITY,2633.40,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,633.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2501.73,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,501.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,2212.06,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,212.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1869.71,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,869.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1922.38,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,922.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,1279.83,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,279.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2238.39,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,238.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,HUMANA,HUMANA CHOICE CARE HMO,1316.70,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,316.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,HUMANA,HUMANA CHOICE CARE PPO,2238.39,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,238.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,HUMANA,HUMANA NATIIONAL POS HMO,1316.70,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,316.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1922.38,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,922.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2633.40,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,633.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1316.70,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,316.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2212.06,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,212.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1975.05,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,975.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2422.73,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $2,422.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1680.90,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,680.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1896.05,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,896.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1896.05,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,896.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1632.71,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,632.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1896.05,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,896.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1896.05,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,896.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023342,CDM,,,,both,,,2633.4000,1738.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1580.04,,,,,,,1279.8300,2633.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,633.40 in Billed Charges for Rev 278 Proc C1713 = $1,580.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,AETNA,AETNA HSHS,229.94,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $229.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,AETNA,ALL COMMERCIAL AETNA,355.95,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $355.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,355.95,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $355.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,CENPATICO,ALL MEDICAID CENPATICO,355.95,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $355.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,302.56,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $302.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,CIGNA,ALL COMMERCIAL CIGNA,249.17,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $249.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,COFINITY,COFINITY,355.95,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $355.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,338.15,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $338.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,299.00,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $299.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,252.72,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,259.84,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $259.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,172.99,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $172.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,302.56,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $302.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,HUMANA,HUMANA CHOICE CARE PPO,302.56,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $302.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,259.84,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $259.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,355.95,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $355.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,177.98,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $177.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,299.00,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $299.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,266.96,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $266.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,327.47,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $327.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,227.20,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $227.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,256.28,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $256.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,256.28,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $256.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,220.69,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $220.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,256.28,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $256.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,256.28,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $256.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 10 HOLE,C1713,HCPCS,278,RC,10001630,CDM,,,,both,,,355.9500,234.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,213.57,,,,,,,172.9900,355.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $355.95 in Billed Charges for Rev 278 Proc C1713 = $213.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,AETNA,AETNA HSHS,198.41,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $198.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,AETNA,ALL COMMERCIAL AETNA,307.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $307.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,307.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $307.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,CENPATICO,ALL MEDICAID CENPATICO,307.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $307.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,261.06,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $261.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,CIGNA,ALL COMMERCIAL CIGNA,214.99,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $214.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,COFINITY,COFINITY,307.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $307.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,291.77,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $291.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,HEALTH CARE ALLIANCE,THE ALLIANCE,257.99,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $257.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,218.06,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $218.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,224.20,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $224.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,HSHS EMPLOYEES,HSHS EMPLOYEES,149.27,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $149.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,261.06,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $261.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,HUMANA,HUMANA CHOICE CARE PPO,261.06,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $261.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,224.20,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $224.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,LIVE360,LIVE360 HSHS HEALTHY PLAN,307.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $307.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,153.57,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $153.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,257.99,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $257.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,230.35,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $230.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,282.56,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $282.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,196.04,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $196.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,221.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $221.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,221.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $221.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,190.42,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $190.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,221.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $221.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,221.13,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $221.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 6 HOLE,C1713,HCPCS,278,RC,10011779,CDM,,,,both,,,307.1300,202.7100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,184.28,,,,,,,149.2700,307.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $307.13 in Billed Charges for Rev 278 Proc C1713 = $184.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,AETNA,AETNA HSHS,205.52,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $205.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,AETNA,ALL COMMERCIAL AETNA,318.15,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $318.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,318.15,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $318.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,CENPATICO,ALL MEDICAID CENPATICO,318.15,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $318.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,270.43,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $270.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,CIGNA,ALL COMMERCIAL CIGNA,222.71,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $222.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,COFINITY,COFINITY,318.15,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $318.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,302.24,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $302.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,267.25,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $267.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,225.89,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $225.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,232.25,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $232.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,154.62,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $154.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,270.43,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $270.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,HUMANA,HUMANA CHOICE CARE PPO,270.43,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $270.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,232.25,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $232.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,318.15,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $318.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,159.08,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $159.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,267.25,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $267.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,238.61,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $238.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,292.70,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $292.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,203.08,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $203.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,229.07,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $229.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,229.07,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $229.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,197.25,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $197.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,229.07,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $229.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,229.07,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $229.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011811,CDM,,,,both,,,318.1500,209.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,190.89,,,,,,,154.6200,318.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $318.15 in Billed Charges for Rev 278 Proc C1713 = $190.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,AETNA,AETNA HSHS,199.28,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $199.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,AETNA,ALL COMMERCIAL AETNA,308.48,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $308.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,308.48,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $308.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,CENPATICO,ALL MEDICAID CENPATICO,308.48,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $308.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,262.21,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $262.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,CIGNA,ALL COMMERCIAL CIGNA,215.94,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $215.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,COFINITY,COFINITY,308.48,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $308.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,293.06,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $293.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,259.12,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $259.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,219.02,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $219.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,225.19,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $225.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,149.92,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $149.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,262.21,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $262.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,HUMANA,HUMANA CHOICE CARE PPO,262.21,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $262.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,225.19,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $225.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,308.48,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $308.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,154.24,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $154.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,259.12,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $259.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,231.36,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $231.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,283.80,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $283.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,196.90,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $196.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,222.11,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $222.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,222.11,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $222.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,191.26,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $191.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,222.11,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $222.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,222.11,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $222.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LC-DCP 8 HOLE,C1713,HCPCS,278,RC,10011812,CDM,,,,both,,,308.4800,203.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,185.09,,,,,,,149.9200,308.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $308.48 in Billed Charges for Rev 278 Proc C1713 = $185.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,AETNA,AETNA HSHS,1775.93,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,775.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,AETNA,ALL COMMERCIAL AETNA,2749.11,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,749.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,ANTHEM,ANTHEM POS/HMO,1429.54,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,429.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,ANTHEM,ANTHEM PPO,1429.54,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,429.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2749.11,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,749.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,CENPATICO,ALL MEDICAID CENPATICO,2749.11,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,749.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2336.74,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,336.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,CIGNA,ALL COMMERCIAL CIGNA,1924.38,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,924.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,COFINITY,COFINITY,2749.11,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,749.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2611.65,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,611.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,2309.25,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,309.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1951.87,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,951.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2006.85,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,006.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,1336.07,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,336.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2336.74,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,336.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,HUMANA,HUMANA CHOICE CARE HMO,1374.56,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,374.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,HUMANA,HUMANA CHOICE CARE PPO,2336.74,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,336.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,HUMANA,HUMANA NATIIONAL POS HMO,1374.56,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,374.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2006.85,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,006.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,2749.11,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,749.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1374.56,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,374.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2309.25,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,309.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2061.83,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,061.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2529.18,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $2,529.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1754.76,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,754.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1979.36,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,979.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1979.36,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,979.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1704.45,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,704.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1979.36,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,979.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1979.36,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,979.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM LEFT,C1713,HCPCS,278,RC,70409765,CDM,,,,both,,,2749.1100,1814.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1649.47,,,,,,,1336.0700,2749.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,749.11 in Billed Charges for Rev 278 Proc C1713 = $1,649.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,AETNA,AETNA HSHS,2287.57,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,287.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,AETNA,ALL COMMERCIAL AETNA,3541.13,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,541.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,ANTHEM,ANTHEM POS/HMO,1841.39,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $1,841.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,ANTHEM,ANTHEM PPO,1841.39,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $1,841.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3541.13,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,541.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,CENPATICO,ALL MEDICAID CENPATICO,3541.13,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,541.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3009.96,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,009.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,CIGNA,ALL COMMERCIAL CIGNA,2478.79,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,478.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,COFINITY,COFINITY,3541.13,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,541.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3364.07,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,364.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,2974.55,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,974.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2514.20,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,514.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2585.02,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,585.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,1720.99,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $1,720.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3009.96,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,009.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,HUMANA,HUMANA CHOICE CARE HMO,1770.57,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $1,770.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,HUMANA,HUMANA CHOICE CARE PPO,3009.96,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,009.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,HUMANA,HUMANA NATIIONAL POS HMO,1770.57,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $1,770.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2585.02,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,585.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,3541.13,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,541.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1770.57,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $1,770.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2974.55,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,974.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2655.85,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,655.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3257.84,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $3,257.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2260.30,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,260.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2549.61,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,549.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2549.61,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,549.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2195.50,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,195.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2549.61,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,549.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2549.61,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,549.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 10H 194MM RIGHT,C1713,HCPCS,278,RC,10006838,CDM,,,,both,,,3541.1300,2337.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2124.68,,,,,,,1720.9900,3541.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,541.13 in Billed Charges for Rev 278 Proc C1713 = $2,124.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,AETNA,AETNA HSHS,1794.83,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,794.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,AETNA,ALL COMMERCIAL AETNA,2778.37,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,778.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,ANTHEM,ANTHEM POS/HMO,1444.75,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,444.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,ANTHEM,ANTHEM PPO,1444.75,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,444.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2778.37,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,778.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,CENPATICO,ALL MEDICAID CENPATICO,2778.37,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,778.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2361.61,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,361.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,CIGNA,ALL COMMERCIAL CIGNA,1944.86,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,944.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,COFINITY,COFINITY,2778.37,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,778.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2639.45,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,639.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,2333.83,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,333.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1972.64,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,972.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2028.21,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,028.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,1350.29,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,350.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2361.61,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,361.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,HUMANA,HUMANA CHOICE CARE HMO,1389.19,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,389.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,HUMANA,HUMANA CHOICE CARE PPO,2361.61,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,361.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,HUMANA,HUMANA NATIIONAL POS HMO,1389.19,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,389.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2028.21,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,028.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2778.37,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,778.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1389.19,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,389.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2333.83,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,333.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2083.78,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,083.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2556.10,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,556.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1773.43,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,773.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2000.43,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,000.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2000.43,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,000.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1722.59,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,722.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2000.43,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,000.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2000.43,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $2,000.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM LEFT,C1713,HCPCS,278,RC,70409767,CDM,,,,both,,,2778.3700,1833.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1667.02,,,,,,,1350.2900,2778.3700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,778.37 in Billed Charges for Rev 278 Proc C1713 = $1,667.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,AETNA,AETNA HSHS,2311.50,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,311.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,AETNA,ALL COMMERCIAL AETNA,3578.18,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,578.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,ANTHEM,ANTHEM POS/HMO,1860.65,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $1,860.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,ANTHEM,ANTHEM PPO,1860.65,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $1,860.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3578.18,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,578.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,CENPATICO,ALL MEDICAID CENPATICO,3578.18,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,578.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3041.45,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,041.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,CIGNA,ALL COMMERCIAL CIGNA,2504.73,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,504.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,COFINITY,COFINITY,3578.18,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,578.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3399.27,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,399.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,3005.67,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,005.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2540.51,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,540.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2612.07,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,612.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,1739.00,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $1,739.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3041.45,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,041.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,HUMANA,HUMANA CHOICE CARE HMO,1789.09,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $1,789.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,HUMANA,HUMANA CHOICE CARE PPO,3041.45,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,041.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,HUMANA,HUMANA NATIIONAL POS HMO,1789.09,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $1,789.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2612.07,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,612.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3578.18,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,578.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1789.09,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $1,789.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3005.67,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,005.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2683.64,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,683.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3291.93,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $3,291.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2283.95,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,283.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2576.29,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,576.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2576.29,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,576.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2218.47,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,218.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2576.29,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,576.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2576.29,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,576.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP DISTAL TIBIA 12H 220MM RIGHT,C1713,HCPCS,278,RC,10026093,CDM,,,,both,,,3578.1800,2361.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2146.91,,,,,,,1739.0000,3578.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,578.18 in Billed Charges for Rev 278 Proc C1713 = $2,146.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,AETNA,AETNA HSHS,2261.79,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,261.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,AETNA,ALL COMMERCIAL AETNA,3501.23,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $3,501.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,ANTHEM,ANTHEM POS/HMO,1820.64,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $1,820.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,ANTHEM,ANTHEM PPO,1820.64,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $1,820.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3501.23,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $3,501.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,CENPATICO,ALL MEDICAID CENPATICO,3501.23,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $3,501.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2976.05,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,976.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,CIGNA,ALL COMMERCIAL CIGNA,2450.86,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,450.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,COFINITY,COFINITY,3501.23,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $3,501.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3326.17,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $3,326.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,2941.03,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,941.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2485.87,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,485.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2555.90,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,555.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,1701.60,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $1,701.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2976.05,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,976.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,HUMANA,HUMANA CHOICE CARE HMO,1750.62,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $1,750.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,HUMANA,HUMANA CHOICE CARE PPO,2976.05,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,976.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,HUMANA,HUMANA NATIIONAL POS HMO,1750.62,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $1,750.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2555.90,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,555.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,3501.23,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $3,501.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1750.62,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $1,750.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2941.03,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,941.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2625.92,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,625.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3221.13,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $3,221.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2234.84,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,234.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2520.89,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,520.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2520.89,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,520.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2170.76,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,170.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2520.89,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,520.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2520.89,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,520.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10006918,CDM,,,,both,,,3501.2300,2310.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2100.74,,,,,,,1701.6000,3501.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,501.23 in Billed Charges for Rev 278 Proc C1713 = $2,100.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,AETNA,AETNA HSHS,1818.88,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,818.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,AETNA,ALL COMMERCIAL AETNA,2815.61,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,815.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,ANTHEM,ANTHEM POS/HMO,1464.12,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,464.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,ANTHEM,ANTHEM PPO,1464.12,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,464.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2815.61,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,815.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,CENPATICO,ALL MEDICAID CENPATICO,2815.61,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,815.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2393.27,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,393.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,CIGNA,ALL COMMERCIAL CIGNA,1970.93,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,970.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,COFINITY,COFINITY,2815.61,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,815.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2674.83,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,674.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,2365.11,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,365.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1999.08,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,999.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2055.40,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,055.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,1368.39,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,368.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2393.27,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,393.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,HUMANA,HUMANA CHOICE CARE HMO,1407.81,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,407.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,HUMANA,HUMANA CHOICE CARE PPO,2393.27,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,393.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,HUMANA,HUMANA NATIIONAL POS HMO,1407.81,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,407.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2055.40,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,055.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2815.61,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,815.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1407.81,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,407.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2365.11,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,365.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2111.71,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,111.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2590.36,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,590.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1797.20,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,797.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2027.24,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,027.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2027.24,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,027.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1745.68,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,745.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2027.24,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,027.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2027.24,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $2,027.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 5H 142MM,C1713,HCPCS,278,RC,10040239,CDM,,,,both,,,2815.6100,1858.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1689.37,,,,,,,1368.3900,2815.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,815.61 in Billed Charges for Rev 278 Proc C1713 = $1,689.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,AETNA,AETNA HSHS,1891.06,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,891.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,AETNA,ALL COMMERCIAL AETNA,2927.33,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,927.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,ANTHEM,ANTHEM POS/HMO,1522.21,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,522.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,ANTHEM,ANTHEM PPO,1522.21,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,522.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2927.33,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,927.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,CENPATICO,ALL MEDICAID CENPATICO,2927.33,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,927.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2488.23,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,488.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,CIGNA,ALL COMMERCIAL CIGNA,2049.13,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,049.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,COFINITY,COFINITY,2927.33,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,927.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2780.96,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,780.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,2458.96,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,458.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2078.40,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,078.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2136.95,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,136.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,1422.68,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,422.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2488.23,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,488.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,HUMANA,HUMANA CHOICE CARE HMO,1463.67,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,463.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,HUMANA,HUMANA CHOICE CARE PPO,2488.23,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,488.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,HUMANA,HUMANA NATIIONAL POS HMO,1463.67,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,463.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2136.95,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,136.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2927.33,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,927.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1463.67,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,463.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2458.96,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,458.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2195.50,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,195.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2693.14,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,693.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1868.51,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,868.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2107.68,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,107.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2107.68,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,107.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1814.94,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,814.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2107.68,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,107.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2107.68,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $2,107.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 6H 160MM,C1713,HCPCS,278,RC,10022336,CDM,,,,both,,,2927.3300,1932.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1756.40,,,,,,,1422.6800,2927.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,927.33 in Billed Charges for Rev 278 Proc C1713 = $1,756.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,AETNA,AETNA HSHS,1963.87,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,963.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,AETNA,ALL COMMERCIAL AETNA,3040.04,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $3,040.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,ANTHEM,ANTHEM POS/HMO,1580.82,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,580.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,ANTHEM,ANTHEM PPO,1580.82,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,580.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3040.04,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $3,040.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,CENPATICO,ALL MEDICAID CENPATICO,3040.04,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $3,040.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2584.03,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,584.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,CIGNA,ALL COMMERCIAL CIGNA,2128.03,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,128.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,COFINITY,COFINITY,3040.04,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $3,040.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2888.04,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,888.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,2553.63,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,553.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2158.43,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,158.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2219.23,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,219.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,1477.46,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,477.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2584.03,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,584.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,HUMANA,HUMANA CHOICE CARE HMO,1520.02,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,520.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,HUMANA,HUMANA CHOICE CARE PPO,2584.03,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,584.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,HUMANA,HUMANA NATIIONAL POS HMO,1520.02,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,520.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2219.23,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,219.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,3040.04,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $3,040.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1520.02,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,520.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2553.63,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,553.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2280.03,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,280.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2796.84,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,796.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1940.46,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,940.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2188.83,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,188.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2188.83,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,188.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1884.82,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,884.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2188.83,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,188.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2188.83,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $2,188.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP PROXIMAL HUMERUS LONG 8H 196MM,C1713,HCPCS,278,RC,10012858,CDM,,,,both,,,3040.0400,2006.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1824.02,,,,,,,1477.4600,3040.0400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,040.04 in Billed Charges for Rev 278 Proc C1713 = $1,824.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,AETNA,AETNA HSHS,655.70,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $655.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,AETNA,ALL COMMERCIAL AETNA,1015.02,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $1,015.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,ANTHEM,ANTHEM POS/HMO,527.81,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $527.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,ANTHEM,ANTHEM PPO,527.81,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $527.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1015.02,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $1,015.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,CENPATICO,ALL MEDICAID CENPATICO,1015.02,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $1,015.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,862.77,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $862.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,CIGNA,ALL COMMERCIAL CIGNA,710.51,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $710.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,COFINITY,COFINITY,1015.02,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $1,015.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,964.27,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $964.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,HEALTH CARE ALLIANCE,THE ALLIANCE,852.62,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $852.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,720.66,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $720.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,740.96,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $740.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,HSHS EMPLOYEES,HSHS EMPLOYEES,493.30,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $493.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,862.77,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $862.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,HUMANA,HUMANA CHOICE CARE PPO,862.77,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $862.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,740.96,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $740.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1015.02,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $1,015.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,507.51,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $507.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,852.62,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $852.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,761.27,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $761.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,933.82,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $933.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,647.89,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $647.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,730.81,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $730.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,730.81,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $730.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,629.31,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $629.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,730.81,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $730.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,730.81,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $730.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON  7 HOLE,C1713,HCPCS,278,RC,10046449,CDM,,,,both,,,1015.0200,669.9100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,609.01,,,,,,,493.3000,1015.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,015.02 in Billed Charges for Rev 278 Proc C1713 = $609.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,AETNA,AETNA HSHS,676.15,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $676.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,AETNA,ALL COMMERCIAL AETNA,1046.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $1,046.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,ANTHEM,ANTHEM POS/HMO,544.27,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $544.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,ANTHEM,ANTHEM PPO,544.27,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $544.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1046.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $1,046.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,CENPATICO,ALL MEDICAID CENPATICO,1046.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $1,046.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,889.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $889.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,CIGNA,ALL COMMERCIAL CIGNA,732.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $732.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,COFINITY,COFINITY,1046.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $1,046.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,994.34,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $994.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,879.20,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $879.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,743.14,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $743.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,764.07,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $764.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,508.68,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $508.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,889.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $889.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,HUMANA,HUMANA CHOICE CARE PPO,889.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $889.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,764.07,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $764.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1046.67,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $1,046.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,523.34,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $523.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,879.20,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $879.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,785.00,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $785.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,962.94,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $962.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,668.09,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $668.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,753.60,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $753.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,753.60,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $753.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,648.94,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $648.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,753.60,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $753.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,753.60,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $753.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP RECON 10 HOLE,C1713,HCPCS,278,RC,10003464,CDM,,,,both,,,1046.6700,690.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,628.00,,,,,,,508.6800,1046.6700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,046.67 in Billed Charges for Rev 278 Proc C1713 = $628.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,AETNA,AETNA HSHS,1027.71,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,027.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,AETNA,ALL COMMERCIAL AETNA,1590.88,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,590.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,ANTHEM,ANTHEM POS/HMO,827.26,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $827.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,ANTHEM,ANTHEM PPO,827.26,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $827.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1590.88,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,590.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,CENPATICO,ALL MEDICAID CENPATICO,1590.88,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,590.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1352.25,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,352.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,CIGNA,ALL COMMERCIAL CIGNA,1113.62,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,113.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,COFINITY,COFINITY,1590.88,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,590.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1511.34,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,511.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,1336.34,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,336.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1129.52,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,129.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1161.34,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,161.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,773.17,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $773.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1352.25,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,352.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,HUMANA,HUMANA CHOICE CARE PPO,1352.25,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,352.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1161.34,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,161.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1590.88,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,590.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,795.44,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $795.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1336.34,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,336.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1193.16,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,193.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1463.61,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,463.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1015.46,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,015.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1145.43,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,145.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1145.43,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,145.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,986.35,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $986.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1145.43,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,145.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1145.43,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $1,145.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10070587,CDM,,,,both,,,1590.8800,1049.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,954.53,,,,,,,773.1700,1590.8800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,590.88 in Billed Charges for Rev 278 Proc C1713 = $954.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,AETNA,AETNA HSHS,394.89,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $394.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,AETNA,ALL COMMERCIAL AETNA,611.29,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $611.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,611.29,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $611.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,CENPATICO,ALL MEDICAID CENPATICO,611.29,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $611.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,519.60,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $519.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,CIGNA,ALL COMMERCIAL CIGNA,427.90,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $427.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,COFINITY,COFINITY,611.29,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $611.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,580.73,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $580.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,513.48,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $513.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,434.02,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $434.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,446.24,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $446.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,297.09,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $297.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,519.60,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $519.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,HUMANA,HUMANA CHOICE CARE PPO,519.60,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $519.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,446.24,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $446.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,611.29,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $611.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,305.65,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $305.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,513.48,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $513.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,458.47,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $458.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,562.39,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $562.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,390.19,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $390.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,440.13,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $440.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,440.13,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $440.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,379.00,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $379.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,440.13,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $440.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,440.13,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $440.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10044983,CDM,,,,both,,,611.2900,403.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,366.77,,,,,,,297.0900,611.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $611.29 in Billed Charges for Rev 278 Proc C1713 = $366.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,AETNA,AETNA HSHS,441.75,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $441.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,AETNA,ALL COMMERCIAL AETNA,683.83,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $683.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,683.83,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $683.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,CENPATICO,ALL MEDICAID CENPATICO,683.83,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $683.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,581.26,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $581.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,CIGNA,ALL COMMERCIAL CIGNA,478.68,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $478.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,COFINITY,COFINITY,683.83,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $683.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,649.64,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $649.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,574.42,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $574.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,485.52,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $485.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,499.20,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $499.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,332.34,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $332.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,581.26,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $581.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,HUMANA,HUMANA CHOICE CARE PPO,581.26,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $581.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,499.20,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $499.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,683.83,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $683.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,341.92,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $341.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,574.42,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $574.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,512.87,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $512.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,629.12,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $629.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,436.49,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $436.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,492.36,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $492.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,492.36,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $492.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,423.97,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $423.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,492.36,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $492.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,492.36,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $492.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 3H SHAFT OBL RT,C1713,HCPCS,278,RC,10026088,CDM,,,,both,,,683.8300,451.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,410.30,,,,,,,332.3400,683.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $683.83 in Billed Charges for Rev 278 Proc C1713 = $410.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,AETNA,AETNA HSHS,462.42,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $462.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,AETNA,ALL COMMERCIAL AETNA,715.82,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $715.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,715.82,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $715.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,CENPATICO,ALL MEDICAID CENPATICO,715.82,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $715.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,608.45,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $608.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,CIGNA,ALL COMMERCIAL CIGNA,501.07,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $501.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,COFINITY,COFINITY,715.82,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $715.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,680.03,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $680.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,601.29,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $601.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,508.23,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $508.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,522.55,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $522.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,347.89,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $347.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,608.45,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $608.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,HUMANA,HUMANA CHOICE CARE PPO,608.45,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $608.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,522.55,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $522.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,715.82,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $715.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,357.91,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $357.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,601.29,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $601.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,536.87,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $536.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,658.55,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $658.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,456.91,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $456.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,515.39,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $515.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,515.39,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $515.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,443.81,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $443.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,515.39,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $515.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,515.39,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $515.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 4H SHAFT OBL RT,C1713,HCPCS,278,RC,10003458,CDM,,,,both,,,715.8200,472.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,429.49,,,,,,,347.8900,715.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $715.82 in Billed Charges for Rev 278 Proc C1713 = $429.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,AETNA,AETNA HSHS,483.03,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $483.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,AETNA,ALL COMMERCIAL AETNA,747.73,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $747.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,747.73,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $747.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,CENPATICO,ALL MEDICAID CENPATICO,747.73,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $747.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,635.57,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $635.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,CIGNA,ALL COMMERCIAL CIGNA,523.41,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $523.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,COFINITY,COFINITY,747.73,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $747.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,710.34,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $710.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,628.09,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $628.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,530.89,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $530.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,545.84,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $545.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,363.40,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $363.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,635.57,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $635.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,HUMANA,HUMANA CHOICE CARE PPO,635.57,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $635.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,545.84,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $545.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,747.73,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $747.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,373.87,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $373.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,628.09,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $628.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,560.80,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $560.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,687.91,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $687.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,477.28,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $477.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,538.37,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $538.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,538.37,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $538.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,463.59,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $463.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,538.37,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $538.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,538.37,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $538.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 5H SHAFT OBL RT,C1713,HCPCS,278,RC,10040477,CDM,,,,both,,,747.7300,493.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,448.64,,,,,,,363.4000,747.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $747.73 in Billed Charges for Rev 278 Proc C1713 = $448.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,AETNA,AETNA HSHS,525.27,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $525.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,AETNA,ALL COMMERCIAL AETNA,813.11,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $813.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,813.11,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $813.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,CENPATICO,ALL MEDICAID CENPATICO,813.11,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $813.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,691.14,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $691.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,CIGNA,ALL COMMERCIAL CIGNA,569.18,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $569.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,COFINITY,COFINITY,813.11,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $813.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,772.45,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $772.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,683.01,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $683.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,577.31,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $577.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,593.57,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $593.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,395.17,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $395.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,691.14,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $691.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,HUMANA,HUMANA CHOICE CARE PPO,691.14,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $691.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,593.57,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $593.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,813.11,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $813.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,406.56,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $406.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,683.01,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $683.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,609.83,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $609.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,748.06,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $748.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,519.01,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $519.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,585.44,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $585.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,585.44,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $585.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,504.13,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $504.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,585.44,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $585.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,585.44,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $585.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT OBL LT,C1713,HCPCS,278,RC,10003470,CDM,,,,both,,,813.1100,536.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,487.87,,,,,,,395.1700,813.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $813.11 in Billed Charges for Rev 278 Proc C1713 = $487.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,AETNA,AETNA HSHS,654.74,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $654.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,AETNA,ALL COMMERCIAL AETNA,1013.53,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $1,013.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,ANTHEM,ANTHEM POS/HMO,527.04,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $527.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,ANTHEM,ANTHEM PPO,527.04,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $527.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1013.53,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $1,013.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,CENPATICO,ALL MEDICAID CENPATICO,1013.53,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $1,013.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,861.50,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $861.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,CIGNA,ALL COMMERCIAL CIGNA,709.47,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $709.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,COFINITY,COFINITY,1013.53,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $1,013.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,962.85,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $962.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,851.37,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $851.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,719.61,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $719.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,739.88,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $739.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,492.58,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $492.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,861.50,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $861.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,HUMANA,HUMANA CHOICE CARE PPO,861.50,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $861.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,739.88,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $739.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1013.53,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $1,013.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,506.77,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $506.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,851.37,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $851.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,760.15,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $760.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,932.45,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $932.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,646.94,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $646.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,729.74,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $729.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,729.74,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $729.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,628.39,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $628.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,729.74,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $729.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,729.74,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $729.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 3H HEAD 7 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10026086,CDM,,,,both,,,1013.5300,668.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,608.12,,,,,,,492.5800,1013.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,013.53 in Billed Charges for Rev 278 Proc C1713 = $608.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,AETNA,AETNA HSHS,407.06,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $407.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,AETNA,ALL COMMERCIAL AETNA,630.12,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $630.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,630.12,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $630.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,CENPATICO,ALL MEDICAID CENPATICO,630.12,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $630.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,535.60,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $535.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,CIGNA,ALL COMMERCIAL CIGNA,441.08,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $441.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,COFINITY,COFINITY,630.12,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $630.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,598.61,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $598.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,529.30,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $529.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,447.39,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $447.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,459.99,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $459.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,306.24,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $306.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,535.60,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $535.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,HUMANA,HUMANA CHOICE CARE PPO,535.60,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $535.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,459.99,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $459.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,630.12,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $630.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,315.06,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $315.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,529.30,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $529.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,472.59,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $472.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,579.71,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $579.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,402.21,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $402.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,453.69,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $453.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,453.69,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $453.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,390.67,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $390.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,453.69,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $453.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,453.69,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $453.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP T 4H HEAD 4 HOLE SHAFT RT ANGLE,C1713,HCPCS,278,RC,10054049,CDM,,,,both,,,630.1200,415.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,378.07,,,,,,,306.2400,630.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $630.12 in Billed Charges for Rev 278 Proc C1713 = $378.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,AETNA,AETNA HSHS,504.21,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $504.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,AETNA,ALL COMMERCIAL AETNA,780.51,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $780.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,780.51,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $780.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,CENPATICO,ALL MEDICAID CENPATICO,780.51,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $780.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,663.43,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $663.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,CIGNA,ALL COMMERCIAL CIGNA,546.36,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $546.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,COFINITY,COFINITY,780.51,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $780.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,741.48,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $741.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,655.63,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $655.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,554.16,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $554.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,569.77,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $569.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,379.33,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $379.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,663.43,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $663.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,HUMANA,HUMANA CHOICE CARE PPO,663.43,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $663.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,569.77,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $569.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,780.51,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $780.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,390.26,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $390.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,655.63,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $655.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,585.38,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $585.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,718.07,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $718.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,498.20,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $498.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,561.97,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $561.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,561.97,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $561.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,483.92,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $483.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,561.97,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $561.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,561.97,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $561.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 12 HOLE,C1713,HCPCS,278,RC,10003459,CDM,,,,both,,,780.5100,515.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,468.31,,,,,,,379.3300,780.5100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $780.51 in Billed Charges for Rev 278 Proc C1713 = $468.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,AETNA,AETNA HSHS,366.39,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $366.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,AETNA,ALL COMMERCIAL AETNA,567.17,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $567.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,567.17,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $567.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,CENPATICO,ALL MEDICAID CENPATICO,567.17,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $567.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,482.09,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $482.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,CIGNA,ALL COMMERCIAL CIGNA,397.02,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $397.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,COFINITY,COFINITY,567.17,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $567.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,538.81,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $538.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,476.42,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $476.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,402.69,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $402.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,414.03,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $414.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,275.64,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $275.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,482.09,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $482.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,HUMANA,HUMANA CHOICE CARE PPO,482.09,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $482.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,414.03,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $414.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,567.17,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $567.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,283.59,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $283.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,476.42,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $476.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,425.38,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $425.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,521.80,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $521.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,362.02,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $362.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,408.36,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $408.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,408.36,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $408.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,351.65,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $351.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,408.36,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $408.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,408.36,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $408.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 5 HOLE,C1713,HCPCS,278,RC,10003467,CDM,,,,both,,,567.1700,374.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,340.30,,,,,,,275.6400,567.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $567.17 in Billed Charges for Rev 278 Proc C1713 = $340.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,AETNA,AETNA HSHS,443.32,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $443.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,AETNA,ALL COMMERCIAL AETNA,686.26,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $686.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,686.26,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $686.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,CENPATICO,ALL MEDICAID CENPATICO,686.26,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $686.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,583.32,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $583.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,CIGNA,ALL COMMERCIAL CIGNA,480.38,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $480.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,COFINITY,COFINITY,686.26,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $686.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,651.95,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $651.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,576.46,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $576.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,487.24,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $487.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,500.97,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $500.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,333.52,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $333.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,583.32,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $583.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,HUMANA,HUMANA CHOICE CARE PPO,583.32,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $583.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,500.97,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $500.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,686.26,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $686.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,343.13,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $343.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,576.46,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $576.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,514.70,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $514.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,631.36,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $631.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,438.04,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $438.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,494.11,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $494.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,494.11,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $494.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,425.48,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $425.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,494.11,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $494.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,494.11,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $494.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LCP-COMBI 9 HOLE,C1713,HCPCS,278,RC,10028657,CDM,,,,both,,,686.2600,452.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,411.76,,,,,,,333.5200,686.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $686.26 in Billed Charges for Rev 278 Proc C1713 = $411.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,AETNA,AETNA HSHS,419.56,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $419.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,AETNA,ALL COMMERCIAL AETNA,649.47,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $649.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,649.47,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $649.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,CENPATICO,ALL MEDICAID CENPATICO,649.47,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $649.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,552.05,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $552.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,CIGNA,ALL COMMERCIAL CIGNA,454.63,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $454.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,COFINITY,COFINITY,649.47,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $649.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,617.00,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $617.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,545.55,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $545.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,461.12,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $461.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,474.11,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $474.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,315.64,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $315.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,552.05,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $552.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,HUMANA,HUMANA CHOICE CARE PPO,552.05,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $552.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,474.11,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $474.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,649.47,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $649.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,324.74,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $324.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,545.55,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $545.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,487.10,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $487.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,597.51,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $597.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,414.56,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $414.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,467.62,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $467.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,467.62,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $467.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,402.67,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $402.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,467.62,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $467.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,467.62,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $467.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  4H 52MM,C1713,HCPCS,278,RC,10017370,CDM,,,,both,,,649.4700,428.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,389.68,,,,,,,315.6400,649.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $649.47 in Billed Charges for Rev 278 Proc C1713 = $389.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,AETNA,AETNA HSHS,484.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $484.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,AETNA,ALL COMMERCIAL AETNA,750.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $750.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,750.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $750.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,CENPATICO,ALL MEDICAID CENPATICO,750.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $750.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,637.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $637.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,CIGNA,ALL COMMERCIAL CIGNA,525.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $525.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,COFINITY,COFINITY,750.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $750.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,712.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $712.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,630.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $630.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,532.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $532.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,547.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $547.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,364.50,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $364.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,637.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $637.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,HUMANA,HUMANA CHOICE CARE PPO,637.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $637.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,547.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $547.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,750.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $750.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,375.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $375.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,630.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $630.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,562.51,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $562.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,690.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $690.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.73,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $478.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,540.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $540.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,540.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $540.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,465.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $465.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,540.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $540.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,540.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $540.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  6H 78MM,C1713,HCPCS,278,RC,10017347,CDM,,,,both,,,750.0100,495.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,450.01,,,,,,,364.5000,750.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $750.01 in Billed Charges for Rev 278 Proc C1713 = $450.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,AETNA,AETNA HSHS,508.69,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $508.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,AETNA,ALL COMMERCIAL AETNA,787.44,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $787.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,787.44,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $787.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,CENPATICO,ALL MEDICAID CENPATICO,787.44,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $787.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,669.32,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $669.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,CIGNA,ALL COMMERCIAL CIGNA,551.21,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $551.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,COFINITY,COFINITY,787.44,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $787.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,748.07,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $748.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,HEALTH CARE ALLIANCE,THE ALLIANCE,661.45,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $661.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,559.08,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $559.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,574.83,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $574.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,HSHS EMPLOYEES,HSHS EMPLOYEES,382.70,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $382.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,669.32,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $669.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,HUMANA,HUMANA CHOICE CARE PPO,669.32,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $669.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,574.83,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $574.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,LIVE360,LIVE360 HSHS HEALTHY PLAN,787.44,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $787.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,393.72,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $393.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,661.45,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $661.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,590.58,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $590.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,724.44,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $724.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,502.62,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $502.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,566.96,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $566.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,566.96,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $566.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,488.21,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $488.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,566.96,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $566.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,566.96,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $566.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  7H 91MM,C1713,HCPCS,278,RC,10017348,CDM,,,,both,,,787.4400,519.7100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,472.46,,,,,,,382.7000,787.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $787.44 in Billed Charges for Rev 278 Proc C1713 = $472.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,AETNA,AETNA HSHS,50.45,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $50.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,AETNA,ALL COMMERCIAL AETNA,78.10,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $78.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,78.10,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $78.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,CENPATICO,ALL MEDICAID CENPATICO,78.10,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $78.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,66.39,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $66.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,CIGNA,ALL COMMERCIAL CIGNA,54.67,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $54.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,COFINITY,COFINITY,78.10,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $78.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,74.20,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,65.60,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $65.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,55.45,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $55.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,57.01,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $57.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,37.96,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,66.39,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $66.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,HUMANA,HUMANA CHOICE CARE PPO,66.39,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $66.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,57.01,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $57.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,78.10,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $78.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,39.05,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $39.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,65.60,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $65.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,58.58,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $58.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,71.85,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $71.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,49.85,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $49.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,56.23,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $56.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,56.23,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $56.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,48.42,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $48.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,56.23,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $56.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,56.23,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $56.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040541,CDM,,,,both,,,78.1000,51.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,46.86,,,,,,,37.9600,78.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $78.10 in Billed Charges for Rev 278 Proc C1713 = $46.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,AETNA,AETNA HSHS,42.71,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $42.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,AETNA,ALL COMMERCIAL AETNA,66.11,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $66.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,66.11,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $66.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,CENPATICO,ALL MEDICAID CENPATICO,66.11,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $66.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,56.19,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $56.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,CIGNA,ALL COMMERCIAL CIGNA,46.28,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $46.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,COFINITY,COFINITY,66.11,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $66.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,62.80,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $62.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,HEALTH CARE ALLIANCE,THE ALLIANCE,55.53,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $55.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,46.94,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $46.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,48.26,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $48.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,HSHS EMPLOYEES,HSHS EMPLOYEES,32.13,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $32.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,56.19,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $56.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,HUMANA,HUMANA CHOICE CARE PPO,56.19,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $56.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,48.26,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $48.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,LIVE360,LIVE360 HSHS HEALTHY PLAN,66.11,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $66.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,33.06,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $33.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,55.53,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $55.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,49.58,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $49.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,60.82,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $60.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,42.20,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $42.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,47.60,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,47.60,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,40.99,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $40.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,47.60,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,47.60,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 CORTICAL SELF TAPPING 55,C1713,HCPCS,278,RC,10026159,CDM,,,,both,,,66.1100,43.6300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,39.67,,,,,,,32.1300,66.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $66.11 in Billed Charges for Rev 278 Proc C1713 = $39.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,AETNA,AETNA HSHS,59.45,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,AETNA,ALL COMMERCIAL AETNA,92.03,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $92.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,92.03,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $92.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,CENPATICO,ALL MEDICAID CENPATICO,92.03,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $92.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,78.23,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $78.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,CIGNA,ALL COMMERCIAL CIGNA,64.42,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $64.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,COFINITY,COFINITY,92.03,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $92.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,87.43,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $87.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,77.31,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $77.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,65.34,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $65.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,67.18,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,44.73,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $44.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,78.23,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $78.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,HUMANA,HUMANA CHOICE CARE PPO,78.23,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $78.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,67.18,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,92.03,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $92.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.02,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $46.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,77.31,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $77.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,69.02,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $69.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,84.67,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $84.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,58.74,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $58.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,66.26,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $66.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,66.26,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $66.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,57.06,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $57.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,66.26,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $66.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,66.26,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $66.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10080550,CDM,,,,both,,,92.0300,60.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.22,,,,,,,44.7300,92.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $92.03 in Billed Charges for Rev 278 Proc C1713 = $55.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,AETNA,AETNA HSHS,529.04,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $529.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,AETNA,ALL COMMERCIAL AETNA,818.94,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $818.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,818.94,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $818.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,CENPATICO,ALL MEDICAID CENPATICO,818.94,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $818.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,696.10,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $696.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,CIGNA,ALL COMMERCIAL CIGNA,573.26,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $573.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,COFINITY,COFINITY,818.94,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $818.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,777.99,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $777.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,687.91,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $687.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,581.45,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $581.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,597.83,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $597.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,398.00,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $398.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,696.10,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $696.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,HUMANA,HUMANA CHOICE CARE PPO,696.10,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $696.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,597.83,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $597.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,818.94,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $818.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,409.47,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $409.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,687.91,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $687.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,614.21,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $614.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,753.42,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $753.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,522.73,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $522.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,589.64,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $589.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,589.64,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $589.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,507.74,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $507.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,589.64,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $589.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,589.64,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $589.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  8H 104MM,C1713,HCPCS,278,RC,10017349,CDM,,,,both,,,818.9400,540.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,491.36,,,,,,,398.0000,818.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $818.94 in Billed Charges for Rev 278 Proc C1713 = $491.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,AETNA,AETNA HSHS,542.96,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $542.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,AETNA,ALL COMMERCIAL AETNA,840.50,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $840.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,840.50,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $840.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,CENPATICO,ALL MEDICAID CENPATICO,840.50,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $840.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,714.43,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $714.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,CIGNA,ALL COMMERCIAL CIGNA,588.35,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $588.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,COFINITY,COFINITY,840.50,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $840.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,798.48,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $798.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,706.02,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $706.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,596.76,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $596.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,613.57,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $613.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,408.48,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $408.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,714.43,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $714.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,HUMANA,HUMANA CHOICE CARE PPO,714.43,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $714.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,613.57,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $613.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,840.50,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $840.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,420.25,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $420.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,706.02,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $706.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,630.38,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $630.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,773.26,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $773.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,536.49,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $536.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,605.16,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $605.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,605.16,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $605.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,521.11,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $521.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,605.16,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $605.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,605.16,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $605.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON  9H 117MM,C1713,HCPCS,278,RC,10017350,CDM,,,,both,,,840.5000,554.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,504.30,,,,,,,408.4800,840.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $840.50 in Billed Charges for Rev 278 Proc C1713 = $504.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,AETNA,AETNA HSHS,545.80,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $545.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,AETNA,ALL COMMERCIAL AETNA,844.89,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $844.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,844.89,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $844.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,CENPATICO,ALL MEDICAID CENPATICO,844.89,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $844.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,718.16,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $718.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,CIGNA,ALL COMMERCIAL CIGNA,591.42,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $591.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,COFINITY,COFINITY,844.89,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $844.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,802.65,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $802.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,HEALTH CARE ALLIANCE,THE ALLIANCE,709.71,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $709.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,599.87,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $599.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,616.77,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $616.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,HSHS EMPLOYEES,HSHS EMPLOYEES,410.62,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $410.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,718.16,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $718.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,HUMANA,HUMANA CHOICE CARE PPO,718.16,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $718.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,616.77,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $616.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,LIVE360,LIVE360 HSHS HEALTHY PLAN,844.89,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $844.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,422.45,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $422.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,709.71,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $709.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,633.67,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $633.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,777.30,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $777.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,539.29,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $539.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,608.32,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $608.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,608.32,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $608.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,523.83,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $523.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,608.32,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $608.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,608.32,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $608.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 10H 130MM,C1713,HCPCS,278,RC,10017351,CDM,,,,both,,,844.8900,557.6300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,506.93,,,,,,,410.6200,844.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $844.89 in Billed Charges for Rev 278 Proc C1713 = $506.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,AETNA,AETNA HSHS,576.45,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $576.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,AETNA,ALL COMMERCIAL AETNA,892.34,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $892.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,892.34,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $892.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,CENPATICO,ALL MEDICAID CENPATICO,892.34,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $892.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,758.49,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $758.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,CIGNA,ALL COMMERCIAL CIGNA,624.64,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $624.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,COFINITY,COFINITY,892.34,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $892.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,847.72,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $847.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,749.57,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $749.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,633.56,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $633.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,651.41,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $651.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,433.68,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $433.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,758.49,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $758.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,HUMANA,HUMANA CHOICE CARE PPO,758.49,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $758.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,651.41,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $651.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,892.34,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $892.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,446.17,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $446.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,749.57,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $749.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,669.26,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $669.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,820.95,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $820.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,569.58,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $569.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,642.48,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $642.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,642.48,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $642.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,553.25,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $553.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,642.48,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $642.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,642.48,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $642.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 11H 143MM,C1713,HCPCS,278,RC,10017371,CDM,,,,both,,,892.3400,588.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,535.40,,,,,,,433.6800,892.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $892.34 in Billed Charges for Rev 278 Proc C1713 = $535.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,AETNA,AETNA HSHS,650.68,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $650.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,AETNA,ALL COMMERCIAL AETNA,1007.25,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $1,007.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,ANTHEM,ANTHEM POS/HMO,523.77,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $523.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,ANTHEM,ANTHEM PPO,523.77,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $523.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1007.25,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $1,007.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,CENPATICO,ALL MEDICAID CENPATICO,1007.25,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $1,007.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,856.16,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $856.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,CIGNA,ALL COMMERCIAL CIGNA,705.08,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $705.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,COFINITY,COFINITY,1007.25,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $1,007.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,956.89,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $956.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,846.09,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $846.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,715.15,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $715.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,735.29,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $735.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,489.52,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $489.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,856.16,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $856.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,HUMANA,HUMANA CHOICE CARE PPO,856.16,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $856.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,735.29,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $735.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1007.25,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $1,007.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,503.63,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $503.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,846.09,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $846.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,755.44,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $755.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,926.67,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $926.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,642.93,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $642.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,725.22,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $725.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,725.22,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $725.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,624.50,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $624.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,725.22,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $725.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,725.22,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $725.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 14 HOLE,C1713,HCPCS,278,RC,10017353,CDM,,,,both,,,1007.2500,664.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,604.35,,,,,,,489.5200,1007.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,007.25 in Billed Charges for Rev 278 Proc C1713 = $604.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,AETNA,AETNA HSHS,680.61,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $680.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,AETNA,ALL COMMERCIAL AETNA,1053.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $1,053.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,ANTHEM,ANTHEM POS/HMO,547.86,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $547.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,ANTHEM,ANTHEM PPO,547.86,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $547.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1053.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $1,053.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,CENPATICO,ALL MEDICAID CENPATICO,1053.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $1,053.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,895.54,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $895.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,CIGNA,ALL COMMERCIAL CIGNA,737.51,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $737.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,COFINITY,COFINITY,1053.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $1,053.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1000.90,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $1,000.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,885.01,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $885.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,748.04,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $748.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,769.11,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $769.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,512.04,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $512.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,895.54,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $895.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,HUMANA,HUMANA CHOICE CARE PPO,895.54,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $895.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,769.11,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $769.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1053.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $1,053.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,526.79,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $526.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,885.01,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $885.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,790.19,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $790.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,969.29,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $969.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,672.50,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $672.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,758.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $758.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,758.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $758.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,653.22,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $653.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,758.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $758.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,758.58,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $758.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 16 HOLE,C1713,HCPCS,278,RC,10017355,CDM,,,,both,,,1053.5800,695.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,632.15,,,,,,,512.0400,1053.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,053.58 in Billed Charges for Rev 278 Proc C1713 = $632.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,AETNA,AETNA HSHS,709.84,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $709.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,AETNA,ALL COMMERCIAL AETNA,1098.82,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $1,098.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,ANTHEM,ANTHEM POS/HMO,571.39,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $571.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,ANTHEM,ANTHEM PPO,571.39,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $571.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1098.82,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $1,098.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,CENPATICO,ALL MEDICAID CENPATICO,1098.82,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $1,098.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,934.00,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $934.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,CIGNA,ALL COMMERCIAL CIGNA,769.17,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $769.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,COFINITY,COFINITY,1098.82,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $1,098.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1043.88,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $1,043.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,923.01,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $923.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,780.16,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $780.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,802.14,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $802.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,534.03,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $534.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,934.00,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $934.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,HUMANA,HUMANA CHOICE CARE PPO,934.00,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $934.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,802.14,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $802.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1098.82,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $1,098.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,549.41,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $549.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,923.01,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $923.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,824.12,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $824.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1010.91,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $1,010.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,701.38,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $701.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,791.15,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $791.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,791.15,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $791.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,681.27,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $681.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,791.15,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $791.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,791.15,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $791.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 18 HOLE,C1713,HCPCS,278,RC,10017356,CDM,,,,both,,,1098.8200,725.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,659.29,,,,,,,534.0300,1098.8200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,098.82 in Billed Charges for Rev 278 Proc C1713 = $659.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,AETNA,AETNA HSHS,852.33,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $852.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,AETNA,ALL COMMERCIAL AETNA,1319.40,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,319.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,ANTHEM,ANTHEM POS/HMO,686.09,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $686.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,ANTHEM,ANTHEM PPO,686.09,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $686.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1319.40,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,319.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,CENPATICO,ALL MEDICAID CENPATICO,1319.40,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,319.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1121.49,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,121.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,CIGNA,ALL COMMERCIAL CIGNA,923.58,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $923.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,COFINITY,COFINITY,1319.40,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,319.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1253.43,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,253.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,1108.30,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,108.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,936.77,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $936.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,963.16,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $963.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,641.23,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $641.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1121.49,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,121.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,HUMANA,HUMANA CHOICE CARE PPO,1121.49,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,121.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,963.16,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $963.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1319.40,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,319.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,659.70,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $659.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1108.30,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,108.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,989.55,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $989.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1213.85,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $1,213.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,842.17,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $842.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,949.97,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $949.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,949.97,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $949.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,818.03,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $818.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,949.97,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $949.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,949.97,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $949.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LOW PROFILE RECON 20 HOLE,C1713,HCPCS,278,RC,10017357,CDM,,,,both,,,1319.4000,870.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,791.64,,,,,,,641.2300,1319.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,319.40 in Billed Charges for Rev 278 Proc C1713 = $791.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,AETNA,AETNA HSHS,527.95,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $527.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,AETNA,ALL COMMERCIAL AETNA,817.26,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $817.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,817.26,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $817.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,CENPATICO,ALL MEDICAID CENPATICO,817.26,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $817.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,694.67,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $694.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,CIGNA,ALL COMMERCIAL CIGNA,572.08,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $572.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,COFINITY,COFINITY,817.26,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $817.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,776.40,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $776.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,686.50,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $686.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,580.25,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $580.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,596.60,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $596.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,397.19,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $397.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,694.67,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $694.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,HUMANA,HUMANA CHOICE CARE PPO,694.67,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $694.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,596.60,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $596.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,817.26,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $817.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,408.63,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $408.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,686.50,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $686.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,612.95,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $612.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,751.88,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $751.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,521.66,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $521.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,588.43,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $588.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,588.43,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $588.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,506.70,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $506.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,588.43,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $588.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,588.43,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $588.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED  6H 78MM,C1713,HCPCS,278,RC,10017358,CDM,,,,both,,,817.2600,539.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,490.36,,,,,,,397.1900,817.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $817.26 in Billed Charges for Rev 278 Proc C1713 = $490.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,AETNA,AETNA HSHS,573.56,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $573.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,AETNA,ALL COMMERCIAL AETNA,887.86,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $887.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,887.86,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $887.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,CENPATICO,ALL MEDICAID CENPATICO,887.86,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $887.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,754.68,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $754.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,CIGNA,ALL COMMERCIAL CIGNA,621.50,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $621.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,COFINITY,COFINITY,887.86,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $887.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,843.47,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $843.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,745.80,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $745.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,630.38,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $630.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,648.14,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $648.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,431.50,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $431.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,754.68,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $754.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,HUMANA,HUMANA CHOICE CARE PPO,754.68,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $754.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,648.14,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $648.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,887.86,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $887.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,443.93,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $443.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,745.80,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $745.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,665.90,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $665.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,816.83,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $816.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,566.72,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $566.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,639.26,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $639.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,639.26,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $639.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,550.47,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $550.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,639.26,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $639.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,639.26,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $639.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017374,CDM,,,,both,,,887.8600,585.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,532.72,,,,,,,431.5000,887.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $887.86 in Billed Charges for Rev 278 Proc C1713 = $532.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,AETNA,AETNA HSHS,620.42,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $620.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,AETNA,ALL COMMERCIAL AETNA,960.41,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $960.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,960.41,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $960.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,CENPATICO,ALL MEDICAID CENPATICO,960.41,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $960.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,816.35,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $816.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,CIGNA,ALL COMMERCIAL CIGNA,672.29,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $672.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,COFINITY,COFINITY,960.41,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $960.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,912.39,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $912.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,806.74,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $806.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,681.89,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $681.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,701.10,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $701.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,466.76,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $466.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,816.35,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $816.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,HUMANA,HUMANA CHOICE CARE PPO,816.35,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $816.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,701.10,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $701.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,960.41,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $960.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,480.21,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $480.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,806.74,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $806.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,720.31,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $720.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,883.58,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $883.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,613.03,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $613.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,691.50,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $691.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,691.50,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $691.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,595.45,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $595.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,691.50,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $691.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,691.50,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $691.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 10H 130MM,C1713,HCPCS,278,RC,10033619,CDM,,,,both,,,960.4100,633.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,576.25,,,,,,,466.7600,960.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $960.41 in Billed Charges for Rev 278 Proc C1713 = $576.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,AETNA,AETNA HSHS,671.01,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $671.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,AETNA,ALL COMMERCIAL AETNA,1038.71,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $1,038.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,ANTHEM,ANTHEM POS/HMO,540.13,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $540.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,ANTHEM,ANTHEM PPO,540.13,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $540.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1038.71,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $1,038.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,CENPATICO,ALL MEDICAID CENPATICO,1038.71,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $1,038.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,882.90,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $882.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,CIGNA,ALL COMMERCIAL CIGNA,727.10,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $727.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,COFINITY,COFINITY,1038.71,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $1,038.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,986.77,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $986.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,872.52,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $872.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,737.48,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $737.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,758.26,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $758.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,504.81,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $504.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,882.90,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $882.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,HUMANA,HUMANA CHOICE CARE PPO,882.90,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $882.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,758.26,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $758.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1038.71,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $1,038.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,519.36,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $519.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,872.52,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $872.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,779.03,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $779.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,955.61,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $955.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,663.01,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $663.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,747.87,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $747.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,747.87,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $747.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,644.00,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $644.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,747.87,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $747.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,747.87,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $747.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 LP RECON CURVED 12H 156MM,C1713,HCPCS,278,RC,10017359,CDM,,,,both,,,1038.7100,685.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,623.23,,,,,,,504.8100,1038.7100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,038.71 in Billed Charges for Rev 278 Proc C1713 = $623.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,AETNA,AETNA HSHS,1267.23,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,267.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,AETNA,ALL COMMERCIAL AETNA,1961.65,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,961.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,ANTHEM,ANTHEM POS/HMO,1020.06,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,020.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,ANTHEM,ANTHEM PPO,1020.06,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,020.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1961.65,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,961.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,CENPATICO,ALL MEDICAID CENPATICO,1961.65,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,961.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1667.40,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,667.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,CIGNA,ALL COMMERCIAL CIGNA,1373.16,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,373.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,COFINITY,COFINITY,1961.65,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,961.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1863.57,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,863.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,1647.79,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,647.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1392.77,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,392.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1432.00,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,953.36,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $953.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1667.40,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,667.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,HUMANA,HUMANA CHOICE CARE PPO,1667.40,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,667.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1432.00,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1961.65,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,961.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,980.83,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $980.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1647.79,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,647.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1471.24,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,471.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1804.72,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,804.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1252.12,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,252.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1412.39,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,412.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1412.39,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,412.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1216.22,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,216.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1412.39,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,412.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1412.39,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,412.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028780,CDM,,,,both,,,1961.6500,1294.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1176.99,,,,,,,953.3600,1961.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,961.65 in Billed Charges for Rev 278 Proc C1713 = $1,176.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,AETNA,AETNA HSHS,1291.35,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,291.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,AETNA,ALL COMMERCIAL AETNA,1998.99,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,998.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,ANTHEM,ANTHEM POS/HMO,1039.47,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,039.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,ANTHEM,ANTHEM PPO,1039.47,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,039.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1998.99,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,998.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,CENPATICO,ALL MEDICAID CENPATICO,1998.99,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,998.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1699.14,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,699.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,CIGNA,ALL COMMERCIAL CIGNA,1399.29,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,399.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,COFINITY,COFINITY,1998.99,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,998.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1899.04,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,899.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,1679.15,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,679.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1419.28,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,419.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1459.26,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,459.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,971.51,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $971.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1699.14,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,699.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,HUMANA,HUMANA CHOICE CARE PPO,1699.14,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,699.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1459.26,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,459.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1998.99,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,998.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,999.50,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $999.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1679.15,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,679.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1499.24,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,499.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1839.07,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,839.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1275.96,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,275.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1439.27,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,439.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1439.27,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,439.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1239.37,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,239.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1439.27,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,439.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1439.27,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,439.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10011179,CDM,,,,both,,,1998.9900,1319.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1199.39,,,,,,,971.5100,1998.9900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,998.99 in Billed Charges for Rev 278 Proc C1713 = $1,199.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,AETNA,AETNA HSHS,1394.45,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,394.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,AETNA,ALL COMMERCIAL AETNA,2158.59,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $2,158.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,ANTHEM,ANTHEM POS/HMO,1122.47,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,122.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,ANTHEM,ANTHEM PPO,1122.47,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,122.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2158.59,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $2,158.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,CENPATICO,ALL MEDICAID CENPATICO,2158.59,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $2,158.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1834.80,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,834.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,CIGNA,ALL COMMERCIAL CIGNA,1511.01,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,511.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,COFINITY,COFINITY,2158.59,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $2,158.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2050.66,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $2,050.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,1813.22,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,813.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1532.60,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,532.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1575.77,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,575.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,1049.07,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,049.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1834.80,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,834.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,HUMANA,HUMANA CHOICE CARE PPO,1834.80,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,834.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1575.77,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,575.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,2158.59,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $2,158.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1079.30,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,079.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1813.22,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,813.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1618.94,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,618.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1985.90,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,985.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1377.83,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,377.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1554.18,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,554.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1554.18,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,554.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1338.33,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,338.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1554.18,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,554.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1554.18,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,554.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10014146,CDM,,,,both,,,2158.5900,1424.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1295.15,,,,,,,1049.0700,2158.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,158.59 in Billed Charges for Rev 278 Proc C1713 = $1,295.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,AETNA,AETNA HSHS,1038.01,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,038.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,AETNA,ALL COMMERCIAL AETNA,1606.83,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,606.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,ANTHEM,ANTHEM POS/HMO,835.55,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $835.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,ANTHEM,ANTHEM PPO,835.55,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $835.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1606.83,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,606.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,CENPATICO,ALL MEDICAID CENPATICO,1606.83,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,606.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1365.81,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,365.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,CIGNA,ALL COMMERCIAL CIGNA,1124.78,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,124.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,COFINITY,COFINITY,1606.83,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,606.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1526.49,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,526.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,1349.74,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,349.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1140.85,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,140.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1172.99,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,172.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,780.92,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $780.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1365.81,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,365.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,HUMANA,HUMANA CHOICE CARE PPO,1365.81,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,365.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1172.99,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,172.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1606.83,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,606.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,803.42,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $803.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1349.74,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,349.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1205.12,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,205.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1478.28,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,478.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1025.64,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,025.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1156.92,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,156.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1156.92,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,156.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,996.23,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $996.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1156.92,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,156.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1156.92,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $1,156.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10028666,CDM,,,,both,,,1606.8300,1060.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,964.10,,,,,,,780.9200,1606.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,606.83 in Billed Charges for Rev 278 Proc C1713 = $964.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,AETNA,AETNA HSHS,1175.50,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,175.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,AETNA,ALL COMMERCIAL AETNA,1819.66,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,819.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,ANTHEM,ANTHEM POS/HMO,946.22,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $946.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,ANTHEM,ANTHEM PPO,946.22,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $946.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1819.66,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,819.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,CENPATICO,ALL MEDICAID CENPATICO,1819.66,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,819.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1546.71,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,546.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,CIGNA,ALL COMMERCIAL CIGNA,1273.76,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,273.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,COFINITY,COFINITY,1819.66,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,819.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1728.68,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,728.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,1528.51,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,528.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1291.96,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,291.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1328.35,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,328.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,884.35,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $884.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1546.71,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,546.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,HUMANA,HUMANA CHOICE CARE PPO,1546.71,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,546.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1328.35,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,328.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1819.66,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,819.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,909.83,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $909.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1528.51,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,528.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1364.75,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,364.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1674.09,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,674.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1161.49,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,161.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1310.16,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,310.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1310.16,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,310.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1128.19,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,128.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1310.16,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,310.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1310.16,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,310.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002704,CDM,,,,both,,,1819.6600,1200.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1091.80,,,,,,,884.3500,1819.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,819.66 in Billed Charges for Rev 278 Proc C1713 = $1,091.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,AETNA,AETNA HSHS,929.99,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $929.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,AETNA,ALL COMMERCIAL AETNA,1439.61,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,439.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,ANTHEM,ANTHEM POS/HMO,748.60,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $748.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,ANTHEM,ANTHEM PPO,748.60,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $748.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1439.61,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,439.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,CENPATICO,ALL MEDICAID CENPATICO,1439.61,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,439.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1223.67,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,223.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,CIGNA,ALL COMMERCIAL CIGNA,1007.73,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,007.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,COFINITY,COFINITY,1439.61,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,439.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1367.63,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,367.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,1209.27,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,209.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1022.12,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,022.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1050.92,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,050.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,699.65,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $699.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1223.67,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,223.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,HUMANA,HUMANA CHOICE CARE PPO,1223.67,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,223.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1050.92,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,050.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1439.61,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,439.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,719.81,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $719.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1209.27,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,209.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1079.71,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,079.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1324.44,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,324.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,918.90,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $918.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1036.52,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,036.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1036.52,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,036.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,892.56,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $892.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1036.52,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,036.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1036.52,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $1,036.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 MEDIAL DISTAL TIBIAL RT 12 HOLE,C1713,HCPCS,278,RC,10002703,CDM,,,,both,,,1439.6100,950.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,863.77,,,,,,,699.6500,1439.6100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,439.61 in Billed Charges for Rev 278 Proc C1713 = $863.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,AETNA,AETNA HSHS,729.44,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $729.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,AETNA,ALL COMMERCIAL AETNA,1129.16,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $1,129.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,ANTHEM,ANTHEM POS/HMO,587.16,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $587.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,ANTHEM,ANTHEM PPO,587.16,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $587.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1129.16,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $1,129.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,CENPATICO,ALL MEDICAID CENPATICO,1129.16,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $1,129.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,959.79,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $959.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,CIGNA,ALL COMMERCIAL CIGNA,790.41,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $790.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,COFINITY,COFINITY,1129.16,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $1,129.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1072.70,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $1,072.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,HEALTH CARE ALLIANCE,THE ALLIANCE,948.49,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $948.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,801.70,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $801.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,824.29,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $824.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,HSHS EMPLOYEES,HSHS EMPLOYEES,548.77,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $548.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,959.79,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $959.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,HUMANA,HUMANA CHOICE CARE PPO,959.79,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $959.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,824.29,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $824.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1129.16,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $1,129.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,564.58,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $564.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,948.49,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $948.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,846.87,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $846.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1038.83,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $1,038.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,720.74,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $720.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,813.00,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $813.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,813.00,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $813.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,700.08,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $700.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,813.00,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $813.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,813.00,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $813.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002717,CDM,,,,both,,,1129.1600,745.2500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,677.50,,,,,,,548.7700,1129.1600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,129.16 in Billed Charges for Rev 278 Proc C1713 = $677.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,AETNA,AETNA HSHS,1309.87,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,309.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,AETNA,ALL COMMERCIAL AETNA,2027.66,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $2,027.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,ANTHEM,ANTHEM POS/HMO,1054.38,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,054.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,ANTHEM,ANTHEM PPO,1054.38,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,054.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2027.66,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $2,027.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,CENPATICO,ALL MEDICAID CENPATICO,2027.66,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $2,027.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1723.51,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,723.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,CIGNA,ALL COMMERCIAL CIGNA,1419.36,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,419.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,COFINITY,COFINITY,2027.66,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $2,027.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1926.28,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,926.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,1703.23,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,703.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1439.64,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,439.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1480.19,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,480.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,985.44,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $985.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1723.51,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,723.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,HUMANA,HUMANA CHOICE CARE PPO,1723.51,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,723.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1480.19,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,480.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2027.66,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $2,027.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1013.83,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,013.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1703.23,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,703.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1520.75,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,520.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1865.45,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,865.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1294.26,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,294.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1459.92,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,459.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1459.92,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,459.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1257.15,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,257.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1459.92,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,459.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1459.92,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,459.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040288,CDM,,,,both,,,2027.6600,1338.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1216.60,,,,,,,985.4400,2027.6600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,027.66 in Billed Charges for Rev 278 Proc C1713 = $1,216.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,AETNA,AETNA HSHS,1324.00,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,AETNA,ALL COMMERCIAL AETNA,2049.53,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $2,049.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,ANTHEM,ANTHEM POS/HMO,1065.76,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,065.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,ANTHEM,ANTHEM PPO,1065.76,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,065.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2049.53,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $2,049.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,CENPATICO,ALL MEDICAID CENPATICO,2049.53,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $2,049.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1742.10,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,742.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,CIGNA,ALL COMMERCIAL CIGNA,1434.67,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,434.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,COFINITY,COFINITY,2049.53,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $2,049.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1947.05,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,947.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,1721.61,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,721.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1455.17,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,455.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1496.16,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,496.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,996.07,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $996.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1742.10,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,742.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,HUMANA,HUMANA CHOICE CARE PPO,1742.10,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,742.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1496.16,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,496.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,2049.53,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $2,049.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1024.77,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,024.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1721.61,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,721.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1537.15,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,537.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1885.57,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,885.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1308.22,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,308.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1475.66,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,475.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1475.66,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,475.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1270.71,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,270.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1475.66,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,475.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1475.66,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,475.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 POST LAT DIST HUM 5H RGT,C1713,HCPCS,278,RC,70902392,CDM,,,,both,,,2049.5300,1352.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1229.72,,,,,,,996.0700,2049.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,049.53 in Billed Charges for Rev 278 Proc C1713 = $1,229.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,AETNA,AETNA HSHS,1434.83,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,434.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,AETNA,ALL COMMERCIAL AETNA,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,ANTHEM,ANTHEM POS/HMO,1154.97,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,154.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,ANTHEM,ANTHEM PPO,1154.97,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,154.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,CENPATICO,ALL MEDICAID CENPATICO,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1887.94,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,887.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,CIGNA,ALL COMMERCIAL CIGNA,1554.77,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,554.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,COFINITY,COFINITY,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2110.05,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $2,110.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,1865.72,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,865.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1576.98,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,576.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1621.40,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,621.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,1079.45,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,079.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1887.94,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,887.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,HUMANA,HUMANA CHOICE CARE PPO,1887.94,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,887.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1621.40,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,621.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1110.55,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,110.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1865.72,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,865.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1665.83,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,665.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2043.41,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $2,043.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1417.73,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,417.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1599.19,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,599.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1599.19,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,599.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1377.08,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,377.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1599.19,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,599.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1599.19,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,599.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70902395,CDM,,,,both,,,2221.1000,1465.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1332.66,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,221.10 in Billed Charges for Rev 278 Proc C1713 = $1,332.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,AETNA,AETNA HSHS,1029.22,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,029.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,AETNA,ALL COMMERCIAL AETNA,1593.22,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,593.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,ANTHEM,ANTHEM POS/HMO,828.47,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $828.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,ANTHEM,ANTHEM PPO,828.47,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $828.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1593.22,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,593.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,CENPATICO,ALL MEDICAID CENPATICO,1593.22,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,593.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1354.24,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,354.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,CIGNA,ALL COMMERCIAL CIGNA,1115.25,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,115.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,COFINITY,COFINITY,1593.22,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,593.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1513.56,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,513.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,HEALTH CARE ALLIANCE,THE ALLIANCE,1338.30,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,338.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1131.19,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,131.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1163.05,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,163.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,HSHS EMPLOYEES,HSHS EMPLOYEES,774.30,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $774.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1354.24,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,354.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,HUMANA,HUMANA CHOICE CARE PPO,1354.24,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,354.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1163.05,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,163.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1593.22,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,593.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,796.61,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $796.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1338.30,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,338.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1194.92,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,194.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1465.76,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,465.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1016.95,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,016.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1147.12,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,147.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1147.12,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,147.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,987.80,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $987.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1147.12,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,147.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1147.12,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $1,147.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 PUBIC SYMPH 4 HOLE WITH 2 DCP HOLES X 57MM,C1713,HCPCS,278,RC,10084015,CDM,,,,both,,,1593.2200,1051.5300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,955.93,,,,,,,774.3000,1593.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,593.22 in Billed Charges for Rev 278 Proc C1713 = $955.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,AETNA,AETNA HSHS,597.27,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $597.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,AETNA,ALL COMMERCIAL AETNA,924.56,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $924.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,924.56,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $924.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,CENPATICO,ALL MEDICAID CENPATICO,924.56,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $924.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,785.88,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $785.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,CIGNA,ALL COMMERCIAL CIGNA,647.19,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $647.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,COFINITY,COFINITY,924.56,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $924.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,878.33,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $878.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,776.63,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $776.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,656.44,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $656.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,674.93,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $674.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,449.34,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $449.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,785.88,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $785.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,HUMANA,HUMANA CHOICE CARE PPO,785.88,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $785.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,674.93,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $674.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,924.56,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $924.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,462.28,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $462.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,776.63,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $776.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,693.42,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $693.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,850.60,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $850.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,590.15,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $590.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,665.68,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $665.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,665.68,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $665.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,573.23,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $573.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,665.68,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $665.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,665.68,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $665.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 10 HOLE,C1713,HCPCS,278,RC,10028820,CDM,,,,both,,,924.5600,610.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,554.74,,,,,,,449.3400,924.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $924.56 in Billed Charges for Rev 278 Proc C1713 = $554.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,AETNA,AETNA HSHS,621.73,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $621.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,AETNA,ALL COMMERCIAL AETNA,962.43,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $962.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,962.43,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $962.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,CENPATICO,ALL MEDICAID CENPATICO,962.43,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $962.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,818.07,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $818.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,CIGNA,ALL COMMERCIAL CIGNA,673.70,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $673.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,COFINITY,COFINITY,962.43,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $962.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,914.31,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $914.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,808.44,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $808.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,683.33,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $683.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,702.57,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $702.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,467.74,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $467.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,818.07,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $818.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,HUMANA,HUMANA CHOICE CARE PPO,818.07,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $818.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,702.57,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $702.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,962.43,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $962.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,481.22,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $481.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,808.44,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $808.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,721.82,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $721.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,885.44,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $885.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,614.32,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $614.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,692.95,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $692.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,692.95,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $692.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,596.71,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $596.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,692.95,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $692.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,692.95,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $692.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CRVD 12 HOLE,C1713,HCPCS,278,RC,10028671,CDM,,,,both,,,962.4300,635.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,577.46,,,,,,,467.7400,962.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $962.43 in Billed Charges for Rev 278 Proc C1713 = $577.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,AETNA,AETNA HSHS,707.67,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $707.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,AETNA,ALL COMMERCIAL AETNA,1095.46,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $1,095.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,ANTHEM,ANTHEM POS/HMO,569.64,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $569.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,ANTHEM,ANTHEM PPO,569.64,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $569.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1095.46,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $1,095.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,CENPATICO,ALL MEDICAID CENPATICO,1095.46,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $1,095.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,931.14,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $931.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,CIGNA,ALL COMMERCIAL CIGNA,766.82,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $766.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,COFINITY,COFINITY,1095.46,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $1,095.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1040.69,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $1,040.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,920.19,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $920.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,777.78,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $777.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,799.69,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $799.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,532.39,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $532.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,931.14,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $931.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,HUMANA,HUMANA CHOICE CARE PPO,931.14,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $931.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,799.69,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $799.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1095.46,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $1,095.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,547.73,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $547.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,920.19,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $920.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,821.60,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $821.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1007.82,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $1,007.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,699.23,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $699.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,788.73,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $788.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,788.73,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $788.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,679.19,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $679.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,788.73,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $788.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,788.73,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $788.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATE SYNTHES 3.5 RECONST CURVED 16H 190MM,C1713,HCPCS,278,RC,10028670,CDM,,,,both,,,1095.4600,723.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,657.28,,,,,,,532.3900,1095.4600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,095.46 in Billed Charges for Rev 278 Proc C1713 = $657.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,AETNA,AETNA HSHS,88.83,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $88.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,AETNA,ALL COMMERCIAL AETNA,137.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $137.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,137.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $137.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,CENPATICO,ALL MEDICAID CENPATICO,137.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $137.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,116.88,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $116.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,CIGNA,ALL COMMERCIAL CIGNA,96.25,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $96.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,COFINITY,COFINITY,137.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $137.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,130.63,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $130.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,115.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $115.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,97.63,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $97.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,100.38,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $100.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,66.83,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $66.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,116.88,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $116.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,HUMANA,HUMANA CHOICE CARE PPO,116.88,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $116.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,100.38,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $100.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,137.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $137.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,68.75,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $68.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,115.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $115.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,103.13,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $103.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,126.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $126.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,87.77,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $87.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,99.00,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,99.00,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,85.25,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $85.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,99.00,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,99.00,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013961,CDM,,,,both,,,137.5000,90.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,82.50,,,,,,,66.8300,137.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.50 in Billed Charges for Rev 278 Proc C1713 = $82.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,AETNA,AETNA HSHS,45.57,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $45.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,AETNA,ALL COMMERCIAL AETNA,70.54,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $70.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,70.54,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $70.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,CENPATICO,ALL MEDICAID CENPATICO,70.54,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $70.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,59.96,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $59.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,CIGNA,ALL COMMERCIAL CIGNA,49.38,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $49.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,COFINITY,COFINITY,70.54,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $70.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,67.01,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $67.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,59.25,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $59.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,50.08,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $50.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,51.49,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $51.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,34.28,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $34.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,59.96,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $59.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,HUMANA,HUMANA CHOICE CARE PPO,59.96,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $59.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,51.49,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $51.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,70.54,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $70.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35.27,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $35.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,59.25,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $59.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,52.91,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $52.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,64.90,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $64.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,45.03,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $45.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,50.79,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $50.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,50.79,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $50.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,43.73,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $43.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,50.79,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $50.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,50.79,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $50.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001288,CDM,,,,both,,,70.5400,46.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42.32,,,,,,,34.2800,70.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.54 in Billed Charges for Rev 278 Proc C1713 = $42.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,AETNA,AETNA HSHS,47.05,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $47.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,AETNA,ALL COMMERCIAL AETNA,72.83,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $72.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,72.83,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $72.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,CENPATICO,ALL MEDICAID CENPATICO,72.83,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $72.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,61.91,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $61.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,CIGNA,ALL COMMERCIAL CIGNA,50.98,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $50.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,COFINITY,COFINITY,72.83,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $72.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,69.19,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $69.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,61.18,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $61.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,51.71,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $51.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,53.17,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $53.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,35.40,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $35.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,61.91,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $61.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,HUMANA,HUMANA CHOICE CARE PPO,61.91,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $61.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,53.17,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $53.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,72.83,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $72.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,36.42,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $36.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,61.18,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $61.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,54.62,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $54.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,67.00,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,46.49,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $46.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,52.44,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $52.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,52.44,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $52.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.15,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $45.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,52.44,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $52.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,52.44,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $52.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70412564,CDM,,,,both,,,72.8300,48.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,43.70,,,,,,,35.4000,72.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $72.83 in Billed Charges for Rev 278 Proc C1713 = $43.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,AETNA,AETNA HSHS,74.32,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $74.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,AETNA,ALL COMMERCIAL AETNA,115.04,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $115.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,115.04,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $115.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,CENPATICO,ALL MEDICAID CENPATICO,115.04,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $115.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,97.78,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $97.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,CIGNA,ALL COMMERCIAL CIGNA,80.53,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $80.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,COFINITY,COFINITY,115.04,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $115.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,109.29,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $109.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,96.63,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $96.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,81.68,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $81.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,83.98,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $83.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,55.91,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $55.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,97.78,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $97.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,HUMANA,HUMANA CHOICE CARE PPO,97.78,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $97.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,83.98,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $83.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,115.04,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $115.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,57.52,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $57.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,96.63,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $96.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,86.28,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $86.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,105.84,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $105.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,73.43,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $73.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,82.83,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $82.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,82.83,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $82.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,71.32,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $71.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,82.83,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $82.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,82.83,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $82.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040135,CDM,,,,both,,,115.0400,75.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,69.02,,,,,,,55.9100,115.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $115.04 in Billed Charges for Rev 278 Proc C1713 = $69.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,AETNA,AETNA HSHS,184.16,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $184.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,AETNA,ALL COMMERCIAL AETNA,285.08,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $285.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,285.08,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $285.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,CENPATICO,ALL MEDICAID CENPATICO,285.08,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $285.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,242.32,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $242.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,CIGNA,ALL COMMERCIAL CIGNA,199.56,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $199.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,COFINITY,COFINITY,285.08,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $285.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,270.83,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $270.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,239.47,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $239.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,202.41,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $202.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,208.11,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $208.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,138.55,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $138.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,242.32,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $242.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,HUMANA,HUMANA CHOICE CARE PPO,242.32,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $242.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,208.11,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $208.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,285.08,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $285.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,142.54,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $142.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,239.47,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $239.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,213.81,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $213.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,262.27,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $262.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,181.97,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $181.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,205.26,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $205.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,205.26,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $205.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,176.75,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $176.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,205.26,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $205.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,205.26,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $205.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70901359,CDM,,,,both,,,285.0800,188.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,171.05,,,,,,,138.5500,285.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $285.08 in Billed Charges for Rev 278 Proc C1713 = $171.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,AETNA,AETNA HSHS,179.34,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $179.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,AETNA,ALL COMMERCIAL AETNA,277.61,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $277.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,277.61,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $277.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,CENPATICO,ALL MEDICAID CENPATICO,277.61,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $277.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,235.97,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $235.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,CIGNA,ALL COMMERCIAL CIGNA,194.33,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $194.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,COFINITY,COFINITY,277.61,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $277.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,263.73,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $263.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,233.19,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $233.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,197.10,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $197.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,202.66,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $202.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,134.92,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $134.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,235.97,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $235.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,HUMANA,HUMANA CHOICE CARE PPO,235.97,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $235.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,202.66,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $202.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,277.61,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $277.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,138.81,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $138.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,233.19,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $233.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,208.21,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $208.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,255.40,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $255.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,177.20,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $177.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,199.88,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $199.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,199.88,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $199.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,172.12,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $172.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,199.88,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $199.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,199.88,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $199.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10040625,CDM,,,,both,,,277.6100,183.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,166.57,,,,,,,134.9200,277.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $277.61 in Billed Charges for Rev 278 Proc C1713 = $166.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,AETNA,AETNA HSHS,258.72,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $258.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,AETNA,ALL COMMERCIAL AETNA,400.50,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $400.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,400.50,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $400.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,CENPATICO,ALL MEDICAID CENPATICO,400.50,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $400.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,340.43,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $340.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,CIGNA,ALL COMMERCIAL CIGNA,280.35,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $280.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,COFINITY,COFINITY,400.50,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $400.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,380.48,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $380.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,336.42,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $336.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,284.36,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $284.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,292.37,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $292.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,194.64,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $194.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,340.43,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $340.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,HUMANA,HUMANA CHOICE CARE PPO,340.43,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $340.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,292.37,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $292.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,400.50,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $400.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,200.25,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $200.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,336.42,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $336.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,300.38,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $300.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,368.46,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $368.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,255.64,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $255.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,288.36,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $288.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,288.36,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $288.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,248.31,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $248.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,288.36,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $288.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,288.36,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $288.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10034967,CDM,,,,both,,,400.5000,264.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,240.30,,,,,,,194.6400,400.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $400.50 in Billed Charges for Rev 278 Proc C1713 = $240.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,AETNA,AETNA HSHS,207.85,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $207.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,AETNA,ALL COMMERCIAL AETNA,321.75,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $321.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,321.75,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $321.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,CENPATICO,ALL MEDICAID CENPATICO,321.75,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $321.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,273.49,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $273.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,CIGNA,ALL COMMERCIAL CIGNA,225.23,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $225.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,COFINITY,COFINITY,321.75,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $321.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,305.66,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $305.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,270.27,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $270.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,228.44,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $228.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,234.88,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $234.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,156.37,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $156.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,273.49,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $273.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,HUMANA,HUMANA CHOICE CARE PPO,273.49,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $273.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,234.88,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $234.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,321.75,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $321.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,160.88,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $160.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,270.27,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $270.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,241.31,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $241.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,296.01,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $296.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,205.37,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $205.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,231.66,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $231.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,231.66,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $231.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,199.49,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $199.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,231.66,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $231.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,231.66,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $231.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW ZIMMER 3.5 CORTICAL SELF TAPPING 34MM,C1713,HCPCS,278,RC,10039813,CDM,,,,both,,,321.7500,212.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,193.05,,,,,,,156.3700,321.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $321.75 in Billed Charges for Rev 278 Proc C1713 = $193.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,AETNA,AETNA HSHS,178.06,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $178.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,AETNA,ALL COMMERCIAL AETNA,275.63,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $275.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,275.63,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $275.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,CENPATICO,ALL MEDICAID CENPATICO,275.63,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $275.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,234.29,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $234.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,CIGNA,ALL COMMERCIAL CIGNA,192.94,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $192.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,COFINITY,COFINITY,275.63,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $275.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,261.85,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $261.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,231.53,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $231.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,195.70,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $195.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,201.21,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $201.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,133.96,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $133.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,234.29,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $234.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,HUMANA,HUMANA CHOICE CARE PPO,234.29,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $234.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,201.21,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $201.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,275.63,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $275.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,137.82,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $137.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,231.53,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $231.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,206.72,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $206.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,253.58,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $253.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,175.93,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $175.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,198.45,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $198.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,198.45,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $198.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,170.89,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $170.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,198.45,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $198.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,198.45,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $198.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10023234,CDM,,,,both,,,275.6300,181.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,165.38,,,,,,,133.9600,275.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $275.63 in Billed Charges for Rev 278 Proc C1713 = $165.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,AETNA,AETNA HSHS,267.08,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $267.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,AETNA,ALL COMMERCIAL AETNA,413.44,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $413.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,413.44,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $413.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,CENPATICO,ALL MEDICAID CENPATICO,413.44,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $413.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,351.42,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $351.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,CIGNA,ALL COMMERCIAL CIGNA,289.41,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $289.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,COFINITY,COFINITY,413.44,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $413.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,392.77,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $392.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,347.29,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $347.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,293.54,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $293.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,301.81,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $301.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,200.93,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $200.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,351.42,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $351.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,HUMANA,HUMANA CHOICE CARE PPO,351.42,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $351.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,301.81,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $301.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,413.44,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $413.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,206.72,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $206.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,347.29,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $347.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,310.08,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $310.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,380.36,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $380.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,263.90,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $263.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,297.68,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $297.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,297.68,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $297.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,256.33,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $256.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,297.68,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $297.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,297.68,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $297.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032346,CDM,,,,both,,,413.4400,272.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,248.06,,,,,,,200.9300,413.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $413.44 in Billed Charges for Rev 278 Proc C1713 = $248.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,AETNA,AETNA HSHS,280.44,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $280.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,AETNA,ALL COMMERCIAL AETNA,434.12,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $434.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,434.12,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $434.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,CENPATICO,ALL MEDICAID CENPATICO,434.12,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $434.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,369.00,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $369.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,CIGNA,ALL COMMERCIAL CIGNA,303.88,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $303.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,COFINITY,COFINITY,434.12,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $434.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,412.41,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $412.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,364.66,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $364.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,308.23,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $308.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,316.91,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $316.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,210.98,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $210.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,369.00,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $369.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,HUMANA,HUMANA CHOICE CARE PPO,369.00,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $369.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,316.91,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $316.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,434.12,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $434.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,217.06,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $217.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,364.66,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $364.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,325.59,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $325.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,399.39,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $399.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,277.10,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $277.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,312.57,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $312.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,312.57,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $312.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,269.15,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $269.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,312.57,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $312.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,312.57,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $312.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078323,CDM,,,,both,,,434.1200,286.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,260.47,,,,,,,210.9800,434.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $434.12 in Billed Charges for Rev 278 Proc C1713 = $260.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,AETNA,AETNA HSHS,247.24,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $247.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,AETNA,ALL COMMERCIAL AETNA,382.73,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $382.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,382.73,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $382.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,CENPATICO,ALL MEDICAID CENPATICO,382.73,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $382.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,325.32,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $325.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,CIGNA,ALL COMMERCIAL CIGNA,267.91,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $267.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,COFINITY,COFINITY,382.73,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $382.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,363.59,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $363.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,321.49,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $321.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,271.74,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $271.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,279.39,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $279.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,186.01,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $186.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,325.32,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $325.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,HUMANA,HUMANA CHOICE CARE PPO,325.32,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $325.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,279.39,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $279.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,382.73,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $382.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,191.37,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $191.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,321.49,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $321.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,287.05,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $287.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,352.11,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $352.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,244.30,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $244.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,275.57,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $275.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,275.57,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $275.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,237.29,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $237.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,275.57,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $275.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,275.57,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $275.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10008097,CDM,,,,both,,,382.7300,252.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,229.64,,,,,,,186.0100,382.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $382.73 in Billed Charges for Rev 278 Proc C1713 = $229.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,AETNA,AETNA HSHS,377.09,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $377.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,AETNA,ALL COMMERCIAL AETNA,583.73,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $583.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,583.73,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $583.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,CENPATICO,ALL MEDICAID CENPATICO,583.73,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $583.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,496.17,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $496.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,CIGNA,ALL COMMERCIAL CIGNA,408.61,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $408.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,COFINITY,COFINITY,583.73,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $583.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,554.54,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $554.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,490.33,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $490.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,414.45,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $414.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,426.12,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $426.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,283.69,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $283.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,496.17,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $496.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,HUMANA,HUMANA CHOICE CARE PPO,496.17,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $496.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,426.12,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $426.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,583.73,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $583.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,291.87,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $291.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,490.33,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $490.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,437.80,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $437.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,537.03,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $537.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,372.59,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $372.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,420.29,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $420.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,420.29,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $420.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,361.91,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $361.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,420.29,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $420.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,420.29,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $420.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002757,CDM,,,,both,,,583.7300,385.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,350.24,,,,,,,283.6900,583.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $583.73 in Billed Charges for Rev 278 Proc C1713 = $350.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,AETNA,AETNA HSHS,505.91,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $505.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,AETNA,ALL COMMERCIAL AETNA,783.14,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $783.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,783.14,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $783.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,CENPATICO,ALL MEDICAID CENPATICO,783.14,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $783.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,665.67,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $665.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,CIGNA,ALL COMMERCIAL CIGNA,548.20,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $548.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,COFINITY,COFINITY,783.14,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $783.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,743.98,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $743.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,657.84,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $657.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,556.03,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $556.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,571.69,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $571.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,380.61,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $380.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,665.67,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $665.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,HUMANA,HUMANA CHOICE CARE PPO,665.67,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $665.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,571.69,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $571.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,783.14,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $783.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,391.57,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $391.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,657.84,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $657.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,587.36,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $587.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,720.49,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $720.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,499.88,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $499.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,563.86,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $563.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,563.86,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $563.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,485.55,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $485.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,563.86,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $563.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,563.86,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $563.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10019994,CDM,,,,both,,,783.1400,516.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,469.88,,,,,,,380.6100,783.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $783.14 in Billed Charges for Rev 278 Proc C1713 = $469.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,AETNA,AETNA HSHS,2800.14,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,800.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,AETNA,ALL COMMERCIAL AETNA,4334.58,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $4,334.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,ANTHEM,ANTHEM POS/HMO,2253.98,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,253.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,ANTHEM,ANTHEM PPO,2253.98,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,253.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4334.58,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $4,334.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,CENPATICO,ALL MEDICAID CENPATICO,4334.58,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $4,334.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3684.39,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,684.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,CIGNA,ALL COMMERCIAL CIGNA,3034.21,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,034.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,COFINITY,COFINITY,4334.58,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $4,334.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4117.85,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $4,117.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,3641.05,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,641.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3077.55,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,077.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3164.24,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,164.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,2106.61,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,106.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3684.39,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,684.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,HUMANA,HUMANA CHOICE CARE HMO,2167.29,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,167.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,HUMANA,HUMANA CHOICE CARE PPO,3684.39,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,684.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,HUMANA,HUMANA NATIIONAL POS HMO,2167.29,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,167.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3164.24,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,164.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,4334.58,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $4,334.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2167.29,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,167.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3641.05,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,641.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3250.94,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,250.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3987.81,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,987.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2766.76,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,766.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3120.90,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,120.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3120.90,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,120.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2687.44,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,687.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3120.90,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,120.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3120.90,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $3,120.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP VITOSS BONE GRAFT SUBSITUTE FOAM 25 X 100 X 8MM (2102-1120),C1713,HCPCS,278,RC,70408172,CDM,,,,both,,,4334.5800,2860.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2600.75,,,,,,,2106.6100,4334.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,334.58 in Billed Charges for Rev 278 Proc C1713 = $2,600.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,AETNA,AETNA HSHS,6322.55,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $6,322.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,AETNA,ALL COMMERCIAL AETNA,9787.23,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $9,787.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,ANTHEM,ANTHEM POS/HMO,5089.36,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $5,089.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,ANTHEM,ANTHEM PPO,5089.36,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $5,089.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9787.23,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $9,787.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,CENPATICO,ALL MEDICAID CENPATICO,9787.23,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $9,787.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8319.15,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $8,319.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,CIGNA,ALL COMMERCIAL CIGNA,6851.06,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $6,851.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,COFINITY,COFINITY,9787.23,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $9,787.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9297.87,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $9,297.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,8221.27,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $8,221.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6948.93,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $6,948.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7144.68,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $7,144.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,4756.59,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,756.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8319.15,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $8,319.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,HUMANA,HUMANA CHOICE CARE HMO,4893.62,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,893.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,HUMANA,HUMANA CHOICE CARE PPO,8319.15,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $8,319.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,HUMANA,HUMANA NATIIONAL POS HMO,4893.62,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,893.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7144.68,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $7,144.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,9787.23,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $9,787.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4893.62,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,893.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8221.27,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $8,221.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7340.42,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $7,340.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9004.25,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $9,004.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4893.62,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,893.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4893.62,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,893.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,PREVEA HEALTH NETWORK,PREVEA360,4893.62,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,893.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4893.62,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,893.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6247.19,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $6,247.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7046.81,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $7,046.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4560.85,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,560.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,UNITED HEALTHCARE,UHC ONEIDA NATION,4560.85,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,560.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,UNITED HEALTHCARE,UNITED HEALTHCARE,4560.85,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $4,560.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7046.81,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $7,046.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6068.08,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $6,068.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7046.81,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $7,046.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7046.81,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $7,046.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUB BONEGRT 100X25X8MM VITOSS 25MMX100MMX8MM BTCP COLGN VOID,C1713,HCPCS,278,RC,10083833,CDM,,,,both,,,9787.2300,6459.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5872.34,,,,,,,4560.8500,9787.2300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,787.23 in Billed Charges for Rev 278 Proc C1713 = $5,872.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,AETNA,AETNA HSHS,461.89,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $461.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,AETNA,ALL COMMERCIAL AETNA,715.00,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $715.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,715.00,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $715.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,CENPATICO,ALL MEDICAID CENPATICO,715.00,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $715.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,607.75,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $607.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,CIGNA,ALL COMMERCIAL CIGNA,500.50,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $500.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,COFINITY,COFINITY,715.00,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $715.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,679.25,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $679.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,600.60,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $600.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,507.65,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $507.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,521.95,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $521.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,347.49,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $347.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,607.75,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $607.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,HUMANA,HUMANA CHOICE CARE PPO,607.75,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $607.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,521.95,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $521.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,715.00,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $715.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,357.50,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $357.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,600.60,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $600.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,536.25,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $536.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,657.80,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $657.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,456.38,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $456.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,514.80,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $514.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,514.80,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $514.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,443.30,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $443.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,514.80,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $514.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,514.80,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $514.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 5.5 FOOTPRINT,C1713,HCPCS,278,RC,10044885,CDM,,,,both,,,715.0000,471.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,429.00,,,,,,,347.4900,715.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $715.00 in Billed Charges for Rev 278 Proc C1713 = $429.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,AETNA,AETNA HSHS,830.34,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $830.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,AETNA,ALL COMMERCIAL AETNA,1285.35,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,ANTHEM,ANTHEM POS/HMO,668.38,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $668.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,ANTHEM,ANTHEM PPO,668.38,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $668.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1285.35,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,CENPATICO,ALL MEDICAID CENPATICO,1285.35,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1092.55,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,092.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,CIGNA,ALL COMMERCIAL CIGNA,899.75,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $899.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,COFINITY,COFINITY,1285.35,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1221.08,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,221.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,1079.69,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,079.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,912.60,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $912.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,938.31,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $938.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,624.68,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $624.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1092.55,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,092.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,HUMANA,HUMANA CHOICE CARE PPO,1092.55,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,092.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,938.31,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $938.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1285.35,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,642.68,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $642.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1079.69,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,079.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,964.01,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $964.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1182.52,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $1,182.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,820.44,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $820.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,925.45,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $925.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,925.45,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $925.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,796.92,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $796.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,925.45,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $925.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,925.45,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $925.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ANCHOR DEPUY SUPER QUICKANCHOR,C1713,HCPCS,278,RC,10011727,CDM,,,,both,,,1285.3500,848.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,771.21,,,,,,,624.6800,1285.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,285.35 in Billed Charges for Rev 278 Proc C1713 = $771.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,AETNA,AETNA HSHS,35.17,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $35.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,AETNA,ALL COMMERCIAL AETNA,54.45,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $54.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,54.45,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $54.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,CENPATICO,ALL MEDICAID CENPATICO,54.45,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $54.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,46.28,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $46.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,CIGNA,ALL COMMERCIAL CIGNA,38.12,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $38.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,COFINITY,COFINITY,54.45,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $54.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,51.73,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $51.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,45.74,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $45.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,38.66,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $38.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,39.75,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $39.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,26.46,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $26.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,46.28,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $46.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,HUMANA,HUMANA CHOICE CARE PPO,46.28,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $46.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,39.75,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $39.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,54.45,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $54.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27.23,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $27.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,45.74,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $45.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,40.84,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $40.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,50.09,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $50.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,34.76,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $34.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,39.20,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $39.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,39.20,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $39.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,33.76,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $33.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,39.20,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $39.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,39.20,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $39.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX FIBERWARE 2 C-13 38IN BRAID TIES,C1713,HCPCS,278,RC,10035415,CDM,,,,both,,,54.4500,35.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,32.67,,,,,,,26.4600,54.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $54.45 in Billed Charges for Rev 278 Proc C1713 = $32.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,AETNA,AETNA HSHS,1669.91,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,669.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,AETNA,ALL COMMERCIAL AETNA,2585.00,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,ANTHEM,ANTHEM POS/HMO,1344.20,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,344.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,ANTHEM,ANTHEM PPO,1344.20,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,344.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2585.00,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,CENPATICO,ALL MEDICAID CENPATICO,2585.00,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2197.25,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,197.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,CIGNA,ALL COMMERCIAL CIGNA,1809.50,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,809.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,COFINITY,COFINITY,2585.00,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2455.75,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,455.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,2171.40,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,171.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1835.35,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,835.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1887.05,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,887.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,1256.31,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,256.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2197.25,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,197.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,HUMANA,HUMANA CHOICE CARE HMO,1292.50,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,292.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,HUMANA,HUMANA CHOICE CARE PPO,2197.25,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,197.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,HUMANA,HUMANA NATIIONAL POS HMO,1292.50,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,292.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1887.05,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,887.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2585.00,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1292.50,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,292.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2171.40,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,171.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1938.75,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,938.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2378.20,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $2,378.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1650.01,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,650.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1861.20,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,861.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1861.20,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,861.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1602.70,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,602.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1861.20,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,861.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1861.20,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,861.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE ARTHREX KNOTLESS TIGHTROPE,C1713,HCPCS,278,RC,10054314,CDM,,,,both,,,2585.0000,1706.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1551.00,,,,,,,1256.3100,2585.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,585.00 in Billed Charges for Rev 278 Proc C1713 = $1,551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,AETNA,AETNA HSHS,2277.69,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,277.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,AETNA,ALL COMMERCIAL AETNA,3525.83,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $3,525.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,ANTHEM,ANTHEM POS/HMO,1833.43,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $1,833.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,ANTHEM,ANTHEM PPO,1833.43,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $1,833.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3525.83,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $3,525.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,CENPATICO,ALL MEDICAID CENPATICO,3525.83,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $3,525.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2996.96,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,996.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,CIGNA,ALL COMMERCIAL CIGNA,2468.08,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,468.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,COFINITY,COFINITY,3525.83,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $3,525.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3349.54,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $3,349.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,2961.70,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,961.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2503.34,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,503.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2573.86,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,573.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,1713.55,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $1,713.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2996.96,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,996.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,HUMANA,HUMANA CHOICE CARE HMO,1762.92,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $1,762.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,HUMANA,HUMANA CHOICE CARE PPO,2996.96,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,996.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,HUMANA,HUMANA NATIIONAL POS HMO,1762.92,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $1,762.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2573.86,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,573.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,3525.83,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $3,525.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1762.92,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $1,762.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2961.70,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,961.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2644.37,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,644.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3243.76,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $3,243.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2250.54,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,250.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2538.60,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,538.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2538.60,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,538.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2186.01,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,186.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2538.60,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,538.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2538.60,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,538.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM ARTHREX BIOCOMPOSITE MPFL/ACL TIGHTROPE,C1713,HCPCS,278,RC,10068130,CDM,,,,both,,,3525.8300,2327.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2115.50,,,,,,,1713.5500,3525.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,525.83 in Billed Charges for Rev 278 Proc C1713 = $2,115.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,AETNA,AETNA HSHS,227.09,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $227.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,AETNA,ALL COMMERCIAL AETNA,351.54,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $351.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,351.54,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $351.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,CENPATICO,ALL MEDICAID CENPATICO,351.54,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $351.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,298.81,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $298.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,CIGNA,ALL COMMERCIAL CIGNA,246.08,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $246.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,COFINITY,COFINITY,351.54,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $351.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,333.96,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $333.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,295.29,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $295.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,249.59,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $249.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,256.62,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $256.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,170.85,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $170.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,298.81,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $298.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,HUMANA,HUMANA CHOICE CARE PPO,298.81,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $298.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,256.62,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $256.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,351.54,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $351.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,175.77,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $175.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,295.29,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $295.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,263.66,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $263.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,323.42,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $323.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,224.39,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $224.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,253.11,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $253.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,253.11,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $253.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,217.95,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $217.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,253.11,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $253.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,253.11,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $253.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 MTRX-MAND SELF LOCK 12MM,C1713,HCPCS,278,RC,10040005,CDM,,,,both,,,351.5400,232.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,210.92,,,,,,,170.8500,351.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.54 in Billed Charges for Rev 278 Proc C1713 = $210.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,AETNA,AETNA HSHS,134.32,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $134.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,AETNA,ALL COMMERCIAL AETNA,207.92,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $207.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,207.92,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $207.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,CENPATICO,ALL MEDICAID CENPATICO,207.92,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $207.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,176.73,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $176.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,CIGNA,ALL COMMERCIAL CIGNA,145.54,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $145.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,COFINITY,COFINITY,207.92,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $207.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,197.52,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $197.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,174.65,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $174.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,147.62,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $147.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,151.78,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $151.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,101.05,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $101.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,176.73,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $176.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,HUMANA,HUMANA CHOICE CARE PPO,176.73,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $176.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,151.78,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $151.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,207.92,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $207.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,103.96,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $103.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,174.65,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $174.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,155.94,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $155.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,191.29,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $191.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,132.72,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $132.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,149.70,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $149.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,149.70,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $149.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,128.91,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $128.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,149.70,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $149.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,149.70,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $149.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003266,CDM,,,,both,,,207.9200,137.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,124.75,,,,,,,101.0500,207.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $207.92 in Billed Charges for Rev 278 Proc C1713 = $124.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,AETNA,AETNA HSHS,134.30,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $134.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,AETNA,ALL COMMERCIAL AETNA,207.90,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,207.90,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,CENPATICO,ALL MEDICAID CENPATICO,207.90,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,176.72,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $176.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,CIGNA,ALL COMMERCIAL CIGNA,145.53,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $145.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,COFINITY,COFINITY,207.90,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,197.51,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $197.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,174.64,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $174.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,147.61,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $147.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,151.77,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $151.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,101.04,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $101.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,176.72,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $176.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,HUMANA,HUMANA CHOICE CARE PPO,176.72,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $176.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,151.77,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $151.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,207.90,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,103.95,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $103.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,174.64,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $174.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,155.93,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $155.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,191.27,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $191.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,132.70,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $132.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,149.69,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $149.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,149.69,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $149.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,128.90,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $128.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,149.69,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $149.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,149.69,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $149.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI CORTEX SELF TAP 34MM,C1713,HCPCS,278,RC,10016035,CDM,,,,both,,,207.9000,137.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,124.74,,,,,,,101.0400,207.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $207.90 in Billed Charges for Rev 278 Proc C1713 = $124.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,AETNA,AETNA HSHS,98.37,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $98.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,AETNA,ALL COMMERCIAL AETNA,152.28,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $152.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,152.28,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $152.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,CENPATICO,ALL MEDICAID CENPATICO,152.28,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $152.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,129.44,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $129.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,CIGNA,ALL COMMERCIAL CIGNA,106.60,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $106.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,COFINITY,COFINITY,152.28,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $152.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,144.67,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $144.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,127.92,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $127.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,108.12,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $108.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,111.16,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $111.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,74.01,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $74.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,129.44,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $129.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,HUMANA,HUMANA CHOICE CARE PPO,129.44,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $129.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,111.16,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $111.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,152.28,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $152.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,76.14,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $76.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,127.92,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $127.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,114.21,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $114.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,140.10,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $140.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,97.20,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,109.64,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $109.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,109.64,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $109.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,94.41,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $94.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,109.64,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $109.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,109.64,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $109.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10013889,CDM,,,,both,,,152.2800,100.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,91.37,,,,,,,74.0100,152.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $152.28 in Billed Charges for Rev 278 Proc C1713 = $91.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,AETNA,AETNA HSHS,228.20,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $228.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,AETNA,ALL COMMERCIAL AETNA,353.25,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $353.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,353.25,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $353.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,CENPATICO,ALL MEDICAID CENPATICO,353.25,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $353.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,300.26,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $300.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,CIGNA,ALL COMMERCIAL CIGNA,247.28,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $247.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,COFINITY,COFINITY,353.25,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $353.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,335.59,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $335.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,296.73,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $296.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,250.81,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $250.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,257.87,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $257.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,171.68,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $171.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,300.26,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $300.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,HUMANA,HUMANA CHOICE CARE PPO,300.26,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $300.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,257.87,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $257.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,353.25,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $353.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,176.63,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $176.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,296.73,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $296.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,264.94,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $264.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,324.99,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $324.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,225.48,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $225.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,254.34,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $254.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,254.34,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $254.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,219.02,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $219.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,254.34,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $254.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,254.34,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $254.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.4 TI MANDIBLE SELF TAP 10MM,C1713,HCPCS,278,RC,10003717,CDM,,,,both,,,353.2500,233.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,211.95,,,,,,,171.6800,353.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $353.25 in Billed Charges for Rev 278 Proc C1713 = $211.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,AETNA,AETNA HSHS,41.32,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $41.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,AETNA,ALL COMMERCIAL AETNA,63.97,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,63.97,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,CENPATICO,ALL MEDICAID CENPATICO,63.97,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,54.37,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $54.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,CIGNA,ALL COMMERCIAL CIGNA,44.78,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $44.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,COFINITY,COFINITY,63.97,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,60.77,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $60.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,53.73,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $53.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,45.42,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $45.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,46.70,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $46.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,31.09,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $31.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,54.37,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $54.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,HUMANA,HUMANA CHOICE CARE PPO,54.37,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $54.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,46.70,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $46.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,63.97,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,31.99,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $31.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,53.73,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $53.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,47.98,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $47.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,58.85,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $58.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,40.83,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $40.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,46.06,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $46.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,46.06,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $46.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,39.66,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $39.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,46.06,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $46.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,46.06,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $46.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053078,CDM,,,,both,,,63.9700,42.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,38.38,,,,,,,31.0900,63.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $63.97 in Billed Charges for Rev 278 Proc C1713 = $38.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,AETNA,AETNA HSHS,42.95,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $42.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,AETNA,ALL COMMERCIAL AETNA,66.49,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $66.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,66.49,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $66.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,CENPATICO,ALL MEDICAID CENPATICO,66.49,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $66.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,56.52,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $56.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,CIGNA,ALL COMMERCIAL CIGNA,46.54,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $46.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,COFINITY,COFINITY,66.49,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $66.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,63.17,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $63.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,55.85,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $55.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,47.21,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $47.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,48.54,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $48.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,32.31,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $32.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,56.52,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $56.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,HUMANA,HUMANA CHOICE CARE PPO,56.52,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $56.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,48.54,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $48.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,66.49,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $66.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,33.25,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $33.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,55.85,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $55.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,49.87,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $49.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,61.17,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $61.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,42.44,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $42.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,47.87,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $47.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,47.87,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $47.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,41.22,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $41.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,47.87,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $47.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,47.87,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $47.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025949,CDM,,,,both,,,66.4900,43.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,39.89,,,,,,,32.3100,66.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $66.49 in Billed Charges for Rev 278 Proc C1713 = $39.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,AETNA,AETNA HSHS,148.85,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $148.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,AETNA,ALL COMMERCIAL AETNA,230.42,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $230.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,230.42,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $230.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,CENPATICO,ALL MEDICAID CENPATICO,230.42,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $230.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,195.86,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $195.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,CIGNA,ALL COMMERCIAL CIGNA,161.29,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $161.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,COFINITY,COFINITY,230.42,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $230.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,218.90,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $218.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,193.55,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $193.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,163.60,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $163.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,168.21,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $168.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,111.98,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $111.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,195.86,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $195.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,HUMANA,HUMANA CHOICE CARE PPO,195.86,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $195.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,168.21,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $168.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,230.42,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $230.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,115.21,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $115.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,193.55,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $193.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,172.82,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $172.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,211.99,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $211.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,147.08,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $147.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,165.90,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $165.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,165.90,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $165.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,142.86,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $142.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,165.90,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $165.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,165.90,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $165.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10003250,CDM,,,,both,,,230.4200,152.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,138.25,,,,,,,111.9800,230.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $230.42 in Billed Charges for Rev 278 Proc C1713 = $138.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,AETNA,AETNA HSHS,155.13,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $155.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,AETNA,ALL COMMERCIAL AETNA,240.14,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $240.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,240.14,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $240.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,CENPATICO,ALL MEDICAID CENPATICO,240.14,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $240.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,204.12,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $204.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,CIGNA,ALL COMMERCIAL CIGNA,168.10,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $168.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,COFINITY,COFINITY,240.14,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $240.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,228.13,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $228.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,HEALTH CARE ALLIANCE,THE ALLIANCE,201.72,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $201.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,170.50,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $170.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,175.30,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $175.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,HSHS EMPLOYEES,HSHS EMPLOYEES,116.71,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $116.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,204.12,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $204.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,HUMANA,HUMANA CHOICE CARE PPO,204.12,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $204.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,175.30,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $175.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,LIVE360,LIVE360 HSHS HEALTHY PLAN,240.14,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $240.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,120.07,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $120.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,201.72,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $201.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,180.11,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $180.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,220.93,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $220.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,153.28,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $153.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,172.90,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $172.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,172.90,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $172.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,148.89,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $148.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,172.90,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $172.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,172.90,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $172.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035056,CDM,,,,both,,,240.1400,158.4900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,144.08,,,,,,,116.7100,240.1400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $240.14 in Billed Charges for Rev 278 Proc C1713 = $144.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,AETNA,AETNA HSHS,1316.39,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,316.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,AETNA,ALL COMMERCIAL AETNA,2037.75,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $2,037.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,ANTHEM,ANTHEM POS/HMO,1059.63,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,059.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,ANTHEM,ANTHEM PPO,1059.63,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,059.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2037.75,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $2,037.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,CENPATICO,ALL MEDICAID CENPATICO,2037.75,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $2,037.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1732.09,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,732.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,CIGNA,ALL COMMERCIAL CIGNA,1426.43,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,426.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,COFINITY,COFINITY,2037.75,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $2,037.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1935.86,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,935.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,1711.71,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,711.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1446.80,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,446.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1487.56,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,487.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,990.35,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $990.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1732.09,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,732.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,HUMANA,HUMANA CHOICE CARE PPO,1732.09,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,732.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1487.56,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,487.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2037.75,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $2,037.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1018.88,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,018.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1711.71,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,711.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1528.31,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,528.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1874.73,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,874.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1300.70,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,300.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1467.18,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,467.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1467.18,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,467.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1263.41,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,263.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1467.18,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,467.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1467.18,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,467.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074995,CDM,,,,both,,,2037.7500,1344.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1222.65,,,,,,,990.3500,2037.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,037.75 in Billed Charges for Rev 278 Proc C1713 = $1,222.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,AETNA,AETNA HSHS,3118.82,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,118.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,AETNA,ALL COMMERCIAL AETNA,4827.90,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,827.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,ANTHEM,ANTHEM POS/HMO,2510.51,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $2,510.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,ANTHEM,ANTHEM PPO,2510.51,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $2,510.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4827.90,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,827.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,CENPATICO,ALL MEDICAID CENPATICO,4827.90,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,827.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4103.72,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,103.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,CIGNA,ALL COMMERCIAL CIGNA,3379.53,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,379.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,COFINITY,COFINITY,4827.90,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,827.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4586.51,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,586.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,4055.44,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,055.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3427.81,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,427.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3524.37,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,524.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,2346.36,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $2,346.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4103.72,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,103.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,HUMANA,HUMANA CHOICE CARE HMO,2413.95,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $2,413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,HUMANA,HUMANA CHOICE CARE PPO,4103.72,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,103.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,HUMANA,HUMANA NATIIONAL POS HMO,2413.95,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $2,413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3524.37,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,524.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,4827.90,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,827.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2413.95,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $2,413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4055.44,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,055.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3620.93,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,620.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4441.67,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $4,441.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3081.65,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,081.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3476.09,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,476.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3476.09,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,476.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2993.30,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $2,993.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3476.09,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,476.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3476.09,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $3,476.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SPEEDBRIDGE ACHILLES,C1713,HCPCS,278,RC,10075943,CDM,,,,both,,,4827.9000,3186.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2896.74,,,,,,,2346.3600,4827.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,827.90 in Billed Charges for Rev 278 Proc C1713 = $2,896.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,AETNA,AETNA HSHS,2472.89,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,472.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,AETNA,ALL COMMERCIAL AETNA,3828.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,ANTHEM,ANTHEM POS/HMO,1990.56,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $1,990.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,ANTHEM,ANTHEM PPO,1990.56,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $1,990.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3828.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,CENPATICO,ALL MEDICAID CENPATICO,3828.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3253.80,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,253.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,CIGNA,ALL COMMERCIAL CIGNA,2679.60,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,679.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,COFINITY,COFINITY,3828.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3636.60,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,636.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,3215.52,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,215.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2717.88,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,717.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2794.44,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,794.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,1860.41,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $1,860.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3253.80,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,253.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,HUMANA,HUMANA CHOICE CARE HMO,1914.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $1,914.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,HUMANA,HUMANA CHOICE CARE PPO,3253.80,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,253.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,HUMANA,HUMANA NATIIONAL POS HMO,1914.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $1,914.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2794.44,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,794.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3828.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1914.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $1,914.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3215.52,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,215.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2871.00,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,871.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3521.76,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $3,521.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2443.41,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,443.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2756.16,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,756.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2756.16,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,756.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2373.36,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,373.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2756.16,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,756.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2756.16,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,756.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM IMPLANT ACHILLES SPEEDBRIDGE ARTHREX,C1713,HCPCS,278,RC,10051514,CDM,,,,both,,,3828.0000,2526.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2296.80,,,,,,,1860.4100,3828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,828.00 in Billed Charges for Rev 278 Proc C1713 = $2,296.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,AETNA,AETNA HSHS,5302.37,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,302.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,AETNA,ALL COMMERCIAL AETNA,8208.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $8,208.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,ANTHEM,ANTHEM POS/HMO,4268.16,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,268.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,ANTHEM,ANTHEM PPO,4268.16,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,268.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8208.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $8,208.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,CENPATICO,ALL MEDICAID CENPATICO,8208.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $8,208.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6976.80,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $6,976.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,CIGNA,ALL COMMERCIAL CIGNA,5745.60,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,745.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,COFINITY,COFINITY,8208.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $8,208.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7797.60,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $7,797.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6894.72,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $6,894.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5827.68,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,827.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5991.84,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,991.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3989.09,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $3,989.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6976.80,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $6,976.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,HUMANA,HUMANA CHOICE CARE HMO,4104.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,HUMANA,HUMANA CHOICE CARE PPO,6976.80,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $6,976.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,HUMANA,HUMANA NATIIONAL POS HMO,4104.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5991.84,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,991.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8208.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $8,208.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4104.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6894.72,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $6,894.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6156.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $6,156.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7551.36,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $7,551.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4104.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4104.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,PREVEA HEALTH NETWORK,PREVEA360,4104.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4104.00,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5239.17,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,239.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5909.76,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,909.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3824.93,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $3,824.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,3824.93,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $3,824.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,3824.93,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $3,824.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5909.76,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,909.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5088.96,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,088.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5909.76,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,909.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5909.76,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $5,909.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM INT FIX 14X3.9MM 2.7MM,C1713,HCPCS,278,RC,10086329,CDM,,,,both,,,8208.0000,5417.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4924.80,,,,,,,3824.9300,8208.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,208.00 in Billed Charges for Rev 278 Proc C1713 = $4,924.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,AETNA,AETNA HSHS,572.65,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $572.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,AETNA,ALL COMMERCIAL AETNA,886.45,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $886.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,886.45,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $886.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,CENPATICO,ALL MEDICAID CENPATICO,886.45,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $886.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,753.48,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $753.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,CIGNA,ALL COMMERCIAL CIGNA,620.52,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $620.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,COFINITY,COFINITY,886.45,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $886.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,842.13,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $842.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,744.62,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $744.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,629.38,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $629.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,647.11,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $647.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,430.81,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $430.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,753.48,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $753.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,HUMANA,HUMANA CHOICE CARE PPO,753.48,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $753.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,647.11,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $647.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,886.45,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $886.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,443.23,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $443.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,744.62,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $744.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,664.84,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $664.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,815.53,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $815.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,565.82,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $565.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,638.24,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $638.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,638.24,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $638.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,549.60,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $549.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,638.24,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $638.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,638.24,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $638.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10053218,CDM,,,,both,,,886.4500,585.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,531.87,,,,,,,430.8100,886.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $886.45 in Billed Charges for Rev 278 Proc C1713 = $531.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,AETNA,AETNA HSHS,63.15,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $63.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,AETNA,ALL COMMERCIAL AETNA,97.76,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $97.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,97.76,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $97.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,CENPATICO,ALL MEDICAID CENPATICO,97.76,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $97.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,83.10,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $83.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,CIGNA,ALL COMMERCIAL CIGNA,68.43,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $68.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,COFINITY,COFINITY,97.76,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $97.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,92.87,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $92.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,82.12,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $82.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,69.41,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $69.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,71.36,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $71.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,47.51,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $47.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,83.10,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $83.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,HUMANA,HUMANA CHOICE CARE PPO,83.10,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $83.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,71.36,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $71.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,97.76,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $97.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,48.88,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $48.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,82.12,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $82.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,73.32,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $73.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,89.94,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $89.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,62.40,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $62.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,70.39,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $70.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,70.39,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $70.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,60.61,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $60.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,70.39,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $70.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,70.39,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $70.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 295MM BENDING 37 HOLE LOCK RECONSTRUCTION PLATE NONSTERILE,C1713,HCPCS,278,RC,10026212,CDM,,,,both,,,97.7600,64.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,58.66,,,,,,,47.5100,97.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.76 in Billed Charges for Rev 278 Proc C1713 = $58.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,AETNA,AETNA HSHS,44.77,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $44.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,AETNA,ALL COMMERCIAL AETNA,69.30,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $69.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,69.30,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $69.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,CENPATICO,ALL MEDICAID CENPATICO,69.30,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $69.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.91,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $58.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,CIGNA,ALL COMMERCIAL CIGNA,48.51,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $48.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,COFINITY,COFINITY,69.30,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $69.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.84,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $65.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,58.21,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $58.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,49.20,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.59,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $50.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,33.68,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $33.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.91,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $58.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,HUMANA,HUMANA CHOICE CARE PPO,58.91,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $58.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.59,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $50.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,69.30,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $69.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.65,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $34.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,58.21,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $58.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.98,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $51.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.76,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $63.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44.23,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $44.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.90,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $49.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.90,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $49.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.97,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $42.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.90,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $49.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.90,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $49.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10001467,CDM,,,,both,,,69.3000,45.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.58,,,,,,,33.6800,69.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $69.30 in Billed Charges for Rev 278 Proc C1713 = $41.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,AETNA,AETNA HSHS,61.05,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $61.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,AETNA,ALL COMMERCIAL AETNA,94.50,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $94.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,94.50,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $94.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,CENPATICO,ALL MEDICAID CENPATICO,94.50,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $94.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,80.33,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $80.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,CIGNA,ALL COMMERCIAL CIGNA,66.15,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $66.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,COFINITY,COFINITY,94.50,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $94.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,89.78,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $89.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,79.38,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $79.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,67.10,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $67.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,68.99,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $68.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,45.93,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $45.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,80.33,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $80.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,HUMANA,HUMANA CHOICE CARE PPO,80.33,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $80.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,68.99,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $68.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,94.50,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $94.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,47.25,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $47.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,79.38,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $79.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,70.88,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $70.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,86.94,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $86.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,60.32,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $60.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,68.04,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $68.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,68.04,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $68.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.59,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $58.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,68.04,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $68.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,68.04,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $68.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES BENDING 12 HOLE FOR 3.5 LC - DCP & DCP PLATES,C1713,HCPCS,278,RC,10080593,CDM,,,,both,,,94.5000,62.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,56.70,,,,,,,45.9300,94.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $94.50 in Billed Charges for Rev 278 Proc C1713 = $56.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,AETNA,AETNA HSHS,129.22,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $129.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,AETNA,ALL COMMERCIAL AETNA,200.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $200.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,200.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $200.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,CENPATICO,ALL MEDICAID CENPATICO,200.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $200.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,170.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $170.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,CIGNA,ALL COMMERCIAL CIGNA,140.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $140.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,COFINITY,COFINITY,200.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $200.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,190.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $190.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,168.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $168.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,142.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $142.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,146.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $146.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,97.21,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $97.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,170.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $170.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,HUMANA,HUMANA CHOICE CARE PPO,170.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $170.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,146.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $146.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,200.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $200.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,100.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $100.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,168.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $168.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,150.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $150.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,184.03,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $184.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,127.68,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $127.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,144.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $144.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,144.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $144.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,124.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $124.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,144.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $144.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,144.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $144.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES CURVED RECONSTRUCTION 22 HOLE,C1713,HCPCS,278,RC,10001463,CDM,,,,both,,,200.0300,132.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,120.02,,,,,,,97.2100,200.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $200.03 in Billed Charges for Rev 278 Proc C1713 = $120.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,AETNA,AETNA HSHS,350.18,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $350.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,AETNA,ALL COMMERCIAL AETNA,542.08,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $542.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,542.08,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $542.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,CENPATICO,ALL MEDICAID CENPATICO,542.08,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $542.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,460.77,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $460.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,CIGNA,ALL COMMERCIAL CIGNA,379.46,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $379.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,COFINITY,COFINITY,542.08,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $542.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,514.98,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $514.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,455.35,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $455.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,384.88,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $384.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,395.72,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $395.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,263.45,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $263.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,460.77,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $460.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,HUMANA,HUMANA CHOICE CARE PPO,460.77,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $460.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,395.72,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $395.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,542.08,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $542.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,271.04,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $271.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,455.35,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $455.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,406.56,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $406.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,498.71,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $498.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,346.01,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $346.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,390.30,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $390.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,390.30,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $390.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,336.09,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $336.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,390.30,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $390.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,390.30,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $390.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE BUTTON ROUND CONCAVE ARTHREX,C1713,HCPCS,278,RC,SIL6142,CDM,,,,both,,,542.0800,357.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,325.25,,,,,,,263.4500,542.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $542.08 in Billed Charges for Rev 278 Proc C1713 = $325.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,AETNA,AETNA HSHS,852.01,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $852.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,AETNA,ALL COMMERCIAL AETNA,1318.90,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,318.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,ANTHEM,ANTHEM POS/HMO,685.83,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $685.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,ANTHEM,ANTHEM PPO,685.83,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $685.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1318.90,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,318.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,CENPATICO,ALL MEDICAID CENPATICO,1318.90,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,318.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1121.07,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,121.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,CIGNA,ALL COMMERCIAL CIGNA,923.23,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $923.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,COFINITY,COFINITY,1318.90,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,318.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1252.96,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,252.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,1107.88,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,107.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,936.42,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $936.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,962.80,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $962.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,640.99,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $640.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1121.07,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,121.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,HUMANA,HUMANA CHOICE CARE PPO,1121.07,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,121.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,962.80,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $962.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1318.90,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,318.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,659.45,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $659.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1107.88,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,107.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,989.18,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $989.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1213.39,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $1,213.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,841.85,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $841.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,949.61,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $949.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,949.61,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $949.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,817.72,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $817.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,949.61,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $949.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,949.61,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $949.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TIGHTROPE II BTB WITH DEPLOYING SUTURE,C1713,HCPCS,278,RC,ASC180,CDM,,,,both,,,1318.9000,870.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,791.34,,,,,,,640.9900,1318.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,318.90 in Billed Charges for Rev 278 Proc C1713 = $791.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,AETNA,AETNA HSHS,649.31,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $649.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,AETNA,ALL COMMERCIAL AETNA,1005.13,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $1,005.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,ANTHEM,ANTHEM POS/HMO,522.67,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $522.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,ANTHEM,ANTHEM PPO,522.67,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $522.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1005.13,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $1,005.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,CENPATICO,ALL MEDICAID CENPATICO,1005.13,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $1,005.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,854.36,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $854.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,CIGNA,ALL COMMERCIAL CIGNA,703.59,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $703.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,COFINITY,COFINITY,1005.13,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $1,005.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,954.87,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $954.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,844.31,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $844.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,713.64,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $713.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,733.74,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $733.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,488.49,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $488.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,854.36,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $854.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,HUMANA,HUMANA CHOICE CARE PPO,854.36,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $854.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,733.74,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $733.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1005.13,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $1,005.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,502.57,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $502.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,844.31,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $844.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,753.85,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $753.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,924.72,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $924.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,641.57,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $641.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,723.69,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $723.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,723.69,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $723.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,623.18,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $623.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,723.69,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $723.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,723.69,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $723.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10065269,CDM,,,,both,,,1005.1300,663.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,603.08,,,,,,,488.4900,1005.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,005.13 in Billed Charges for Rev 278 Proc C1713 = $603.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,AETNA,AETNA HSHS,159.89,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $159.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,AETNA,ALL COMMERCIAL AETNA,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,CENPATICO,ALL MEDICAID CENPATICO,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,210.38,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $210.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,CIGNA,ALL COMMERCIAL CIGNA,173.25,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $173.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,COFINITY,COFINITY,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,235.13,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $235.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,207.90,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,175.73,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $175.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,180.68,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $180.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,120.29,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $120.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,210.38,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $210.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,HUMANA,HUMANA CHOICE CARE PPO,210.38,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $210.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,180.68,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $180.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,247.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,123.75,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $123.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,207.90,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $207.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,185.63,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $185.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,227.70,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $227.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,157.98,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $157.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,178.20,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $178.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,178.20,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $178.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,153.45,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $153.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,178.20,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $178.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,178.20,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $178.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10009986,CDM,,,,both,,,247.5000,163.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,148.50,,,,,,,120.2900,247.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $247.50 in Billed Charges for Rev 278 Proc C1713 = $148.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,AETNA,AETNA HSHS,60.17,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $60.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,AETNA,ALL COMMERCIAL AETNA,93.15,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $93.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,93.15,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $93.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,CENPATICO,ALL MEDICAID CENPATICO,93.15,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $93.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.18,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $79.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,CIGNA,ALL COMMERCIAL CIGNA,65.21,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $65.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,COFINITY,COFINITY,93.15,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $93.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,88.49,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $88.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,78.25,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $78.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.14,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $66.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,68.00,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $68.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,45.27,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $45.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.18,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $79.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,HUMANA,HUMANA CHOICE CARE PPO,79.18,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $79.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,68.00,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $68.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,93.15,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $93.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.58,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $46.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.25,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $78.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,69.86,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $69.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,85.70,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $85.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,59.46,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $59.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,67.07,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $67.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,67.07,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $67.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,57.75,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $57.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,67.07,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $67.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,67.07,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $67.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SCREW CANN TI STRYKER,C1713,HCPCS,278,RC,10017228,CDM,,,,both,,,93.1500,61.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.89,,,,,,,45.2700,93.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.15 in Billed Charges for Rev 278 Proc C1713 = $55.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,AETNA,AETNA HSHS,178.41,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $178.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,AETNA,ALL COMMERCIAL AETNA,276.17,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $276.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,276.17,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $276.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,CENPATICO,ALL MEDICAID CENPATICO,276.17,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $276.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,234.74,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $234.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,CIGNA,ALL COMMERCIAL CIGNA,193.32,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $193.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,COFINITY,COFINITY,276.17,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $276.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,262.36,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $262.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,231.98,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $231.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,196.08,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $196.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,201.60,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,134.22,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $134.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,234.74,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $234.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,HUMANA,HUMANA CHOICE CARE PPO,234.74,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $234.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,201.60,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,276.17,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $276.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,138.09,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $138.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,231.98,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $231.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,207.13,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $207.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,254.08,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $254.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,176.28,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $176.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,198.84,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $198.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,198.84,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $198.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,171.23,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $171.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,198.84,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $198.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,198.84,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $198.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 3.0 THREADED CANN,C1713,HCPCS,278,RC,10025979,CDM,,,,both,,,276.1700,182.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,165.70,,,,,,,134.2200,276.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $276.17 in Billed Charges for Rev 278 Proc C1713 = $165.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,AETNA,AETNA HSHS,39.02,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $39.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,AETNA,ALL COMMERCIAL AETNA,60.41,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $60.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,60.41,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $60.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,CENPATICO,ALL MEDICAID CENPATICO,60.41,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $60.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,51.35,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $51.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,CIGNA,ALL COMMERCIAL CIGNA,42.29,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $42.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,COFINITY,COFINITY,60.41,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $60.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,57.39,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $57.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,50.74,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $50.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42.89,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $42.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,44.10,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $44.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,29.36,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $29.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,51.35,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $51.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,HUMANA,HUMANA CHOICE CARE PPO,51.35,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $51.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,44.10,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $44.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,60.41,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $60.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,30.21,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $30.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,50.74,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $50.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,45.31,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $45.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,55.58,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $55.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38.56,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $38.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,43.50,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $43.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,43.50,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $43.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37.45,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $37.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,43.50,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $43.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,43.50,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $43.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 6.5MM,C1713,HCPCS,278,RC,10025980,CDM,,,,both,,,60.4100,39.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,36.25,,,,,,,29.3600,60.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $60.41 in Billed Charges for Rev 278 Proc C1713 = $36.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,AETNA,AETNA HSHS,33.15,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $33.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,AETNA,ALL COMMERCIAL AETNA,51.32,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $51.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,51.32,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $51.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,CENPATICO,ALL MEDICAID CENPATICO,51.32,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $51.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,43.62,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $43.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,CIGNA,ALL COMMERCIAL CIGNA,35.92,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $35.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,COFINITY,COFINITY,51.32,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $51.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,48.75,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $48.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,43.11,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $43.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,36.44,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $36.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,37.46,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $37.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,24.94,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $24.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,43.62,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $43.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,HUMANA,HUMANA CHOICE CARE PPO,43.62,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $43.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,37.46,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $37.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,51.32,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $51.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,25.66,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $25.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,43.11,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $43.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,38.49,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $38.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,47.21,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $47.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,32.76,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $32.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,36.95,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $36.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,36.95,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $36.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,31.82,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $31.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,36.95,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $36.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,36.95,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $36.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 7.0MM,C1713,HCPCS,278,RC,10046459,CDM,,,,both,,,51.3200,33.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,30.79,,,,,,,24.9400,51.3200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.32 in Billed Charges for Rev 278 Proc C1713 = $30.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,AETNA,AETNA HSHS,8.07,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,AETNA,ALL COMMERCIAL AETNA,12.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $12.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $12.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,CENPATICO,ALL MEDICAID CENPATICO,12.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $12.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.62,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $10.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,CIGNA,ALL COMMERCIAL CIGNA,8.74,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,COFINITY,COFINITY,12.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $12.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.87,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $11.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,10.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $10.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.87,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $8.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.12,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $9.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,6.07,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $6.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.62,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $10.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,HUMANA,HUMANA CHOICE CARE PPO,10.62,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $10.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.12,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $9.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $12.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.25,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $6.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $10.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.37,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $9.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $11.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.97,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $7.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.99,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $8.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.99,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $8.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.74,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $7.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.99,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $8.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.99,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $8.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 25 GA STRAIGHT,C1713,HCPCS,278,RC,70500905,CDM,,,,both,,,12.4900,8.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.49,,,,,,,6.0700,12.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.49 in Billed Charges for Rev 278 Proc C1713 = $7.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,AETNA,AETNA HSHS,17.15,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,AETNA,ALL COMMERCIAL AETNA,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,CENPATICO,ALL MEDICAID CENPATICO,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,22.57,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $22.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,CIGNA,ALL COMMERCIAL CIGNA,18.59,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $18.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,COFINITY,COFINITY,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,25.22,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $25.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,22.30,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $22.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,18.85,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $18.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,19.38,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,12.90,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $12.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,22.57,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $22.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,HUMANA,HUMANA CHOICE CARE PPO,22.57,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $22.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,19.38,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,26.55,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $26.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.28,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,22.30,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $22.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,19.91,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $19.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,24.43,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $24.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,16.95,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $16.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,19.12,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $19.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,19.12,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $19.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.46,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $16.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,19.12,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $19.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,19.12,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $19.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE 26GA STRAIGHT,C1713,HCPCS,278,RC,70451010,CDM,,,,both,,,26.5500,17.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.93,,,,,,,12.9000,26.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.55 in Billed Charges for Rev 278 Proc C1713 = $15.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,AETNA,AETNA HSHS,98.87,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $98.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,AETNA,ALL COMMERCIAL AETNA,153.05,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $153.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,153.05,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $153.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,CENPATICO,ALL MEDICAID CENPATICO,153.05,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $153.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,130.09,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $130.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,CIGNA,ALL COMMERCIAL CIGNA,107.14,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $107.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,COFINITY,COFINITY,153.05,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $153.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,145.40,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $145.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,128.56,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $128.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,108.67,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $108.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,111.73,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $111.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,74.38,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $74.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,130.09,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $130.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,HUMANA,HUMANA CHOICE CARE PPO,130.09,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $130.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,111.73,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $111.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,153.05,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $153.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,76.53,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $76.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,128.56,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $128.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,114.79,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $114.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,140.81,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $140.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,97.69,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $97.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,110.20,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $110.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,110.20,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $110.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,94.89,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $94.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,110.20,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $110.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,110.20,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $110.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025755,CDM,,,,both,,,153.0500,101.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,91.83,,,,,,,74.3800,153.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $153.05 in Billed Charges for Rev 278 Proc C1713 = $91.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,AETNA,AETNA HSHS,18.71,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $18.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,AETNA,ALL COMMERCIAL AETNA,28.97,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $28.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,28.97,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $28.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,CENPATICO,ALL MEDICAID CENPATICO,28.97,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $28.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,24.62,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $24.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,CIGNA,ALL COMMERCIAL CIGNA,20.28,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $20.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,COFINITY,COFINITY,28.97,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $28.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,27.52,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $27.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,24.33,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $24.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,20.57,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $20.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,21.15,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $21.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,14.08,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $14.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,24.62,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $24.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,HUMANA,HUMANA CHOICE CARE PPO,24.62,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $24.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,21.15,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $21.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,28.97,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $28.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,14.49,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $14.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,24.33,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $24.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,21.73,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $21.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,26.65,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $26.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,18.49,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $18.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,20.86,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $20.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,20.86,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $20.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.96,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $17.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,20.86,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $20.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,20.86,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $20.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10056241,CDM,,,,both,,,28.9700,19.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,17.38,,,,,,,14.0800,28.9700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $28.97 in Billed Charges for Rev 278 Proc C1713 = $17.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,AETNA,AETNA HSHS,85.06,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $85.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,AETNA,ALL COMMERCIAL AETNA,131.67,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $131.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,131.67,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $131.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,CENPATICO,ALL MEDICAID CENPATICO,131.67,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $131.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,111.92,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $111.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,CIGNA,ALL COMMERCIAL CIGNA,92.17,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $92.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,COFINITY,COFINITY,131.67,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $131.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,125.09,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $125.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,110.60,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $110.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,93.49,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $93.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,96.12,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $96.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,63.99,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $63.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,111.92,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $111.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,HUMANA,HUMANA CHOICE CARE PPO,111.92,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $111.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,96.12,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $96.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,131.67,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $131.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.84,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $65.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,110.60,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $110.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,98.75,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $98.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,121.14,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $121.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,84.05,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $84.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,94.80,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $94.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,94.80,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $94.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,81.64,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $81.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,94.80,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $94.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,94.80,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $94.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 18 GA,C1713,HCPCS,278,RC,70401061,CDM,,,,both,,,131.6700,86.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,79.00,,,,,,,63.9900,131.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $131.67 in Billed Charges for Rev 278 Proc C1713 = $79.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,AETNA,AETNA HSHS,156.05,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $156.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,AETNA,ALL COMMERCIAL AETNA,241.56,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $241.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,241.56,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $241.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,CENPATICO,ALL MEDICAID CENPATICO,241.56,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $241.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,205.33,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $205.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,CIGNA,ALL COMMERCIAL CIGNA,169.09,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $169.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,COFINITY,COFINITY,241.56,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $241.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,229.48,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $229.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,202.91,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $202.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,171.51,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $171.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,176.34,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $176.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,117.40,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $117.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,205.33,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $205.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,HUMANA,HUMANA CHOICE CARE PPO,205.33,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $205.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,176.34,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $176.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,241.56,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $241.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,120.78,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $120.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,202.91,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $202.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,181.17,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $181.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,222.24,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $222.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,154.19,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $154.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,173.92,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $173.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,173.92,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $173.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,149.77,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $149.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,173.92,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $173.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,173.92,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $173.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025815,CDM,,,,both,,,241.5600,159.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,144.94,,,,,,,117.4000,241.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $241.56 in Billed Charges for Rev 278 Proc C1713 = $144.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,AETNA,AETNA HSHS,269.48,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $269.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,AETNA,ALL COMMERCIAL AETNA,417.15,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $417.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,417.15,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $417.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,CENPATICO,ALL MEDICAID CENPATICO,417.15,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $417.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,354.58,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $354.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,CIGNA,ALL COMMERCIAL CIGNA,292.01,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $292.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,COFINITY,COFINITY,417.15,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $417.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,396.29,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $396.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,350.41,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $350.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,296.18,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $296.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,304.52,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $304.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,202.73,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $202.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,354.58,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $354.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,HUMANA,HUMANA CHOICE CARE PPO,354.58,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $354.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,304.52,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $304.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,417.15,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $417.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,208.58,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $208.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,350.41,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $350.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,312.86,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $312.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,383.78,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $383.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,266.27,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $266.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,300.35,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $300.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,300.35,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $300.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,258.63,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $258.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,300.35,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $300.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,300.35,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $300.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 24GA,C1713,HCPCS,278,RC,10025760,CDM,,,,both,,,417.1500,275.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,250.29,,,,,,,202.7300,417.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $417.15 in Billed Charges for Rev 278 Proc C1713 = $250.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,AETNA,AETNA HSHS,46.57,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $46.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,AETNA,ALL COMMERCIAL AETNA,72.09,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $72.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,72.09,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $72.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,CENPATICO,ALL MEDICAID CENPATICO,72.09,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $72.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,61.28,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $61.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,CIGNA,ALL COMMERCIAL CIGNA,50.46,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $50.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,COFINITY,COFINITY,72.09,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $72.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,68.49,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $68.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,60.56,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $60.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,51.18,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $51.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,52.63,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $52.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,35.04,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $35.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,61.28,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $61.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,HUMANA,HUMANA CHOICE CARE PPO,61.28,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $61.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,52.63,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $52.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,72.09,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $72.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,36.05,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $36.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,60.56,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $60.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,54.07,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $54.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,66.32,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $66.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,46.02,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $46.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,51.90,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $51.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,51.90,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $51.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,44.70,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $44.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,51.90,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $51.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,51.90,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $51.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70450703,CDM,,,,both,,,72.0900,47.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,43.25,,,,,,,35.0400,72.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $72.09 in Billed Charges for Rev 278 Proc C1713 = $43.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,AETNA,AETNA HSHS,10.01,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $10.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,AETNA,ALL COMMERCIAL AETNA,15.50,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15.50,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,CENPATICO,ALL MEDICAID CENPATICO,15.50,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.18,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $13.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,CIGNA,ALL COMMERCIAL CIGNA,10.85,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $10.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,COFINITY,COFINITY,15.50,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14.73,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $14.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,13.02,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $13.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.01,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $11.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.32,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $11.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,7.53,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $7.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.18,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $13.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,HUMANA,HUMANA CHOICE CARE PPO,13.18,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $13.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.32,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $11.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,15.50,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.75,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.02,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $13.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.63,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $11.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,14.26,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $14.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.89,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $9.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.16,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $11.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.16,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $11.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.61,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $9.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.16,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $11.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.16,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $11.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10026058,CDM,,,,both,,,15.5000,10.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.30,,,,,,,7.5300,15.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.50 in Billed Charges for Rev 278 Proc C1713 = $9.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,AETNA,AETNA HSHS,11.58,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $11.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,AETNA,ALL COMMERCIAL AETNA,17.93,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17.93,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,CENPATICO,ALL MEDICAID CENPATICO,17.93,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15.24,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $15.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,CIGNA,ALL COMMERCIAL CIGNA,12.55,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $12.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,COFINITY,COFINITY,17.93,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17.03,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,15.06,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $15.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12.73,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $12.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13.09,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $13.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,8.71,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $8.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15.24,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $15.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,HUMANA,HUMANA CHOICE CARE PPO,15.24,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $15.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13.09,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $13.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,17.93,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.97,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $8.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15.06,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $15.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13.45,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,16.50,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $16.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.44,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $11.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.91,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $12.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.91,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $12.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.12,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $11.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.91,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $12.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.91,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $12.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10036474,CDM,,,,both,,,17.9300,11.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.76,,,,,,,8.7100,17.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.93 in Billed Charges for Rev 278 Proc C1713 = $10.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,AETNA,AETNA HSHS,62.60,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $62.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,AETNA,ALL COMMERCIAL AETNA,96.91,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $96.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,96.91,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $96.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,CENPATICO,ALL MEDICAID CENPATICO,96.91,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $96.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,82.37,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $82.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,CIGNA,ALL COMMERCIAL CIGNA,67.84,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $67.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,COFINITY,COFINITY,96.91,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $96.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,92.06,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $92.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,81.40,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $81.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,68.81,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $68.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,70.74,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $70.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,47.10,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $47.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,82.37,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $82.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,HUMANA,HUMANA CHOICE CARE PPO,82.37,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $82.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,70.74,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $70.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,96.91,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $96.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,48.46,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $48.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,81.40,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $81.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,72.68,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $72.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,89.16,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $89.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,61.86,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $61.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,69.78,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $69.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,69.78,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $69.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,60.08,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $60.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,69.78,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $69.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,69.78,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $69.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084079,CDM,,,,both,,,96.9100,63.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,58.15,,,,,,,47.1000,96.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $96.91 in Billed Charges for Rev 278 Proc C1713 = $58.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,AETNA,AETNA HSHS,312.67,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $312.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,AETNA,ALL COMMERCIAL AETNA,484.01,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $484.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,484.01,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $484.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,CENPATICO,ALL MEDICAID CENPATICO,484.01,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $484.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,411.41,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $411.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,CIGNA,ALL COMMERCIAL CIGNA,338.81,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $338.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,COFINITY,COFINITY,484.01,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $484.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,459.81,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $459.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,406.57,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $406.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,343.65,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $343.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,353.33,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $353.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,235.23,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $235.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,411.41,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $411.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,HUMANA,HUMANA CHOICE CARE PPO,411.41,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $411.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,353.33,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $353.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,484.01,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $484.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,242.01,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $242.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,406.57,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $406.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,363.01,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $363.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,445.29,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $445.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,308.94,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $308.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,348.49,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $348.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,348.49,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $348.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,300.09,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $300.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,348.49,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $348.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,348.49,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $348.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 SPADE POINT REDUCTION,C1713,HCPCS,278,RC,10036398,CDM,,,,both,,,484.0100,319.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,290.41,,,,,,,235.2300,484.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $484.01 in Billed Charges for Rev 278 Proc C1713 = $290.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,AETNA,AETNA HSHS,14.43,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $14.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,AETNA,ALL COMMERCIAL AETNA,22.34,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $22.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,22.34,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $22.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,CENPATICO,ALL MEDICAID CENPATICO,22.34,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $22.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18.99,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $18.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,CIGNA,ALL COMMERCIAL CIGNA,15.64,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,COFINITY,COFINITY,22.34,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $22.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,21.22,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $21.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,18.77,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $18.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15.86,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $15.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16.31,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $16.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,10.86,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $10.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18.99,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $18.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,HUMANA,HUMANA CHOICE CARE PPO,18.99,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $18.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16.31,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $16.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,22.34,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $22.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.17,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $11.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18.77,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $18.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16.76,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $16.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,20.55,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $20.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14.26,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $14.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,16.08,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $16.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,16.08,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $16.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13.85,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $13.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,16.08,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $16.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,16.08,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $16.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5 KIRSCHNER 285MM,C1713,HCPCS,278,RC,10051742,CDM,,,,both,,,22.3400,14.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.40,,,,,,,10.8600,22.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.34 in Billed Charges for Rev 278 Proc C1713 = $13.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,AETNA,AETNA HSHS,23.95,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $23.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,AETNA,ALL COMMERCIAL AETNA,37.08,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $37.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,37.08,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $37.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,CENPATICO,ALL MEDICAID CENPATICO,37.08,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $37.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,31.52,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $31.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,CIGNA,ALL COMMERCIAL CIGNA,25.96,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $25.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,COFINITY,COFINITY,37.08,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $37.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,35.23,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $35.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,31.15,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $31.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,26.33,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $26.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,27.07,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $27.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,18.02,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $18.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,31.52,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $31.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,HUMANA,HUMANA CHOICE CARE PPO,31.52,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $31.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,27.07,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $27.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,37.08,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $37.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,18.54,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $18.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,31.15,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $31.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,27.81,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $27.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,34.11,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $34.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,23.67,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $23.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,26.70,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $26.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,26.70,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $26.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,22.99,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $22.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,26.70,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $26.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,26.70,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $26.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.5MM KIRSHCNER THREADED,C1713,HCPCS,278,RC,10028653,CDM,,,,both,,,37.0800,24.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,22.25,,,,,,,18.0200,37.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $37.08 in Billed Charges for Rev 278 Proc C1713 = $22.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,AETNA,AETNA HSHS,101.78,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $101.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,AETNA,ALL COMMERCIAL AETNA,157.55,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $157.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,157.55,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $157.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,CENPATICO,ALL MEDICAID CENPATICO,157.55,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $157.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,133.92,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $133.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,CIGNA,ALL COMMERCIAL CIGNA,110.29,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $110.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,COFINITY,COFINITY,157.55,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $157.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,149.67,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $149.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,132.34,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $132.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,111.86,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $111.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,115.01,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $115.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,76.57,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $76.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,133.92,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $133.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,HUMANA,HUMANA CHOICE CARE PPO,133.92,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $133.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,115.01,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $115.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,157.55,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $157.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,78.78,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $78.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,132.34,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $132.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,118.16,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $118.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,144.95,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $144.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,100.56,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $100.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,113.44,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $113.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,113.44,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $113.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,97.68,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $97.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,113.44,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $113.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,113.44,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $113.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES GUIDE 2.8 THREADED 450/300MM,C1713,HCPCS,278,RC,10040888,CDM,,,,both,,,157.5500,103.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,94.53,,,,,,,76.5700,157.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $157.55 in Billed Charges for Rev 278 Proc C1713 = $94.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,AETNA,AETNA HSHS,905.82,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $905.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,AETNA,ALL COMMERCIAL AETNA,1402.20,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,ANTHEM,ANTHEM POS/HMO,729.14,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $729.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,ANTHEM,ANTHEM PPO,729.14,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $729.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1402.20,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,CENPATICO,ALL MEDICAID CENPATICO,1402.20,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1191.87,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,191.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,COFINITY,COFINITY,1402.20,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1332.09,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,332.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,1177.85,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,177.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,995.56,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $995.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1023.61,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,023.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,681.47,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $681.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1191.87,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,191.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,HUMANA,HUMANA CHOICE CARE PPO,1191.87,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,191.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1023.61,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,023.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1402.20,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,701.10,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $701.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1177.85,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,177.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1051.65,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,051.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1290.02,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,290.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,895.02,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $895.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1009.58,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,009.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1009.58,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,009.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,869.36,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $869.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1009.58,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,009.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1009.58,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $1,009.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATHETER RELIEVA SOLO PRO SINUS BALLOON 6 X 16,C1726,HCPCS,278,RC,10033624,CDM,,,,both,,,1402.2000,925.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,841.32,,,,,,,681.4700,1402.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,402.20 in Billed Charges for Rev 278 Proc C1726 = $841.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,AETNA,AETNA HSHS,802.00,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,AETNA,ALL COMMERCIAL AETNA,1241.48,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,241.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,ANTHEM,ANTHEM POS/HMO,645.57,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $645.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,ANTHEM,ANTHEM PPO,645.57,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $645.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1241.48,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,241.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,CENPATICO,ALL MEDICAID CENPATICO,1241.48,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,241.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1055.26,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,055.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,COFINITY,COFINITY,1241.48,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,241.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1179.41,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,179.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,1042.84,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,042.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,881.45,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $881.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,906.28,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $906.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,603.36,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $603.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1055.26,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,055.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,HUMANA,HUMANA CHOICE CARE PPO,1055.26,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,055.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,906.28,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $906.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1241.48,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,241.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,620.74,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $620.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1042.84,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,042.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,931.11,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $931.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1142.16,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $1,142.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,792.44,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $792.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,893.87,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $893.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,893.87,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $893.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,769.72,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $769.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,893.87,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $893.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,893.87,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $893.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRACKER NVG 23CM NONINVS STYLET,C1729,HCPCS,278,RC,10041317,CDM,,,,both,,,1241.4800,819.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,744.89,,,,,,,603.3600,1241.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,241.48 in Billed Charges for Rev 278 Proc C1729 = $744.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,AETNA,AETNA HSHS,5188.04,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,188.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,AETNA,ALL COMMERCIAL AETNA,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,ANTHEM,ANTHEM POS/HMO,4176.13,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,176.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,ANTHEM,ANTHEM PPO,4176.13,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,176.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,CENPATICO,ALL MEDICAID CENPATICO,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6826.37,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $6,826.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,COFINITY,COFINITY,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7629.47,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $7,629.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,6746.06,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $6,746.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5702.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,702.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5862.64,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,862.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,3903.08,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $3,903.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6826.37,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $6,826.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,HUMANA,HUMANA CHOICE CARE HMO,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,HUMANA,HUMANA CHOICE CARE PPO,6826.37,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $6,826.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,HUMANA,HUMANA NATIIONAL POS HMO,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5862.64,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,862.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,8031.02,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $8,031.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6746.06,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $6,746.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6023.27,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $6,023.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7388.54,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $7,388.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,PREVEA HEALTH NETWORK,PREVEA360,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4015.51,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,015.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5126.20,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,126.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5782.33,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,782.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3742.46,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $3,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,3742.46,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $3,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,3742.46,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $3,742.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5782.33,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,782.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4979.23,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,979.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5782.33,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,782.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5782.33,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $5,782.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VALVE SHNT PRGM CDMN CERTAS + SPHGRD INLN,C1729,HCPCS,278,RC,10085907,CDM,,,,both,,,8031.0200,5300.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4818.61,,,,,,,3742.4600,8031.0200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,031.02 in Billed Charges for Rev 278 Proc C1729 = $4,818.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,AETNA,AETNA HSHS,309.65,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $309.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,AETNA,ALL COMMERCIAL AETNA,479.34,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $479.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,479.34,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $479.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,CENPATICO,ALL MEDICAID CENPATICO,479.34,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $479.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,407.44,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $407.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,COFINITY,COFINITY,479.34,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $479.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,455.37,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $455.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,402.65,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $402.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,340.33,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $340.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,349.92,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $349.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,232.96,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $232.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,407.44,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $407.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,HUMANA,HUMANA CHOICE CARE PPO,407.44,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $407.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,349.92,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $349.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,479.34,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $479.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,239.67,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $239.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,402.65,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $402.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,359.51,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $359.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,440.99,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $440.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,305.96,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $305.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,345.12,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $345.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,345.12,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $345.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,297.19,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $297.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,345.12,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $345.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,345.12,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $345.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KIT EXT DRAIN 80CM LUMBR II TUOHY NEEDLE,C1729,HCPCS,278,RC,10016873,CDM,,,,both,,,479.3400,316.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,287.60,,,,,,,232.9600,479.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $479.34 in Billed Charges for Rev 278 Proc C1729 = $287.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,AETNA,AETNA HSHS,88.66,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $88.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,AETNA,ALL COMMERCIAL AETNA,137.25,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $137.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,137.25,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $137.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,CENPATICO,ALL MEDICAID CENPATICO,137.25,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $137.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,116.66,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $116.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,COFINITY,COFINITY,137.25,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $137.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,130.39,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $130.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,HEALTH CARE ALLIANCE,THE ALLIANCE,115.29,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $115.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,97.45,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $97.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,100.19,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $100.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,HSHS EMPLOYEES,HSHS EMPLOYEES,66.70,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $66.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,116.66,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $116.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,HUMANA,HUMANA CHOICE CARE PPO,116.66,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $116.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,100.19,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $100.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,LIVE360,LIVE360 HSHS HEALTHY PLAN,137.25,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $137.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,68.63,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $68.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,115.29,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $115.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,102.94,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $102.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,126.27,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $126.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,87.61,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $87.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,98.82,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $98.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,98.82,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $98.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,85.10,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $85.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,98.82,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $98.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,98.82,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $98.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PIGTAIL 14FR X 25CM,C1729,HCPCS,278,RC,10005136,CDM,,,,both,,,137.2500,90.5900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,82.35,,,,,,,66.7000,137.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.25 in Billed Charges for Rev 278 Proc C1729 = $82.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,AETNA,AETNA HSHS,102.37,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $102.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,AETNA,ALL COMMERCIAL AETNA,158.47,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $158.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,158.47,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $158.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,CENPATICO,ALL MEDICAID CENPATICO,158.47,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $158.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,134.70,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $134.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,CIGNA,ALL COMMERCIAL CIGNA,110.93,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $110.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,COFINITY,COFINITY,158.47,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $158.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,150.55,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $150.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,HEALTH CARE ALLIANCE,THE ALLIANCE,133.11,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $133.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,112.51,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $112.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,115.68,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $115.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,HSHS EMPLOYEES,HSHS EMPLOYEES,77.02,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $77.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,134.70,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $134.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,HUMANA,HUMANA CHOICE CARE PPO,134.70,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $134.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,115.68,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $115.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,LIVE360,LIVE360 HSHS HEALTHY PLAN,158.47,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $158.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,79.24,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $79.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,133.11,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $133.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,118.85,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $118.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,145.79,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $145.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,101.15,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $101.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,114.10,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $114.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,114.10,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $114.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,98.25,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $98.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,114.10,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $114.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,114.10,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $114.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER CURL PERITONEAL DIALYSIS 62 (278006),C1750,HCPCS,278,RC,10010473,CDM,,,,both,,,158.4700,104.5900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,95.08,,,,,,,77.0200,158.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $158.47 in Billed Charges for Rev 278 Proc C1750 = $95.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,AETNA,AETNA HSHS,573.49,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $573.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,AETNA,ALL COMMERCIAL AETNA,887.76,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $887.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,887.76,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $887.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,CENPATICO,ALL MEDICAID CENPATICO,887.76,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $887.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,754.60,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $754.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,CIGNA,ALL COMMERCIAL CIGNA,621.43,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $621.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,COFINITY,COFINITY,887.76,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $887.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,843.37,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $843.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,745.72,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $745.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,630.31,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $630.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,648.06,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $648.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,431.45,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $431.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,754.60,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $754.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,HUMANA,HUMANA CHOICE CARE PPO,754.60,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $754.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,648.06,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $648.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,887.76,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $887.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,443.88,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $443.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,745.72,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $745.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,665.82,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $665.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,816.74,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $816.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,566.66,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $566.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,639.19,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $639.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,639.19,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $639.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,550.41,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $550.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,639.19,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $639.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,639.19,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $639.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER DIALYSIS QUINTON PRESTERNAL PERITONEAL 44IN,C1750,HCPCS,278,RC,10021877,CDM,,,,both,,,887.7600,585.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,532.66,,,,,,,431.4500,887.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $887.76 in Billed Charges for Rev 278 Proc C1750 = $532.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,AETNA,AETNA HSHS,306.67,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $306.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,AETNA,ALL COMMERCIAL AETNA,474.72,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $474.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,474.72,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $474.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,CENPATICO,ALL MEDICAID CENPATICO,474.72,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $474.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,403.51,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $403.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,CIGNA,ALL COMMERCIAL CIGNA,332.30,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $332.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,COFINITY,COFINITY,474.72,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $474.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,450.98,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $450.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,398.76,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $398.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,337.05,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $337.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,346.55,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $346.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,230.71,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $230.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,403.51,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $403.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,HUMANA,HUMANA CHOICE CARE PPO,403.51,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $403.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,346.55,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $346.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,474.72,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $474.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,237.36,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $237.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,398.76,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $398.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,356.04,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $356.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,436.74,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $436.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,303.01,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $303.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,341.80,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $341.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,341.80,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $341.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,294.33,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $294.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,341.80,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $341.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,341.80,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $341.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER HEMOSTAR,C1750,HCPCS,278,RC,10022285,CDM,,,,both,,,474.7200,313.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,284.83,,,,,,,230.7100,474.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $474.72 in Billed Charges for Rev 278 Proc C1750 = $284.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,AETNA,AETNA HSHS,2790.72,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,790.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,AETNA,ALL COMMERCIAL AETNA,4320.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $4,320.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,ANTHEM,ANTHEM POS/HMO,2246.40,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,246.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,ANTHEM,ANTHEM PPO,2246.40,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,246.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4320.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $4,320.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,CENPATICO,ALL MEDICAID CENPATICO,4320.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $4,320.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3672.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,672.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,CIGNA,ALL COMMERCIAL CIGNA,3024.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,024.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,COFINITY,COFINITY,4320.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $4,320.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4104.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,3628.80,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,628.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3067.20,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,067.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3153.60,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,153.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,2099.52,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,099.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3672.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,672.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,HUMANA,HUMANA CHOICE CARE HMO,2160.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,160.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,HUMANA,HUMANA CHOICE CARE PPO,3672.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,672.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,HUMANA,HUMANA NATIIONAL POS HMO,2160.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,160.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3153.60,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,153.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,4320.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $4,320.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2160.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,160.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3628.80,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,628.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3240.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3974.40,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,974.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2757.46,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,757.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3110.40,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,110.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3110.40,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,110.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2678.40,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,678.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3110.40,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,110.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3110.40,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $3,110.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENOUS OUTFLOW 5MMX40CM,C1750,HCPCS,278,RC,10051302,CDM,,,,both,,,4320.0000,2851.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2592.00,,,,,,,2099.5200,4320.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,320.00 in Billed Charges for Rev 278 Proc C1750 = $2,592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,AETNA,AETNA HSHS,4634.14,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $4,634.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,AETNA,ALL COMMERCIAL AETNA,7173.59,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $7,173.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,ANTHEM,ANTHEM POS/HMO,3730.27,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,730.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,ANTHEM,ANTHEM PPO,3730.27,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,730.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7173.59,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $7,173.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,CENPATICO,ALL MEDICAID CENPATICO,7173.59,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $7,173.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6097.55,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $6,097.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,CIGNA,ALL COMMERCIAL CIGNA,5021.51,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,021.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,COFINITY,COFINITY,7173.59,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $7,173.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6814.91,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $6,814.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,6025.82,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $6,025.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5093.25,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,093.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5236.72,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,236.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,3486.36,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,486.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6097.55,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $6,097.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,HUMANA,HUMANA CHOICE CARE HMO,3586.80,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,586.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,HUMANA,HUMANA CHOICE CARE PPO,6097.55,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $6,097.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,HUMANA,HUMANA NATIIONAL POS HMO,3586.80,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,586.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5236.72,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,236.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,7173.59,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $7,173.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3586.80,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,586.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6025.82,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $6,025.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5380.19,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,380.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6599.70,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $6,599.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3586.80,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,586.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3586.80,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,586.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,PREVEA HEALTH NETWORK,PREVEA360,3586.80,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,586.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3586.80,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,586.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4578.90,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $4,578.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5164.98,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,164.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3342.89,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,342.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,UNITED HEALTHCARE,UHC ONEIDA NATION,3342.89,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,342.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,UNITED HEALTHCARE,UNITED HEALTHCARE,3342.89,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $3,342.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5164.98,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,164.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4447.63,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $4,447.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5164.98,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,164.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5164.98,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $5,164.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DECELLULARIZED ARTHROFLEX DERMIS LIFENET 40X70 2.5-3.5MM,C1762,HCPCS,278,RC,10075548,CDM,,,,both,,,7173.5900,4734.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4304.15,,,,,,,3342.8900,7173.5900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,173.59 in Billed Charges for Rev 278 Proc C1762 = $4,304.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,AETNA,AETNA HSHS,1532.05,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,532.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,AETNA,ALL COMMERCIAL AETNA,2371.60,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,371.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,ANTHEM,ANTHEM POS/HMO,1233.23,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,233.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,ANTHEM,ANTHEM PPO,1233.23,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,233.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2371.60,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,371.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,CENPATICO,ALL MEDICAID CENPATICO,2371.60,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,371.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2015.86,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,015.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,CIGNA,ALL COMMERCIAL CIGNA,1660.12,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,660.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,COFINITY,COFINITY,2371.60,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,371.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2253.02,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,253.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,1992.14,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,992.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1683.84,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,683.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1731.27,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,731.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,1152.60,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,152.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2015.86,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,015.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,HUMANA,HUMANA CHOICE CARE PPO,2015.86,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,015.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1731.27,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,731.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2371.60,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,371.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1185.80,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,185.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1992.14,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,992.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1778.70,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,778.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2181.87,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $2,181.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1513.79,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,513.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1707.55,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,707.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1707.55,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,707.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1470.39,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,470.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1707.55,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,707.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1707.55,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,707.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BIOCARTILAGE 1CC ARTHREX,C1762,HCPCS,278,RC,148-14163,CDM,,,,both,,,2371.6000,1565.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1422.96,,,,,,,1152.6000,2371.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,371.60 in Billed Charges for Rev 278 Proc C1762 = $1,422.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,AETNA,AETNA HSHS,1620.17,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,620.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,AETNA,ALL COMMERCIAL AETNA,2508.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,ANTHEM,ANTHEM POS/HMO,1304.16,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,304.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,ANTHEM,ANTHEM PPO,1304.16,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,304.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2508.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,CENPATICO,ALL MEDICAID CENPATICO,2508.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2131.80,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,131.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,CIGNA,ALL COMMERCIAL CIGNA,1755.60,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,755.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,COFINITY,COFINITY,2508.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2382.60,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,382.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,2106.72,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,106.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1780.68,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,780.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1830.84,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,830.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,1218.89,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,218.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2131.80,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,131.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,HUMANA,HUMANA CHOICE CARE HMO,1254.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,HUMANA,HUMANA CHOICE CARE PPO,2131.80,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,131.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,HUMANA,HUMANA NATIIONAL POS HMO,1254.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1830.84,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,830.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2508.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1254.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2106.72,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,106.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1881.00,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,881.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2307.36,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $2,307.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1600.86,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,600.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1805.76,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,805.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1805.76,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,805.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1554.96,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,554.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1805.76,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,805.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1805.76,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,805.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE FASCIA LATA TUTOPLAST,C1762,HCPCS,278,RC,10019777,CDM,,,,both,,,2508.0000,1655.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1504.80,,,,,,,1218.8900,2508.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,508.00 in Billed Charges for Rev 278 Proc C1762 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,AETNA,AETNA HSHS,443.06,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $443.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,AETNA,ALL COMMERCIAL AETNA,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,CENPATICO,ALL MEDICAID CENPATICO,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,582.97,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $582.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,CIGNA,ALL COMMERCIAL CIGNA,480.10,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $480.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,COFINITY,COFINITY,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,651.56,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $651.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,576.11,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $576.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,486.95,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $486.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,500.67,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $500.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,333.32,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $333.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,582.97,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $582.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,HUMANA,HUMANA CHOICE CARE PPO,582.97,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $582.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,500.67,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $500.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,685.85,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $685.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,342.93,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $342.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,576.11,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $576.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,514.39,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $514.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,630.98,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $630.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,437.78,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $437.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,493.81,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $493.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,493.81,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $493.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,425.23,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $425.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,493.81,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $493.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,493.81,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $493.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUTOPLAST SCLERA INNOVATIVE OPHTHALMIC 0.5CM X 0.8CM,C1762,HCPCS,278,RC,10021011,CDM,,,,both,,,685.8500,452.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,411.51,,,,,,,333.3200,685.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $685.85 in Billed Charges for Rev 278 Proc C1762 = $411.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,AETNA,AETNA HSHS,846.23,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $846.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,AETNA,ALL COMMERCIAL AETNA,1309.95,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,309.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,ANTHEM,ANTHEM POS/HMO,681.17,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $681.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,ANTHEM,ANTHEM PPO,681.17,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $681.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1309.95,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,309.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,CENPATICO,ALL MEDICAID CENPATICO,1309.95,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,309.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1113.46,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,113.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,CIGNA,ALL COMMERCIAL CIGNA,916.97,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $916.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,COFINITY,COFINITY,1309.95,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,309.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1244.45,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,244.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,1100.36,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,100.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,930.06,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $930.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,956.26,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $956.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,636.64,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $636.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1113.46,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,113.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,HUMANA,HUMANA CHOICE CARE PPO,1113.46,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,113.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,956.26,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $956.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1309.95,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,309.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,654.98,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $654.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1100.36,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,100.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,982.46,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $982.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1205.15,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $1,205.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,836.14,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $836.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,943.16,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $943.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,943.16,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $943.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,812.17,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $812.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,943.16,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $943.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,943.16,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $943.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 8X14-20MM,C1762,HCPCS,278,RC,10074989,CDM,,,,both,,,1309.9500,864.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,785.97,,,,,,,636.6400,1309.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,309.95 in Billed Charges for Rev 278 Proc C1762 = $785.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,AETNA,AETNA HSHS,840.98,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $840.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,AETNA,ALL COMMERCIAL AETNA,1301.83,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,ANTHEM,ANTHEM POS/HMO,676.95,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $676.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,ANTHEM,ANTHEM PPO,676.95,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $676.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1301.83,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,CENPATICO,ALL MEDICAID CENPATICO,1301.83,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1106.56,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,106.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,CIGNA,ALL COMMERCIAL CIGNA,911.28,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $911.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,COFINITY,COFINITY,1301.83,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1236.74,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,236.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,1093.54,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,093.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,924.30,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $924.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,950.34,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $950.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,632.69,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $632.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1106.56,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,106.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,HUMANA,HUMANA CHOICE CARE PPO,1106.56,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,106.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,950.34,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $950.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1301.83,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,301.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,650.92,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $650.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1093.54,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,093.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,976.37,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $976.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1197.68,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $1,197.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,830.96,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $830.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,937.32,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $937.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,937.32,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $937.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,807.13,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $807.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,937.32,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $937.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,937.32,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $937.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 8X12CM,C1763,HCPCS,278,RC,10065393,CDM,,,,both,,,1301.8300,859.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,781.10,,,,,,,632.6900,1301.8300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,301.83 in Billed Charges for Rev 278 Proc C1763 = $781.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,AETNA,AETNA HSHS,2052.21,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,052.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,AETNA,ALL COMMERCIAL AETNA,3176.80,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $3,176.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,ANTHEM,ANTHEM POS/HMO,1651.94,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $1,651.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,ANTHEM,ANTHEM PPO,1651.94,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $1,651.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3176.80,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $3,176.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,CENPATICO,ALL MEDICAID CENPATICO,3176.80,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $3,176.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2700.28,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,700.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,CIGNA,ALL COMMERCIAL CIGNA,2223.76,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,223.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,COFINITY,COFINITY,3176.80,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $3,176.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3017.96,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $3,017.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,2668.51,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,668.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2255.53,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,255.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2319.06,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,319.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,1543.92,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $1,543.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2700.28,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,700.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,HUMANA,HUMANA CHOICE CARE HMO,1588.40,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $1,588.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,HUMANA,HUMANA CHOICE CARE PPO,2700.28,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,700.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,HUMANA,HUMANA NATIIONAL POS HMO,1588.40,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $1,588.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2319.06,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,319.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,3176.80,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $3,176.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1588.40,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $1,588.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2668.51,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,668.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2382.60,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,382.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2922.66,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,922.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2027.75,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,027.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2287.30,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,287.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2287.30,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,287.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1969.62,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $1,969.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2287.30,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,287.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2287.30,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $2,287.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT SFT TIS 12X8CM XENFORM PELV FLR FTL BOVN DERM MTRX,C1763,HCPCS,278,RC,10029486,CDM,,,,both,,,3176.8000,2096.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1906.08,,,,,,,1543.9200,3176.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,176.80 in Billed Charges for Rev 278 Proc C1763 = $1,906.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,AETNA,AETNA HSHS,331.17,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $331.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,AETNA,ALL COMMERCIAL AETNA,512.65,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $512.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,512.65,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $512.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,CENPATICO,ALL MEDICAID CENPATICO,512.65,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $512.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,435.75,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $435.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,CIGNA,ALL COMMERCIAL CIGNA,358.86,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $358.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,COFINITY,COFINITY,512.65,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $512.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,487.02,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $487.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,430.63,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $430.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,363.98,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $363.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,374.23,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $374.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,249.15,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $249.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,435.75,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $435.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,HUMANA,HUMANA CHOICE CARE PPO,435.75,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $435.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,374.23,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $374.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,512.65,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $512.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,256.33,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $256.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,430.63,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $430.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,384.49,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $384.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,471.64,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $471.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,327.22,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $327.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,369.11,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $369.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,369.11,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $369.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,317.84,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $317.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,369.11,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $369.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,369.11,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $369.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH DURAMATRIX ONLAY 1X1IN  (CDSLM11),C1763,HCPCS,278,RC,10083836,CDM,,,,both,,,512.6500,338.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,307.59,,,,,,,249.1500,512.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $512.65 in Billed Charges for Rev 278 Proc C1763 = $307.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,AETNA,AETNA HSHS,1850.73,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,850.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,AETNA,ALL COMMERCIAL AETNA,2864.90,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,864.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,ANTHEM,ANTHEM POS/HMO,1489.75,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,489.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,ANTHEM,ANTHEM PPO,1489.75,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,489.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2864.90,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,864.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,CENPATICO,ALL MEDICAID CENPATICO,2864.90,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,864.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2435.17,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,435.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,CIGNA,ALL COMMERCIAL CIGNA,2005.43,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,005.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,COFINITY,COFINITY,2864.90,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,864.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2721.66,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,721.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,2406.52,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,406.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2034.08,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,034.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2091.38,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,091.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,1392.34,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,392.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2435.17,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,435.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,HUMANA,HUMANA CHOICE CARE HMO,1432.45,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,432.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,HUMANA,HUMANA CHOICE CARE PPO,2435.17,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,435.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,HUMANA,HUMANA NATIIONAL POS HMO,1432.45,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,432.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2091.38,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,091.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,2864.90,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,864.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1432.45,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,432.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2406.52,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,406.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2148.68,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,148.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2635.71,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,635.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1828.67,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,828.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2062.73,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,062.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2062.73,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,062.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1776.24,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,776.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2062.73,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,062.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2062.73,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $2,062.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 4 X 5,C1763,HCPCS,278,RC,10017534,CDM,,,,both,,,2864.9000,1890.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1718.94,,,,,,,1392.3400,2864.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,864.90 in Billed Charges for Rev 278 Proc C1763 = $1,718.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,AETNA,AETNA HSHS,13988.95,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $13,988.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,AETNA,ALL COMMERCIAL AETNA,21654.72,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $21,654.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,ANTHEM,ANTHEM POS/HMO,11260.45,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $11,260.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,ANTHEM,ANTHEM PPO,11260.45,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $11,260.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,21654.72,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $21,654.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,CENPATICO,ALL MEDICAID CENPATICO,21654.72,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $21,654.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18406.51,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $18,406.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,CIGNA,ALL COMMERCIAL CIGNA,15158.30,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $15,158.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,COFINITY,COFINITY,21654.72,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $21,654.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,20571.98,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $20,571.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,18189.96,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $18,189.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15374.85,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $15,374.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15807.95,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $15,807.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,10524.19,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,524.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18406.51,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $18,406.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,HUMANA,HUMANA CHOICE CARE HMO,10827.36,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,827.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,HUMANA,HUMANA CHOICE CARE PPO,18406.51,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $18,406.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,HUMANA,HUMANA NATIIONAL POS HMO,10827.36,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,827.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15807.95,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $15,807.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,21654.72,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $21,654.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10827.36,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,827.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18189.96,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $18,189.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16241.04,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $16,241.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,19922.34,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $19,922.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10827.36,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,827.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10827.36,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,827.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,PREVEA HEALTH NETWORK,PREVEA360,10827.36,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,827.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10827.36,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,827.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13822.21,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $13,822.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15591.40,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $15,591.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10091.10,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,091.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,10091.10,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,091.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,10091.10,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $10,091.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15591.40,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $15,591.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13425.93,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $13,425.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15591.40,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $15,591.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15591.40,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $15,591.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NEUROSTIMULATOR MEDTRONIC,C1767,HCPCS,278,RC,10041909,CDM,,,,both,,,21654.7200,14292.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12992.83,,,,,,,10091.1000,21654.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $21,654.72 in Billed Charges for Rev 278 Proc C1767 = $12,992.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,AETNA,AETNA HSHS,1067.39,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,067.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,AETNA,ALL COMMERCIAL AETNA,1652.30,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,652.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,ANTHEM,ANTHEM POS/HMO,859.20,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $859.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,ANTHEM,ANTHEM PPO,859.20,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $859.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1652.30,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,652.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,CENPATICO,ALL MEDICAID CENPATICO,1652.30,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,652.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1404.46,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,404.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,CIGNA,ALL COMMERCIAL CIGNA,1156.61,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,156.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,COFINITY,COFINITY,1652.30,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,652.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1569.69,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,569.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,1387.93,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,387.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1173.13,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,173.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1206.18,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,206.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,803.02,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $803.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1404.46,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,404.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,HUMANA,HUMANA CHOICE CARE PPO,1404.46,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,404.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1206.18,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,206.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1652.30,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,652.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,826.15,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $826.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1387.93,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,387.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1239.23,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,239.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1520.12,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,520.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1054.66,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,054.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1189.66,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,189.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1189.66,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,189.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1024.43,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,024.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1189.66,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,189.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1189.66,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $1,189.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
NRSTM IMPL VNS THERPY DEMIPULSE .4IN VAGUS NERVE SIL ACC PK,C1767,HCPCS,278,RC,10016218,CDM,,,,both,,,1652.3000,1090.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,991.38,,,,,,,803.0200,1652.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,652.30 in Billed Charges for Rev 278 Proc C1767 = $991.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,AETNA,AETNA HSHS,102.77,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $102.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,AETNA,ALL COMMERCIAL AETNA,159.08,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $159.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,159.08,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $159.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,CENPATICO,ALL MEDICAID CENPATICO,159.08,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $159.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,135.22,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $135.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,CIGNA,ALL COMMERCIAL CIGNA,111.36,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $111.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,COFINITY,COFINITY,159.08,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $159.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,151.13,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $151.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,133.63,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $133.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,112.95,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $112.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,116.13,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $116.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,77.31,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $77.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,135.22,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $135.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,HUMANA,HUMANA CHOICE CARE PPO,135.22,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $135.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,116.13,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $116.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,159.08,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $159.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,79.54,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $79.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,133.63,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $133.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,119.31,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $119.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,146.35,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $146.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,101.54,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $101.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,114.54,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $114.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,114.54,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $114.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,98.63,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $98.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,114.54,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $114.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,114.54,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $114.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FELT CV 4X4IN THK1.65MM PTFE PTCH STER,C1768,HCPCS,278,RC,10051896,CDM,,,,both,,,159.0800,104.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,95.45,,,,,,,77.3100,159.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $159.08 in Billed Charges for Rev 278 Proc C1768 = $95.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,AETNA,AETNA HSHS,1350.14,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,350.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,AETNA,ALL COMMERCIAL AETNA,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,ANTHEM,ANTHEM POS/HMO,1086.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,086.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,ANTHEM,ANTHEM PPO,1086.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,086.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,CENPATICO,ALL MEDICAID CENPATICO,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1776.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,776.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,CIGNA,ALL COMMERCIAL CIGNA,1463.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,463.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,COFINITY,COFINITY,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1985.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,985.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,1755.60,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,755.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1483.90,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,483.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1525.70,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,525.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,1015.74,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,015.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1776.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,776.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,HUMANA,HUMANA CHOICE CARE PPO,1776.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,776.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1525.70,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,525.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2090.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $2,090.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1045.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,045.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1755.60,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,755.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1567.50,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,567.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1922.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,922.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1334.05,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,334.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1504.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1504.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1295.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,295.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1504.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1504.80,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,504.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ARTERIAL COMPONENT 6MMX53CM,C1768,HCPCS,278,RC,10040000,CDM,,,,both,,,2090.0000,1379.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1254.00,,,,,,,1015.7400,2090.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,090.00 in Billed Charges for Rev 278 Proc C1768 = $1,254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,AETNA,AETNA HSHS,2417.36,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,417.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,AETNA,ALL COMMERCIAL AETNA,3742.05,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,742.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,ANTHEM,ANTHEM POS/HMO,1945.87,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $1,945.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,ANTHEM,ANTHEM PPO,1945.87,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $1,945.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3742.05,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,742.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,CENPATICO,ALL MEDICAID CENPATICO,3742.05,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,742.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3180.74,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,180.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,CIGNA,ALL COMMERCIAL CIGNA,2619.44,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,619.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,COFINITY,COFINITY,3742.05,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,742.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3554.95,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,554.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,3143.32,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,143.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2656.86,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,656.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2731.70,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,731.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,1818.64,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $1,818.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3180.74,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,180.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,HUMANA,HUMANA CHOICE CARE HMO,1871.03,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $1,871.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,HUMANA,HUMANA CHOICE CARE PPO,3180.74,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,180.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,HUMANA,HUMANA NATIIONAL POS HMO,1871.03,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $1,871.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2731.70,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,731.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,3742.05,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,742.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1871.03,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $1,871.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3143.32,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,143.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2806.54,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,806.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3442.69,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $3,442.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2388.55,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,388.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2694.28,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,694.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2694.28,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,694.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2320.07,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,320.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2694.28,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,694.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2694.28,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,694.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003893,CDM,,,,both,,,3742.0500,2469.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2245.23,,,,,,,1818.6400,3742.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,742.05 in Billed Charges for Rev 278 Proc C1768 = $2,245.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,AETNA,AETNA HSHS,44.51,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $44.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,AETNA,ALL COMMERCIAL AETNA,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,CENPATICO,ALL MEDICAID CENPATICO,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.57,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $58.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,CIGNA,ALL COMMERCIAL CIGNA,48.23,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $48.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,COFINITY,COFINITY,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.46,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $65.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,57.88,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $57.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.92,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $48.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.30,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $50.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,33.49,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $33.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.57,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $58.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,HUMANA,HUMANA CHOICE CARE PPO,58.57,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $58.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.30,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $50.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.45,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $34.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.88,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $57.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.68,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $51.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.39,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $63.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.98,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $43.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.61,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $49.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.61,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $49.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.72,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $42.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.61,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $49.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.61,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $49.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10052516,CDM,,,,both,,,68.9000,45.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.34,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.90 in Billed Charges for Rev 278 Proc C1713 = $41.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,AETNA,AETNA HSHS,40.94,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $40.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,AETNA,ALL COMMERCIAL AETNA,63.38,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $63.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,63.38,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $63.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,CENPATICO,ALL MEDICAID CENPATICO,63.38,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $63.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,53.87,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $53.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,CIGNA,ALL COMMERCIAL CIGNA,44.37,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $44.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,COFINITY,COFINITY,63.38,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $63.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,60.21,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $60.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,53.24,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $53.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,45.00,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,46.27,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $46.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,30.80,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $30.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,53.87,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $53.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,HUMANA,HUMANA CHOICE CARE PPO,53.87,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $53.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,46.27,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $46.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,63.38,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $63.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,31.69,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $31.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,53.24,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $53.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,47.54,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $47.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,58.31,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $58.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,40.46,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $40.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,45.63,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $45.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,45.63,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $45.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,39.30,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $39.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,45.63,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $45.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,45.63,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $45.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.7 TI CORTEX  6MM,C1713,HCPCS,278,RC,70412572,CDM,,,,both,,,63.3800,41.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,38.03,,,,,,,30.8000,63.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $63.38 in Billed Charges for Rev 278 Proc C1713 = $38.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,AETNA,AETNA HSHS,188.81,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $188.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,AETNA,ALL COMMERCIAL AETNA,292.28,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $292.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,292.28,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $292.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,CENPATICO,ALL MEDICAID CENPATICO,292.28,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $292.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,248.44,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $248.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,CIGNA,ALL COMMERCIAL CIGNA,204.60,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $204.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,COFINITY,COFINITY,292.28,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $292.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,277.67,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $277.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,245.52,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $245.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,207.52,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,213.36,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $213.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,142.05,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $142.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,248.44,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $248.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,HUMANA,HUMANA CHOICE CARE PPO,248.44,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $248.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,213.36,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $213.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,292.28,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $292.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,146.14,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $146.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,245.52,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $245.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,219.21,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $219.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,268.90,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $268.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,186.56,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $186.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,210.44,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $210.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,210.44,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $210.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,181.21,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $181.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,210.44,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $210.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,210.44,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $210.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10049512,CDM,,,,both,,,292.2800,192.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,175.37,,,,,,,142.0500,292.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $292.28 in Billed Charges for Rev 278 Proc C1713 = $175.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,AETNA,AETNA HSHS,331.85,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $331.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,AETNA,ALL COMMERCIAL AETNA,513.70,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $513.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,513.70,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $513.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,CENPATICO,ALL MEDICAID CENPATICO,513.70,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $513.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,436.65,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $436.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,CIGNA,ALL COMMERCIAL CIGNA,359.59,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $359.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,COFINITY,COFINITY,513.70,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $513.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,488.02,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $488.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,431.51,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $431.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,364.73,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $364.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,375.00,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,249.66,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $249.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,436.65,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $436.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,HUMANA,HUMANA CHOICE CARE PPO,436.65,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $436.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,375.00,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,513.70,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $513.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,256.85,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $256.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,431.51,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $431.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,385.28,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $385.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,472.60,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $472.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,327.89,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $327.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,369.86,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $369.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,369.86,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $369.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,318.49,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $318.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,369.86,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $369.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,369.86,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $369.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM LOCKING SELF-TAPPING 8MM,C1713,HCPCS,278,RC,10037526,CDM,,,,both,,,513.7000,339.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,308.22,,,,,,,249.6600,513.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $513.70 in Billed Charges for Rev 278 Proc C1713 = $308.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,AETNA,AETNA HSHS,163.39,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $163.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,AETNA,ALL COMMERCIAL AETNA,252.92,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $252.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,252.92,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $252.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,CENPATICO,ALL MEDICAID CENPATICO,252.92,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $252.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,214.98,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $214.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,CIGNA,ALL COMMERCIAL CIGNA,177.04,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $177.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,COFINITY,COFINITY,252.92,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $252.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,240.27,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $240.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,212.45,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $212.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,179.57,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $179.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,184.63,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $184.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,122.92,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $122.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,214.98,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $214.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,HUMANA,HUMANA CHOICE CARE PPO,214.98,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $214.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,184.63,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $184.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,252.92,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $252.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,126.46,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $126.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,212.45,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $212.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,189.69,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $189.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,232.69,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $232.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,161.44,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $161.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,182.10,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $182.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,182.10,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $182.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,156.81,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $156.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,182.10,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $182.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,182.10,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $182.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCREW SYNTHES 2.9MM NON-LOCKING SELF-TAPPING 6MM,C1713,HCPCS,278,RC,70901611,CDM,,,,both,,,252.9200,166.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,151.75,,,,,,,122.9200,252.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $252.92 in Billed Charges for Rev 278 Proc C1713 = $151.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,AETNA,AETNA HSHS,256.63,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $256.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,AETNA,ALL COMMERCIAL AETNA,397.26,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $397.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,397.26,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $397.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,CENPATICO,ALL MEDICAID CENPATICO,397.26,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $397.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,337.67,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $337.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,CIGNA,ALL COMMERCIAL CIGNA,278.08,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $278.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,COFINITY,COFINITY,397.26,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $397.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,377.40,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $377.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,333.70,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $333.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,282.05,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $282.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,290.00,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $290.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,193.07,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $193.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,337.67,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $337.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,HUMANA,HUMANA CHOICE CARE PPO,337.67,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $337.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,290.00,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $290.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,397.26,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $397.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,198.63,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $198.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,333.70,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $333.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,297.95,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $297.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,365.48,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $365.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,253.57,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $253.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,286.03,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $286.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,286.03,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $286.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,246.30,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $246.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,286.03,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $286.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,286.03,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $286.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025965,CDM,,,,both,,,397.2600,262.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,238.36,,,,,,,193.0700,397.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $397.26 in Billed Charges for Rev 278 Proc C1713 = $238.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,AETNA,AETNA HSHS,269.63,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $269.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,AETNA,ALL COMMERCIAL AETNA,417.38,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $417.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,417.38,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $417.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,CENPATICO,ALL MEDICAID CENPATICO,417.38,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $417.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,354.77,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $354.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,CIGNA,ALL COMMERCIAL CIGNA,292.17,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $292.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,COFINITY,COFINITY,417.38,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $417.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,396.51,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $396.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,350.60,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $350.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,296.34,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $296.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,304.69,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $304.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,202.85,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $202.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,354.77,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $354.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,HUMANA,HUMANA CHOICE CARE PPO,354.77,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $354.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,304.69,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $304.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,417.38,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $417.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,208.69,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $208.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,350.60,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $350.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,313.04,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $313.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,383.99,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $383.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,266.41,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $266.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,300.51,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $300.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,300.51,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $300.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,258.78,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $258.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,300.51,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $300.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,300.51,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $300.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,70403346,CDM,,,,both,,,417.3800,275.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,250.43,,,,,,,202.8500,417.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $417.38 in Billed Charges for Rev 278 Proc C1713 = $250.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,AETNA,AETNA HSHS,208.33,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $208.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,AETNA,ALL COMMERCIAL AETNA,322.49,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $322.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,322.49,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $322.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,CENPATICO,ALL MEDICAID CENPATICO,322.49,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $322.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,274.12,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $274.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,CIGNA,ALL COMMERCIAL CIGNA,225.74,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $225.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,COFINITY,COFINITY,322.49,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $322.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,306.37,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $306.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,270.89,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $270.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,228.97,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $228.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,235.42,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $235.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,156.73,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $156.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,274.12,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $274.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,HUMANA,HUMANA CHOICE CARE PPO,274.12,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $274.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,235.42,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $235.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,322.49,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $322.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,161.25,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $161.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,270.89,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $270.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,241.87,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $241.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,296.69,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $296.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,205.85,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $205.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,232.19,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $232.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,232.19,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $232.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,199.94,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $199.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,232.19,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $232.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,232.19,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $232.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10032300,CDM,,,,both,,,322.4900,212.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,193.49,,,,,,,156.7300,322.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $322.49 in Billed Charges for Rev 278 Proc C1713 = $193.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,AETNA,AETNA HSHS,206.55,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $206.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,AETNA,ALL COMMERCIAL AETNA,319.73,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $319.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,319.73,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $319.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,CENPATICO,ALL MEDICAID CENPATICO,319.73,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $319.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,271.77,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $271.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,CIGNA,ALL COMMERCIAL CIGNA,223.81,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $223.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,COFINITY,COFINITY,319.73,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $319.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,303.74,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $303.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,268.57,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $268.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,227.01,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $227.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,233.40,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $233.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,155.39,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $155.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,271.77,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $271.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,HUMANA,HUMANA CHOICE CARE PPO,271.77,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $271.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,233.40,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $233.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,319.73,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $319.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,159.87,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $159.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,268.57,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $268.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,239.80,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $239.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,294.15,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $294.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,204.08,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $204.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,230.21,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $230.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,230.21,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $230.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,198.23,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $198.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,230.21,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $230.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,230.21,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $230.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10025179,CDM,,,,both,,,319.7300,211.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,191.84,,,,,,,155.3900,319.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $319.73 in Billed Charges for Rev 278 Proc C1713 = $191.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,AETNA,AETNA HSHS,2263.33,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,263.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,AETNA,ALL COMMERCIAL AETNA,3503.60,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $3,503.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,ANTHEM,ANTHEM POS/HMO,1821.87,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $1,821.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,ANTHEM,ANTHEM PPO,1821.87,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $1,821.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3503.60,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $3,503.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,CENPATICO,ALL MEDICAID CENPATICO,3503.60,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $3,503.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2978.06,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,978.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,CIGNA,ALL COMMERCIAL CIGNA,2452.52,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,452.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,COFINITY,COFINITY,3503.60,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $3,503.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3328.42,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $3,328.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,2943.02,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,943.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2487.56,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,487.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2557.63,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,557.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,1702.75,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $1,702.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2978.06,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,978.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,HUMANA,HUMANA CHOICE CARE HMO,1751.80,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $1,751.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,HUMANA,HUMANA CHOICE CARE PPO,2978.06,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,978.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,HUMANA,HUMANA NATIIONAL POS HMO,1751.80,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $1,751.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2557.63,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,557.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3503.60,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $3,503.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1751.80,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $1,751.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2943.02,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,943.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2627.70,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,627.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3223.31,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $3,223.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2236.35,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,236.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2522.59,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,522.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2522.59,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,522.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2172.23,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,172.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2522.59,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,522.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2522.59,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,522.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 80MM SMALL BEAD FLEX,C1768,HCPCS,278,RC,10005970,CDM,,,,both,,,3503.6000,2312.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2102.16,,,,,,,1702.7500,3503.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,503.60 in Billed Charges for Rev 278 Proc C1768 = $2,102.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,AETNA,AETNA HSHS,2858.16,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,858.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,AETNA,ALL COMMERCIAL AETNA,4424.40,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $4,424.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,ANTHEM,ANTHEM POS/HMO,2300.69,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,300.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,ANTHEM,ANTHEM PPO,2300.69,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,300.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4424.40,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $4,424.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,CENPATICO,ALL MEDICAID CENPATICO,4424.40,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $4,424.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3760.74,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,760.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,CIGNA,ALL COMMERCIAL CIGNA,3097.08,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,097.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,COFINITY,COFINITY,4424.40,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $4,424.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4203.18,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $4,203.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,3716.50,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,716.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3141.32,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,141.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3229.81,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,229.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,2150.26,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,150.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3760.74,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,760.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,HUMANA,HUMANA CHOICE CARE HMO,2212.20,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,212.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,HUMANA,HUMANA CHOICE CARE PPO,3760.74,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,760.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,HUMANA,HUMANA NATIIONAL POS HMO,2212.20,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,212.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3229.81,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,229.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,4424.40,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $4,424.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2212.20,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,212.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3716.50,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,716.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3318.30,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,318.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4070.45,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $4,070.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2824.09,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,824.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3185.57,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,185.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3185.57,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,185.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2743.13,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,743.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3185.57,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,185.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3185.57,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $3,185.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 90CM MINI CUFF BYPASS,C1768,HCPCS,278,RC,10038302,CDM,,,,both,,,4424.4000,2920.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2654.64,,,,,,,2150.2600,4424.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,424.40 in Billed Charges for Rev 278 Proc C1768 = $2,654.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,AETNA,AETNA HSHS,671.42,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $671.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,AETNA,ALL COMMERCIAL AETNA,1039.35,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $1,039.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,ANTHEM,ANTHEM POS/HMO,540.46,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $540.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,ANTHEM,ANTHEM PPO,540.46,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $540.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1039.35,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $1,039.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,CENPATICO,ALL MEDICAID CENPATICO,1039.35,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $1,039.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,883.45,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $883.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,CIGNA,ALL COMMERCIAL CIGNA,727.55,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $727.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,COFINITY,COFINITY,1039.35,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $1,039.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,987.38,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $987.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,873.05,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $873.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,737.94,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $737.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,758.73,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $758.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,505.12,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $505.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,883.45,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $883.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,HUMANA,HUMANA CHOICE CARE PPO,883.45,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $883.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,758.73,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $758.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1039.35,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $1,039.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,519.68,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $519.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,873.05,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $873.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,779.51,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $779.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,956.20,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $956.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,663.42,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $663.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,748.33,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $748.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,748.33,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $748.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,644.40,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $644.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,748.33,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $748.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,748.33,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $748.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,70200844,CDM,,,,both,,,1039.3500,685.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,623.61,,,,,,,505.1200,1039.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,039.35 in Billed Charges for Rev 278 Proc C1768 = $623.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,AETNA,AETNA HSHS,878.01,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $878.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,AETNA,ALL COMMERCIAL AETNA,1359.15,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,359.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,ANTHEM,ANTHEM POS/HMO,706.76,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $706.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,ANTHEM,ANTHEM PPO,706.76,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $706.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1359.15,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,359.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,CENPATICO,ALL MEDICAID CENPATICO,1359.15,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,359.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1155.28,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,155.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,CIGNA,ALL COMMERCIAL CIGNA,951.41,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $951.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,COFINITY,COFINITY,1359.15,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,359.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1291.19,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,291.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,1141.69,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,141.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,965.00,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $965.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,992.18,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $992.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,660.55,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $660.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1155.28,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,155.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,HUMANA,HUMANA CHOICE CARE PPO,1155.28,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,155.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,992.18,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $992.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1359.15,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,359.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,679.58,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $679.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1141.69,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,141.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1019.36,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,019.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1250.42,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $1,250.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,867.55,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $867.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,978.59,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $978.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,978.59,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $978.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,842.67,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $842.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,978.59,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $978.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,978.59,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $978.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10070524,CDM,,,,both,,,1359.1500,897.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,815.49,,,,,,,660.5500,1359.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,359.15 in Billed Charges for Rev 278 Proc C1768 = $815.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,AETNA,AETNA HSHS,3197.70,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,197.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,AETNA,ALL COMMERCIAL AETNA,4950.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,ANTHEM,ANTHEM POS/HMO,2574.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $2,574.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,ANTHEM,ANTHEM PPO,2574.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $2,574.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4950.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,CENPATICO,ALL MEDICAID CENPATICO,4950.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4207.50,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,207.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,CIGNA,ALL COMMERCIAL CIGNA,3465.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,COFINITY,COFINITY,4950.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4702.50,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,702.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,4158.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,158.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3514.50,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,514.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3613.50,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,613.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,2405.70,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $2,405.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4207.50,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,207.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,HUMANA,HUMANA CHOICE CARE HMO,2475.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $2,475.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,HUMANA,HUMANA CHOICE CARE PPO,4207.50,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,207.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,HUMANA,HUMANA NATIIONAL POS HMO,2475.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $2,475.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3613.50,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,613.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,4950.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,950.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2475.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $2,475.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4158.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,158.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3712.50,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,712.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4554.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $4,554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3159.59,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,159.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3564.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3564.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3069.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,069.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3564.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3564.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $3,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064864,CDM,,,,both,,,4950.0000,3267.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2970.00,,,,,,,2405.7000,4950.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,950.00 in Billed Charges for Rev 278 Proc C1768 = $2,970.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,AETNA,AETNA HSHS,983.95,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $983.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,AETNA,ALL COMMERCIAL AETNA,1523.15,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,523.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,ANTHEM,ANTHEM POS/HMO,792.04,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $792.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,ANTHEM,ANTHEM PPO,792.04,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $792.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1523.15,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,523.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,CENPATICO,ALL MEDICAID CENPATICO,1523.15,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,523.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1294.68,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,294.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,CIGNA,ALL COMMERCIAL CIGNA,1066.21,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,066.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,COFINITY,COFINITY,1523.15,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,523.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1446.99,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,446.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,1279.45,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,279.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1081.44,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,081.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1111.90,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,111.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,740.25,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $740.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1294.68,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,294.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,HUMANA,HUMANA CHOICE CARE PPO,1294.68,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,294.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1111.90,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,111.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1523.15,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,523.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,761.58,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $761.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1279.45,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,279.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1142.36,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,142.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1401.30,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,401.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,972.23,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $972.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1096.67,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,096.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1096.67,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,096.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,944.35,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $944.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1096.67,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,096.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1096.67,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $1,096.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL 10MM X 80CM,C1768,HCPCS,278,RC,10000098,CDM,,,,both,,,1523.1500,1005.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,913.89,,,,,,,740.2500,1523.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,523.15 in Billed Charges for Rev 278 Proc C1768 = $913.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,AETNA,AETNA HSHS,670.10,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $670.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,AETNA,ALL COMMERCIAL AETNA,1037.30,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $1,037.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,ANTHEM,ANTHEM POS/HMO,539.40,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $539.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,ANTHEM,ANTHEM PPO,539.40,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $539.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1037.30,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $1,037.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,CENPATICO,ALL MEDICAID CENPATICO,1037.30,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $1,037.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,881.71,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $881.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,CIGNA,ALL COMMERCIAL CIGNA,726.11,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $726.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,COFINITY,COFINITY,1037.30,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $1,037.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,985.44,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $985.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,871.33,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $871.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,736.48,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $736.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,757.23,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $757.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,504.13,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $504.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,881.71,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $881.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,HUMANA,HUMANA CHOICE CARE PPO,881.71,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $881.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,757.23,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $757.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1037.30,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $1,037.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,518.65,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $518.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,871.33,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $871.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,777.98,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $777.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,954.32,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $954.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,662.11,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $662.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,746.86,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $746.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,746.86,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $746.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,643.13,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $643.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,746.86,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $746.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,746.86,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $746.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX STANDARD WALL TAPERED 4-7 X 40,C1768,HCPCS,278,RC,10000100,CDM,,,,both,,,1037.3000,684.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,622.38,,,,,,,504.1300,1037.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,037.30 in Billed Charges for Rev 278 Proc C1768 = $622.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,AETNA,AETNA HSHS,1244.58,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,244.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,AETNA,ALL COMMERCIAL AETNA,1926.60,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,ANTHEM,ANTHEM POS/HMO,1001.83,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,001.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,ANTHEM,ANTHEM PPO,1001.83,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,001.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1926.60,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,CENPATICO,ALL MEDICAID CENPATICO,1926.60,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1637.61,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,637.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,CIGNA,ALL COMMERCIAL CIGNA,1348.62,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,348.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,COFINITY,COFINITY,1926.60,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1830.27,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,830.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,1618.34,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,618.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1367.89,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,367.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1406.42,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,406.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,936.33,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $936.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1637.61,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,637.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,HUMANA,HUMANA CHOICE CARE PPO,1637.61,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,637.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1406.42,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,406.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1926.60,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,963.30,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $963.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1618.34,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,618.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1444.95,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,444.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1772.47,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,772.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1229.75,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,229.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1387.15,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,387.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1387.15,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,387.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1194.49,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,194.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1387.15,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,387.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1387.15,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,387.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10044901,CDM,,,,both,,,1926.6000,1271.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1155.96,,,,,,,936.3300,1926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,926.60 in Billed Charges for Rev 278 Proc C1768 = $1,155.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,AETNA,AETNA HSHS,242.73,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $242.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,AETNA,ALL COMMERCIAL AETNA,375.75,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $375.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,375.75,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $375.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,CENPATICO,ALL MEDICAID CENPATICO,375.75,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $375.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,319.39,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $319.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,CIGNA,ALL COMMERCIAL CIGNA,263.03,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $263.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,COFINITY,COFINITY,375.75,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $375.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,356.96,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $356.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,315.63,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $315.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,266.78,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $266.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,274.30,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $274.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,182.61,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $182.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,319.39,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $319.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,HUMANA,HUMANA CHOICE CARE PPO,319.39,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $319.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,274.30,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $274.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,375.75,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $375.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,187.88,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $187.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,315.63,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $315.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,281.81,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $281.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,345.69,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $345.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,239.84,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $239.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,270.54,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $270.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,270.54,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $270.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,232.97,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $232.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,270.54,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $270.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,270.54,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $270.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORE-TEX THIN WALL 6MM  X 10CM,C1768,HCPCS,278,RC,10000114,CDM,,,,both,,,375.7500,248.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,225.45,,,,,,,182.6100,375.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $375.75 in Billed Charges for Rev 278 Proc C1768 = $225.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,AETNA,AETNA HSHS,1132.28,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,132.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,AETNA,ALL COMMERCIAL AETNA,1752.75,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,752.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,ANTHEM,ANTHEM POS/HMO,911.43,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $911.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,ANTHEM,ANTHEM PPO,911.43,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $911.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1752.75,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,752.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,CENPATICO,ALL MEDICAID CENPATICO,1752.75,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,752.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1489.84,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,489.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,CIGNA,ALL COMMERCIAL CIGNA,1226.93,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,226.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,COFINITY,COFINITY,1752.75,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,752.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1665.11,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,665.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,1472.31,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,472.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1244.45,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,244.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1279.51,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,279.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,851.84,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $851.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1489.84,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,489.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,HUMANA,HUMANA CHOICE CARE PPO,1489.84,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,489.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1279.51,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,279.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1752.75,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,752.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,876.38,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $876.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1472.31,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,472.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1314.56,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,314.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1612.53,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,612.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1118.78,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,118.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1261.98,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,261.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1261.98,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,261.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1086.71,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,086.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1261.98,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,261.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1261.98,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,261.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 5 X 50CM,C1768,HCPCS,278,RC,10066586,CDM,,,,both,,,1752.7500,1156.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1051.65,,,,,,,851.8400,1752.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,752.75 in Billed Charges for Rev 278 Proc C1768 = $1,051.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,AETNA,AETNA HSHS,2292.78,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,292.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,AETNA,ALL COMMERCIAL AETNA,3549.20,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,549.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,ANTHEM,ANTHEM POS/HMO,1845.58,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $1,845.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,ANTHEM,ANTHEM PPO,1845.58,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $1,845.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3549.20,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,549.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,CENPATICO,ALL MEDICAID CENPATICO,3549.20,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,549.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3016.82,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,016.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,CIGNA,ALL COMMERCIAL CIGNA,2484.44,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,484.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,COFINITY,COFINITY,3549.20,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,549.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3371.74,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,371.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,2981.33,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,981.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2519.93,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,519.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2590.92,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,590.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,1724.91,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $1,724.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3016.82,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,016.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,HUMANA,HUMANA CHOICE CARE HMO,1774.60,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $1,774.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,HUMANA,HUMANA CHOICE CARE PPO,3016.82,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,016.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,HUMANA,HUMANA NATIIONAL POS HMO,1774.60,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $1,774.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2590.92,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,590.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,3549.20,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,549.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1774.60,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $1,774.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2981.33,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,981.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2661.90,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,661.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3265.26,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $3,265.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2265.45,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,265.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2555.42,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,555.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2555.42,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,555.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2200.50,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,200.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2555.42,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,555.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2555.42,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,555.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 100 CM TW RING,C1768,HCPCS,278,RC,10000495,CDM,,,,both,,,3549.2000,2342.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2129.52,,,,,,,1724.9100,3549.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,549.20 in Billed Charges for Rev 278 Proc C1768 = $2,129.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,AETNA,AETNA HSHS,762.80,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $762.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,AETNA,ALL COMMERCIAL AETNA,1180.80,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,ANTHEM,ANTHEM POS/HMO,614.02,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $614.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,ANTHEM,ANTHEM PPO,614.02,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $614.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1180.80,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,CENPATICO,ALL MEDICAID CENPATICO,1180.80,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1003.68,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,003.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,CIGNA,ALL COMMERCIAL CIGNA,826.56,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $826.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,COFINITY,COFINITY,1180.80,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1121.76,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,991.87,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $991.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,838.37,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $838.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,861.98,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $861.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,573.87,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $573.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1003.68,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,003.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,HUMANA,HUMANA CHOICE CARE PPO,1003.68,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,003.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,861.98,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $861.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1180.80,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,590.40,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $590.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,991.87,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $991.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,885.60,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $885.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1086.34,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $1,086.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,753.70,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $753.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,850.18,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $850.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,850.18,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $850.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,732.10,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $732.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,850.18,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $850.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,850.18,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $850.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 50CM,C1768,HCPCS,278,RC,10000103,CDM,,,,both,,,1180.8000,779.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,708.48,,,,,,,573.8700,1180.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,180.80 in Billed Charges for Rev 278 Proc C1768 = $708.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,AETNA,AETNA HSHS,1803.05,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,803.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,AETNA,ALL COMMERCIAL AETNA,2791.10,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,791.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,ANTHEM,ANTHEM POS/HMO,1451.37,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,451.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,ANTHEM,ANTHEM PPO,1451.37,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,451.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2791.10,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,791.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,CENPATICO,ALL MEDICAID CENPATICO,2791.10,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,791.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2372.44,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,372.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,CIGNA,ALL COMMERCIAL CIGNA,1953.77,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,953.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,COFINITY,COFINITY,2791.10,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,791.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2651.55,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,651.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,HEALTH CARE ALLIANCE,THE ALLIANCE,2344.52,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,344.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1981.68,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,981.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2037.50,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,037.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,HSHS EMPLOYEES,HSHS EMPLOYEES,1356.47,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,356.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2372.44,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,372.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,HUMANA,HUMANA CHOICE CARE HMO,1395.55,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,395.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,HUMANA,HUMANA CHOICE CARE PPO,2372.44,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,372.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,HUMANA,HUMANA NATIIONAL POS HMO,1395.55,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,395.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2037.50,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,037.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,LIVE360,LIVE360 HSHS HEALTHY PLAN,2791.10,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,791.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1395.55,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,395.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2344.52,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,344.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2093.33,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,093.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2567.81,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,567.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1781.56,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,781.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2009.59,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,009.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2009.59,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,009.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1730.48,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,730.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2009.59,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,009.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2009.59,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $2,009.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 100 CM TW RING,C1768,HCPCS,278,RC,10000153,CDM,,,,both,,,2791.1000,1842.1300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1674.66,,,,,,,1356.4700,2791.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,791.10 in Billed Charges for Rev 278 Proc C1768 = $1,674.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,AETNA,AETNA HSHS,720.42,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $720.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,AETNA,ALL COMMERCIAL AETNA,1115.20,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $1,115.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,ANTHEM,ANTHEM POS/HMO,579.90,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $579.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,ANTHEM,ANTHEM PPO,579.90,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $579.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1115.20,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $1,115.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,CENPATICO,ALL MEDICAID CENPATICO,1115.20,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $1,115.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,947.92,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $947.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,CIGNA,ALL COMMERCIAL CIGNA,780.64,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $780.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,COFINITY,COFINITY,1115.20,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $1,115.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1059.44,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $1,059.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,HEALTH CARE ALLIANCE,THE ALLIANCE,936.77,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $936.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,791.79,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $791.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,814.10,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $814.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,HSHS EMPLOYEES,HSHS EMPLOYEES,541.99,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $541.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,947.92,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $947.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,HUMANA,HUMANA CHOICE CARE PPO,947.92,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $947.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,814.10,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $814.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1115.20,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $1,115.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,557.60,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $557.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,936.77,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $936.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,836.40,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $836.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1025.98,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $1,025.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,711.83,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $711.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,802.94,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $802.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,802.94,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $802.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,691.42,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $691.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,802.94,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $802.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,802.94,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $802.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 40CM THIN WALL,C1768,HCPCS,278,RC,10000106,CDM,,,,both,,,1115.2000,736.0300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,669.12,,,,,,,541.9900,1115.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,115.20 in Billed Charges for Rev 278 Proc C1768 = $669.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,AETNA,AETNA HSHS,1661.90,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,661.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,AETNA,ALL COMMERCIAL AETNA,2572.60,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,572.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,ANTHEM,ANTHEM POS/HMO,1337.75,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,337.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,ANTHEM,ANTHEM PPO,1337.75,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,337.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2572.60,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,572.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,CENPATICO,ALL MEDICAID CENPATICO,2572.60,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,572.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2186.71,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,186.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,CIGNA,ALL COMMERCIAL CIGNA,1800.82,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,800.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,COFINITY,COFINITY,2572.60,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,572.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2443.97,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,443.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,2160.98,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,160.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1826.55,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,826.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1878.00,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,1250.28,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,250.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2186.71,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,186.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,HUMANA,HUMANA CHOICE CARE HMO,1286.30,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,286.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,HUMANA,HUMANA CHOICE CARE PPO,2186.71,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,186.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,HUMANA,HUMANA NATIIONAL POS HMO,1286.30,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,286.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1878.00,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2572.60,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,572.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1286.30,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,286.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2160.98,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,160.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1929.45,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,929.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2366.79,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $2,366.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1642.09,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,642.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1852.27,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,852.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1852.27,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,852.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1595.01,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,595.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1852.27,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,852.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1852.27,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,852.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 8 X 70CM TW RING,C1768,HCPCS,278,RC,10015812,CDM,,,,both,,,2572.6000,1697.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1543.56,,,,,,,1250.2800,2572.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,572.60 in Billed Charges for Rev 278 Proc C1768 = $1,543.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,AETNA,AETNA HSHS,1207.76,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,207.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,AETNA,ALL COMMERCIAL AETNA,1869.60,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,869.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,ANTHEM,ANTHEM POS/HMO,972.19,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $972.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,ANTHEM,ANTHEM PPO,972.19,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $972.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1869.60,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,869.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,CENPATICO,ALL MEDICAID CENPATICO,1869.60,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,869.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1589.16,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,589.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,CIGNA,ALL COMMERCIAL CIGNA,1308.72,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,308.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,COFINITY,COFINITY,1869.60,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,869.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1776.12,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,776.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,1570.46,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,570.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1327.42,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,327.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1364.81,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,364.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,908.63,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $908.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1589.16,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,589.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,HUMANA,HUMANA CHOICE CARE PPO,1589.16,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,589.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1364.81,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,364.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1869.60,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,869.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,934.80,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $934.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1570.46,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,570.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1402.20,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,402.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1720.03,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,720.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1193.37,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,193.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1346.11,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,346.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1346.11,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,346.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1159.15,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,159.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1346.11,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,346.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1346.11,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,346.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 10 X 15,C1768,HCPCS,278,RC,10030889,CDM,,,,both,,,1869.6000,1233.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1121.76,,,,,,,908.6300,1869.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,869.60 in Billed Charges for Rev 278 Proc C1768 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,AETNA,AETNA HSHS,368.06,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $368.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,AETNA,ALL COMMERCIAL AETNA,569.75,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $569.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,569.75,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $569.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,CENPATICO,ALL MEDICAID CENPATICO,569.75,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $569.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,484.29,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $484.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,CIGNA,ALL COMMERCIAL CIGNA,398.83,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $398.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,COFINITY,COFINITY,569.75,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $569.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,541.26,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $541.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,478.59,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $478.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,404.52,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $404.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,415.92,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $415.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,276.90,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $276.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,484.29,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $484.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,HUMANA,HUMANA CHOICE CARE PPO,484.29,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $484.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,415.92,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $415.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,569.75,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $569.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,284.88,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $284.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,478.59,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $478.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,427.31,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $427.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,524.17,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $524.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,363.67,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $363.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,410.22,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $410.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,410.22,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $410.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,353.25,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $353.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,410.22,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $410.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,410.22,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $410.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 20 CM,C1768,HCPCS,278,RC,10026249,CDM,,,,both,,,569.7500,376.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,341.85,,,,,,,276.9000,569.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $569.75 in Billed Charges for Rev 278 Proc C1768 = $341.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,AETNA,AETNA HSHS,631.95,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $631.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,AETNA,ALL COMMERCIAL AETNA,978.25,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $978.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,978.25,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $978.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,CENPATICO,ALL MEDICAID CENPATICO,978.25,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $978.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,831.51,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $831.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,CIGNA,ALL COMMERCIAL CIGNA,684.78,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $684.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,COFINITY,COFINITY,978.25,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $978.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,929.34,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $929.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,821.73,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $821.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,694.56,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $694.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,714.12,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $714.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,475.43,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $475.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,831.51,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $831.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,HUMANA,HUMANA CHOICE CARE PPO,831.51,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $831.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,714.12,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $714.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,978.25,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $978.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,489.13,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $489.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,821.73,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $821.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,733.69,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $733.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,899.99,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $899.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,624.42,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $624.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,704.34,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $704.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,704.34,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $704.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,606.52,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $606.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,704.34,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $704.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,704.34,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $704.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 6 X 40 CM,C1768,HCPCS,278,RC,10028867,CDM,,,,both,,,978.2500,645.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,586.95,,,,,,,475.4300,978.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $978.25 in Billed Charges for Rev 278 Proc C1768 = $586.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,AETNA,AETNA HSHS,279.07,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $279.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,AETNA,ALL COMMERCIAL AETNA,432.00,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,432.00,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,CENPATICO,ALL MEDICAID CENPATICO,432.00,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,367.20,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $367.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,CIGNA,ALL COMMERCIAL CIGNA,302.40,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,COFINITY,COFINITY,432.00,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,410.40,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $410.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,362.88,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $362.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,306.72,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $306.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,315.36,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $315.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,209.95,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $209.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,367.20,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $367.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,HUMANA,HUMANA CHOICE CARE PPO,367.20,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $367.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,315.36,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $315.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,432.00,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,216.00,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,362.88,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $362.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,324.00,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,397.44,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $397.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,275.75,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $275.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,311.04,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $311.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,311.04,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $311.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,267.84,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $267.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,311.04,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $311.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,311.04,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $311.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT GORTEX REGULAR 8 MM X 20 CM,C1768,HCPCS,278,RC,70404027,CDM,,,,both,,,432.0000,285.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,259.20,,,,,,,209.9500,432.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $432.00 in Billed Charges for Rev 278 Proc C1768 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,AETNA,AETNA HSHS,1276.36,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,276.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,AETNA,ALL COMMERCIAL AETNA,1975.79,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,975.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,ANTHEM,ANTHEM POS/HMO,1027.41,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,027.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,ANTHEM,ANTHEM PPO,1027.41,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,027.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1975.79,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,975.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,CENPATICO,ALL MEDICAID CENPATICO,1975.79,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,975.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1679.42,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,679.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,CIGNA,ALL COMMERCIAL CIGNA,1383.05,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,383.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,COFINITY,COFINITY,1975.79,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,975.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1877.00,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,877.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,1659.66,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,659.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1402.81,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,402.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1442.33,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,442.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,960.23,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $960.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1679.42,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,679.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,HUMANA,HUMANA CHOICE CARE PPO,1679.42,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,679.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1442.33,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,442.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1975.79,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,975.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,987.90,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $987.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1659.66,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,659.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1481.84,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,481.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1817.73,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,817.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1261.15,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,261.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1422.57,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,422.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1422.57,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,422.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1224.99,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,224.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1422.57,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,422.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1422.57,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,422.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059023,CDM,,,,both,,,1975.7900,1304.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1185.47,,,,,,,960.2300,1975.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,975.79 in Billed Charges for Rev 278 Proc C1768 = $1,185.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,AETNA,AETNA HSHS,1314.55,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,314.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,AETNA,ALL COMMERCIAL AETNA,2034.91,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $2,034.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,ANTHEM,ANTHEM POS/HMO,1058.15,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,058.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,ANTHEM,ANTHEM PPO,1058.15,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,058.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2034.91,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $2,034.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,CENPATICO,ALL MEDICAID CENPATICO,2034.91,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $2,034.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1729.67,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,729.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,CIGNA,ALL COMMERCIAL CIGNA,1424.44,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,424.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,COFINITY,COFINITY,2034.91,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $2,034.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1933.16,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,933.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,1709.32,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,709.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1444.79,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,444.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1485.48,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,485.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,988.97,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $988.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1729.67,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,729.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,HUMANA,HUMANA CHOICE CARE PPO,1729.67,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,729.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1485.48,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,485.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2034.91,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $2,034.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1017.46,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,017.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1709.32,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,709.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1526.18,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,526.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1872.12,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,872.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1298.88,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,298.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1465.14,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,465.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1465.14,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,465.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1261.64,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,261.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1465.14,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,465.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1465.14,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,465.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD ONE BRANCH 30 X 50,C1768,HCPCS,278,RC,70200290,CDM,,,,both,,,2034.9100,1343.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1220.95,,,,,,,988.9700,2034.9100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,034.91 in Billed Charges for Rev 278 Proc C1768 = $1,220.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,AETNA,AETNA HSHS,592.94,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $592.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,AETNA,ALL COMMERCIAL AETNA,917.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $917.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,917.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $917.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,CENPATICO,ALL MEDICAID CENPATICO,917.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $917.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,780.18,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $780.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,CIGNA,ALL COMMERCIAL CIGNA,642.50,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $642.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,COFINITY,COFINITY,917.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $917.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,871.97,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $871.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,771.00,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $771.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,651.68,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $651.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,670.04,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $670.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,446.08,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $446.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,780.18,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $780.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,HUMANA,HUMANA CHOICE CARE PPO,780.18,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $780.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,670.04,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $670.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,917.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $917.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,458.93,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $458.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,771.00,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $771.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,688.40,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $688.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,844.43,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $844.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,585.87,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $585.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,660.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $660.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,660.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $660.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,569.07,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $569.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,660.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $660.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,660.86,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $660.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10040037,CDM,,,,both,,,917.8600,605.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,550.72,,,,,,,446.0800,917.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $917.86 in Billed Charges for Rev 278 Proc C1768 = $550.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,AETNA,AETNA HSHS,1117.71,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,117.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,AETNA,ALL COMMERCIAL AETNA,1730.20,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,730.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,ANTHEM,ANTHEM POS/HMO,899.70,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $899.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,ANTHEM,ANTHEM PPO,899.70,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $899.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1730.20,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,730.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,CENPATICO,ALL MEDICAID CENPATICO,1730.20,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,730.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1470.67,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,470.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,CIGNA,ALL COMMERCIAL CIGNA,1211.14,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,211.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,COFINITY,COFINITY,1730.20,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,730.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1643.69,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,643.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,1453.37,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,453.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1228.44,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,228.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1263.05,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,263.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,840.88,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $840.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1470.67,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,470.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,HUMANA,HUMANA CHOICE CARE PPO,1470.67,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,470.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1263.05,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,263.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1730.20,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,730.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,865.10,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $865.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1453.37,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,453.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1297.65,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,297.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1591.78,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,591.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1104.39,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,104.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1245.74,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,245.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1245.74,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,245.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1072.72,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,072.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1245.74,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,245.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1245.74,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,245.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10003061,CDM,,,,both,,,1730.2000,1141.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1038.12,,,,,,,840.8800,1730.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,730.20 in Billed Charges for Rev 278 Proc C1768 = $1,038.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,AETNA,AETNA HSHS,116.73,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $116.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,AETNA,ALL COMMERCIAL AETNA,180.70,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $180.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,180.70,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $180.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,CENPATICO,ALL MEDICAID CENPATICO,180.70,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $180.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,153.60,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $153.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,CIGNA,ALL COMMERCIAL CIGNA,126.49,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $126.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,COFINITY,COFINITY,180.70,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $180.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,171.67,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $171.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,151.79,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $151.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,128.30,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $128.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,131.91,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $131.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,87.82,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $87.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,153.60,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $153.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,HUMANA,HUMANA CHOICE CARE PPO,153.60,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $153.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,131.91,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $131.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,180.70,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $180.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,90.35,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $90.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,151.79,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $151.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,135.53,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $135.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,166.24,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $166.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,115.34,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $115.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,130.10,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $130.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,130.10,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $130.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,112.03,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $112.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,130.10,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $130.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,130.10,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $130.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PATCH HEMASHIELD PLATINUM  0.8CMX7.6CM,C1768,HCPCS,278,RC,10058859,CDM,,,,both,,,180.7000,119.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,108.42,,,,,,,87.8200,180.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $180.70 in Billed Charges for Rev 278 Proc C1768 = $108.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,AETNA,AETNA HSHS,609.73,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $609.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,AETNA,ALL COMMERCIAL AETNA,943.85,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $943.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,943.85,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $943.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,CENPATICO,ALL MEDICAID CENPATICO,943.85,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $943.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,802.27,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $802.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,CIGNA,ALL COMMERCIAL CIGNA,660.70,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $660.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,COFINITY,COFINITY,943.85,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $943.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,896.66,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $896.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,792.83,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $792.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,670.13,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $670.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,689.01,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $689.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,458.71,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $458.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,802.27,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $802.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,HUMANA,HUMANA CHOICE CARE PPO,802.27,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $802.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,689.01,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $689.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,943.85,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $943.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,471.93,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $471.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,792.83,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $792.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,707.89,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $707.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,868.34,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $868.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,602.46,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $602.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,679.57,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $679.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,679.57,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $679.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,585.19,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $585.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,679.57,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $679.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,679.57,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $679.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH 1 X 14CM,C1768,HCPCS,278,RC,10065675,CDM,,,,both,,,943.8500,622.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,566.31,,,,,,,458.7100,943.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $943.85 in Billed Charges for Rev 278 Proc C1768 = $566.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,AETNA,AETNA HSHS,1378.37,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,378.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,AETNA,ALL COMMERCIAL AETNA,2133.70,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $2,133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,ANTHEM,ANTHEM POS/HMO,1109.52,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,109.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,ANTHEM,ANTHEM PPO,1109.52,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,109.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2133.70,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $2,133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,CENPATICO,ALL MEDICAID CENPATICO,2133.70,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $2,133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1813.65,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,813.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,CIGNA,ALL COMMERCIAL CIGNA,1493.59,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,493.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,COFINITY,COFINITY,2133.70,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $2,133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2027.02,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $2,027.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,1792.31,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,792.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1514.93,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,514.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1557.60,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,557.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,1036.98,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,036.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1813.65,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,813.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,HUMANA,HUMANA CHOICE CARE PPO,1813.65,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,813.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1557.60,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,557.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2133.70,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $2,133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1066.85,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,066.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1792.31,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,792.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1600.28,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,600.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1963.00,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,963.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1361.94,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,361.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1536.26,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,536.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1536.26,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,536.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1322.89,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,322.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1536.26,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,536.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1536.26,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,536.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN STANDARD WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022766,CDM,,,,both,,,2133.7000,1408.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1280.22,,,,,,,1036.9800,2133.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,133.70 in Billed Charges for Rev 278 Proc C1768 = $1,280.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,AETNA,AETNA HSHS,3534.91,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,534.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,AETNA,ALL COMMERCIAL AETNA,5472.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $5,472.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,ANTHEM,ANTHEM POS/HMO,2845.44,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,845.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,ANTHEM,ANTHEM PPO,2845.44,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,845.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5472.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $5,472.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,CENPATICO,ALL MEDICAID CENPATICO,5472.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $5,472.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4651.20,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $4,651.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,CIGNA,ALL COMMERCIAL CIGNA,3830.40,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,830.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,COFINITY,COFINITY,5472.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $5,472.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5198.40,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $5,198.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,4596.48,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $4,596.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3885.12,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,885.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3994.56,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,994.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,2659.39,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,659.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4651.20,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $4,651.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,HUMANA,HUMANA CHOICE CARE HMO,2736.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,736.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,HUMANA,HUMANA CHOICE CARE PPO,4651.20,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $4,651.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,HUMANA,HUMANA NATIIONAL POS HMO,2736.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,736.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3994.56,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,994.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,5472.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $5,472.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2736.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,736.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4596.48,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $4,596.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4104.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $4,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5034.24,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $5,034.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2736.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,736.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2736.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,736.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,PREVEA HEALTH NETWORK,PREVEA360,2736.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,736.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2736.00,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $2,736.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3492.78,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,492.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3939.84,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,939.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3939.84,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,939.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3392.64,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,392.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3939.84,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,939.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3939.84,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,939.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 8MM X 80CM,C1768,HCPCS,278,RC,10052315,CDM,,,,both,,,5472.0000,3611.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3283.20,,,,,,,2659.3900,5472.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,472.00 in Billed Charges for Rev 278 Proc C1768 = $3,283.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,AETNA,AETNA HSHS,345.84,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $345.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,AETNA,ALL COMMERCIAL AETNA,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,CENPATICO,ALL MEDICAID CENPATICO,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,455.05,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $455.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,CIGNA,ALL COMMERCIAL CIGNA,374.75,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $374.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,COFINITY,COFINITY,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,508.58,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $508.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,449.69,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $449.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,380.10,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $380.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,390.81,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $390.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,260.18,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $260.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,455.05,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $455.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,HUMANA,HUMANA CHOICE CARE PPO,455.05,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $455.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,390.81,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $390.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,535.35,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $535.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,267.68,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $267.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,449.69,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $449.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,401.51,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $401.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,492.52,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $492.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,341.71,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $341.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,385.45,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $385.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,385.45,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $385.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,331.92,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $331.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,385.45,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $385.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,385.45,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $385.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT XENOSURE BIOLOGIC PATCH 0.8 X 8CM,C1768,HCPCS,278,RC,10065670,CDM,,,,both,,,535.3500,353.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,321.21,,,,,,,260.1800,535.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $535.35 in Billed Charges for Rev 278 Proc C1768 = $321.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,AETNA,AETNA HSHS,334.53,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $334.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,AETNA,ALL COMMERCIAL AETNA,517.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $517.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,517.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $517.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,CENPATICO,ALL MEDICAID CENPATICO,517.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $517.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,440.17,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $440.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,CIGNA,ALL COMMERCIAL CIGNA,362.50,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $362.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,COFINITY,COFINITY,517.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $517.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,491.96,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $491.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,434.99,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $434.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,367.67,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $367.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,378.03,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $378.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,251.68,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $251.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,440.17,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $440.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,HUMANA,HUMANA CHOICE CARE PPO,440.17,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $440.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,378.03,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $378.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,517.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $517.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,258.93,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $258.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,434.99,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $434.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,388.39,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $388.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,476.42,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $476.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,330.54,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $330.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,372.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $372.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,372.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $372.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,321.07,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $321.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,372.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $372.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,372.85,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $372.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PERI. VASC. VASCU-GUARD 0.8CM X 8CM,C1768,HCPCS,278,RC,10058431,CDM,,,,both,,,517.8500,341.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,310.71,,,,,,,251.6800,517.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $517.85 in Billed Charges for Rev 278 Proc C1768 = $310.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,AETNA,AETNA HSHS,11191.95,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $11,191.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,AETNA,ALL COMMERCIAL AETNA,17325.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $17,325.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,ANTHEM,ANTHEM POS/HMO,9009.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $9,009.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,ANTHEM,ANTHEM PPO,9009.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $9,009.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17325.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $17,325.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,CENPATICO,ALL MEDICAID CENPATICO,17325.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $17,325.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14726.25,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $14,726.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,CIGNA,ALL COMMERCIAL CIGNA,12127.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,COFINITY,COFINITY,17325.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $17,325.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16458.75,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $16,458.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,14553.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $14,553.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12300.75,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,300.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12647.25,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,647.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,8419.95,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,419.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14726.25,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $14,726.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,HUMANA,HUMANA CHOICE CARE HMO,8662.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,662.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,HUMANA,HUMANA CHOICE CARE PPO,14726.25,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $14,726.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,HUMANA,HUMANA NATIIONAL POS HMO,8662.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,662.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12647.25,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,647.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,17325.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $17,325.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8662.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,662.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14553.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $14,553.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12993.75,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,993.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15939.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $15,939.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8662.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,662.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8662.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,662.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,PREVEA HEALTH NETWORK,PREVEA360,8662.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,662.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8662.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,662.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11058.55,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $11,058.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12474.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8073.45,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,073.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,8073.45,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,073.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,8073.45,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $8,073.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12474.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10741.50,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $10,741.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12474.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12474.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $12,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP SYNCHROMED EL INFUSION (CATHETER AND PASSER INCLU.),C1772,HCPCS,278,RC,70402758,CDM,,,,both,,,17325.0000,11434.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10395.00,,,,,,,8073.4500,17325.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $17,325.00 in Billed Charges for Rev 278 Proc C1772 = $10,395.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,AETNA,AETNA HSHS,339.20,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $339.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,AETNA,ALL COMMERCIAL AETNA,525.07,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $525.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,525.07,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $525.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,CENPATICO,ALL MEDICAID CENPATICO,525.07,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $525.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,446.31,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $446.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,CIGNA,ALL COMMERCIAL CIGNA,367.55,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $367.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,COFINITY,COFINITY,525.07,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $525.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,498.82,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $498.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,441.06,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $441.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,372.80,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $372.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,383.30,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $383.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,255.18,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $255.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,446.31,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $446.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,HUMANA,HUMANA CHOICE CARE PPO,446.31,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $446.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,383.30,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $383.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,525.07,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $525.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,262.54,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $262.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,441.06,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $441.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,393.80,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $393.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,483.06,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $483.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,335.15,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $335.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,378.05,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $378.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,378.05,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $378.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,325.54,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $325.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,378.05,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $378.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,378.05,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $378.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,10038679,CDM,,,,both,,,525.0700,346.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,315.04,,,,,,,255.1800,525.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $525.07 in Billed Charges for Rev 278 Proc C1781 = $315.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,AETNA,AETNA HSHS,38604.38,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $38,604.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,AETNA,ALL COMMERCIAL AETNA,59759.10,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $59,759.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,ANTHEM,ANTHEM POS/HMO,31074.73,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $31,074.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,ANTHEM,ANTHEM PPO,31074.73,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $31,074.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,59759.10,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $59,759.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,CENPATICO,ALL MEDICAID CENPATICO,59759.10,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $59,759.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,50795.24,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $50,795.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,CIGNA,ALL COMMERCIAL CIGNA,41831.37,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $41,831.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,COFINITY,COFINITY,59759.10,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $59,759.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,56771.15,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $56,771.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,50197.64,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $50,197.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42428.96,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $42,428.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,43624.14,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $43,624.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,29042.92,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $29,042.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,50795.24,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $50,795.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,HUMANA,HUMANA CHOICE CARE HMO,29879.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $29,879.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,HUMANA,HUMANA CHOICE CARE PPO,50795.24,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $50,795.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,HUMANA,HUMANA NATIIONAL POS HMO,29879.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $29,879.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,43624.14,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $43,624.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,59759.10,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $59,759.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,29879.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $29,879.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,50197.64,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $50,197.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,44819.33,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $44,819.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,54978.37,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $54,978.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29879.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $29,879.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29879.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $29,879.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,PREVEA HEALTH NETWORK,PREVEA360,29879.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $29,879.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29879.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $29,879.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38144.23,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $38,144.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,43026.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $43,026.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27847.74,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $27,847.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,UNITED HEALTHCARE,UHC ONEIDA NATION,27847.74,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $27,847.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,UNITED HEALTHCARE,UNITED HEALTHCARE,27847.74,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $27,847.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,43026.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $43,026.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37050.64,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $37,050.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,43026.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $43,026.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,43026.55,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $43,026.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 14IN X 12IN,C1781,HCPCS,278,RC,10094014,CDM,,,,both,,,59759.1000,39441.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,35855.46,,,,,,,27847.7400,59759.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $59,759.10 in Billed Charges for Rev 278 Proc C1781 = $35,855.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,AETNA,AETNA HSHS,2855.72,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,855.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,AETNA,ALL COMMERCIAL AETNA,4420.62,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $4,420.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,ANTHEM,ANTHEM POS/HMO,2298.72,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,298.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,ANTHEM,ANTHEM PPO,2298.72,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,298.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4420.62,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $4,420.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,CENPATICO,ALL MEDICAID CENPATICO,4420.62,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $4,420.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3757.53,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,757.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,CIGNA,ALL COMMERCIAL CIGNA,3094.43,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,094.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,COFINITY,COFINITY,4420.62,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $4,420.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4199.59,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $4,199.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,3713.32,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,713.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3138.64,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,138.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3227.05,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,227.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,2148.42,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,148.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3757.53,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,757.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,HUMANA,HUMANA CHOICE CARE HMO,2210.31,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,210.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,HUMANA,HUMANA CHOICE CARE PPO,3757.53,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,757.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,HUMANA,HUMANA NATIIONAL POS HMO,2210.31,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,210.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3227.05,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,227.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,4420.62,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $4,420.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2210.31,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,210.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3713.32,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,713.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3315.47,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,315.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4066.97,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $4,066.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2821.68,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,821.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3182.85,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,182.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3182.85,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,182.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2740.78,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,740.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3182.85,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,182.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3182.85,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $3,182.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 4IN X 3IN,C1781,HCPCS,278,RC,10085060,CDM,,,,both,,,4420.6200,2917.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2652.37,,,,,,,2148.4200,4420.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,420.62 in Billed Charges for Rev 278 Proc C1781 = $2,652.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,AETNA,AETNA HSHS,4451.20,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,451.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,AETNA,ALL COMMERCIAL AETNA,6890.40,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $6,890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,ANTHEM,ANTHEM POS/HMO,3583.01,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,583.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,ANTHEM,ANTHEM PPO,3583.01,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,583.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6890.40,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $6,890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,CENPATICO,ALL MEDICAID CENPATICO,6890.40,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $6,890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5856.84,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $5,856.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,CIGNA,ALL COMMERCIAL CIGNA,4823.28,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,823.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,COFINITY,COFINITY,6890.40,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $6,890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6545.88,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $6,545.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,5787.94,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $5,787.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4892.18,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,892.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5029.99,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $5,029.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,3348.73,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,348.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5856.84,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $5,856.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,HUMANA,HUMANA CHOICE CARE HMO,3445.20,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,HUMANA,HUMANA CHOICE CARE PPO,5856.84,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $5,856.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,HUMANA,HUMANA NATIIONAL POS HMO,3445.20,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5029.99,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $5,029.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,6890.40,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $6,890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3445.20,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5787.94,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $5,787.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5167.80,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $5,167.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6339.17,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $6,339.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3445.20,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3445.20,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,PREVEA HEALTH NETWORK,PREVEA360,3445.20,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3445.20,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4398.14,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,398.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4961.09,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,961.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3210.93,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,210.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,3210.93,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,210.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,3210.93,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $3,210.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4961.09,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,961.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4272.05,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,272.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4961.09,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,961.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4961.09,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,961.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 10 X 16 FIRM,C1781,HCPCS,278,RC,10051399,CDM,,,,both,,,6890.4000,4547.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4134.24,,,,,,,3210.9300,6890.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,890.40 in Billed Charges for Rev 278 Proc C1781 = $4,134.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,AETNA,AETNA HSHS,11125.67,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $11,125.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,AETNA,ALL COMMERCIAL AETNA,17222.40,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $17,222.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,ANTHEM,ANTHEM POS/HMO,8955.65,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,955.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,ANTHEM,ANTHEM PPO,8955.65,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,955.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17222.40,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $17,222.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,CENPATICO,ALL MEDICAID CENPATICO,17222.40,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $17,222.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14639.04,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $14,639.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,CIGNA,ALL COMMERCIAL CIGNA,12055.68,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,055.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,COFINITY,COFINITY,17222.40,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $17,222.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16361.28,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $16,361.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,14466.82,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $14,466.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12227.90,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,227.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12572.35,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,572.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,8370.09,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,370.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14639.04,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $14,639.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,HUMANA,HUMANA CHOICE CARE HMO,8611.20,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,611.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,HUMANA,HUMANA CHOICE CARE PPO,14639.04,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $14,639.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,HUMANA,HUMANA NATIIONAL POS HMO,8611.20,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,611.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12572.35,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,572.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,17222.40,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $17,222.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8611.20,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,611.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14466.82,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $14,466.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12916.80,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,916.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15844.61,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $15,844.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8611.20,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,611.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8611.20,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,611.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,PREVEA HEALTH NETWORK,PREVEA360,8611.20,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,611.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8611.20,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,611.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10993.06,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $10,993.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12400.13,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,400.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8025.64,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,025.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,8025.64,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,025.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,8025.64,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $8,025.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12400.13,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,400.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10677.89,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $10,677.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12400.13,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,400.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12400.13,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $12,400.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 20,C1781,HCPCS,278,RC,10042288,CDM,,,,both,,,17222.4000,11366.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10333.44,,,,,,,8025.6400,17222.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $17,222.40 in Billed Charges for Rev 278 Proc C1781 = $10,333.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,AETNA,AETNA HSHS,701.88,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $701.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,AETNA,ALL COMMERCIAL AETNA,1086.50,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $1,086.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,ANTHEM,ANTHEM POS/HMO,564.98,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $564.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,ANTHEM,ANTHEM PPO,564.98,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $564.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1086.50,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $1,086.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,CENPATICO,ALL MEDICAID CENPATICO,1086.50,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $1,086.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,923.53,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $923.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,CIGNA,ALL COMMERCIAL CIGNA,760.55,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $760.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,COFINITY,COFINITY,1086.50,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $1,086.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1032.18,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $1,032.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,912.66,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $912.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,771.42,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $771.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,793.15,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $793.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,528.04,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $528.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,923.53,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $923.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,HUMANA,HUMANA CHOICE CARE PPO,923.53,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $923.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,793.15,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $793.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1086.50,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $1,086.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,543.25,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $543.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,912.66,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $912.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,814.88,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $814.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,999.58,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $999.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,693.51,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $693.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,782.28,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $782.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,782.28,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $782.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,673.63,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $673.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,782.28,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $782.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,782.28,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $782.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SURG GORE BIO-A TISS REINF 10X7CM TISS REINF SYNTH,C1781,HCPCS,278,RC,10040818,CDM,,,,both,,,1086.5000,717.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,651.90,,,,,,,528.0400,1086.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,086.50 in Billed Charges for Rev 278 Proc C1781 = $651.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,AETNA,AETNA HSHS,733.70,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $733.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,AETNA,ALL COMMERCIAL AETNA,1135.76,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $1,135.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,ANTHEM,ANTHEM POS/HMO,590.60,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $590.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,ANTHEM,ANTHEM PPO,590.60,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $590.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1135.76,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $1,135.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,CENPATICO,ALL MEDICAID CENPATICO,1135.76,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $1,135.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,965.40,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $965.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,CIGNA,ALL COMMERCIAL CIGNA,795.03,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $795.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,COFINITY,COFINITY,1135.76,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $1,135.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1078.97,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $1,078.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,954.04,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $954.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,806.39,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $806.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,829.10,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $829.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,551.98,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $551.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,965.40,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $965.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,HUMANA,HUMANA CHOICE CARE PPO,965.40,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $965.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,829.10,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $829.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1135.76,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $1,135.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,567.88,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $567.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,954.04,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $954.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,851.82,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $851.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1044.90,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $1,044.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,724.96,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $724.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,817.75,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $817.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,817.75,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $817.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,704.17,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $704.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,817.75,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $817.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,817.75,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $817.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 20CMX12CM,C1781,HCPCS,278,RC,70409959,CDM,,,,both,,,1135.7600,749.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,681.46,,,,,,,551.9800,1135.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,135.76 in Billed Charges for Rev 278 Proc C1781 = $681.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,AETNA,AETNA HSHS,1159.29,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,159.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,AETNA,ALL COMMERCIAL AETNA,1794.57,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,794.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,ANTHEM,ANTHEM POS/HMO,933.18,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $933.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,ANTHEM,ANTHEM PPO,933.18,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $933.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1794.57,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,794.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,CENPATICO,ALL MEDICAID CENPATICO,1794.57,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,794.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1525.38,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,525.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,CIGNA,ALL COMMERCIAL CIGNA,1256.20,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,COFINITY,COFINITY,1794.57,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,794.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1704.84,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,704.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,1507.44,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,507.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1274.14,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,274.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1310.04,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,310.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,872.16,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $872.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1525.38,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,525.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,HUMANA,HUMANA CHOICE CARE PPO,1525.38,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,525.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1310.04,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,310.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1794.57,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,794.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,897.29,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $897.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1507.44,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,507.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1345.93,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,345.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1651.00,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1145.47,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,145.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1292.09,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,292.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1292.09,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,292.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1112.63,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,112.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1292.09,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,292.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1292.09,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,292.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX LARGE 5950009,C1781,HCPCS,278,RC,10051861,CDM,,,,both,,,1794.5700,1184.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1076.74,,,,,,,872.1600,1794.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,794.57 in Billed Charges for Rev 278 Proc C1781 = $1,076.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,AETNA,AETNA HSHS,755.25,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $755.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,AETNA,ALL COMMERCIAL AETNA,1169.12,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $1,169.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,ANTHEM,ANTHEM POS/HMO,607.94,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $607.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,ANTHEM,ANTHEM PPO,607.94,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $607.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1169.12,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $1,169.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,CENPATICO,ALL MEDICAID CENPATICO,1169.12,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $1,169.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,993.75,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $993.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,CIGNA,ALL COMMERCIAL CIGNA,818.38,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $818.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,COFINITY,COFINITY,1169.12,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $1,169.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1110.66,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $1,110.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,982.06,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $982.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,830.08,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $830.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,853.46,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $853.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,568.19,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $568.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,993.75,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $993.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,HUMANA,HUMANA CHOICE CARE PPO,993.75,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $993.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,853.46,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $853.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1169.12,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $1,169.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,584.56,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $584.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,982.06,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $982.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,876.84,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $876.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1075.59,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $1,075.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,746.25,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $746.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,841.77,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $841.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,841.77,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $841.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,724.85,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $724.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,841.77,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $841.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,841.77,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $841.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX SMALL WITH STRAP 5950007,C1781,HCPCS,278,RC,10051859,CDM,,,,both,,,1169.1200,771.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,701.47,,,,,,,568.1900,1169.1200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,169.12 in Billed Charges for Rev 278 Proc C1781 = $701.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,AETNA,AETNA HSHS,2580.83,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,580.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,AETNA,ALL COMMERCIAL AETNA,3995.10,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,995.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,ANTHEM,ANTHEM POS/HMO,2077.45,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,077.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,ANTHEM,ANTHEM PPO,2077.45,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,077.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3995.10,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,995.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,CENPATICO,ALL MEDICAID CENPATICO,3995.10,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,995.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3395.84,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,395.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,CIGNA,ALL COMMERCIAL CIGNA,2796.57,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,796.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,COFINITY,COFINITY,3995.10,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,995.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3795.35,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,795.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,3355.88,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,355.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2836.52,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,836.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2916.42,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,916.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,1941.62,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $1,941.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3395.84,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,395.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,HUMANA,HUMANA CHOICE CARE HMO,1997.55,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $1,997.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,HUMANA,HUMANA CHOICE CARE PPO,3395.84,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,395.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,HUMANA,HUMANA NATIIONAL POS HMO,1997.55,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $1,997.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2916.42,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,916.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,3995.10,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,995.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1997.55,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $1,997.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3355.88,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,355.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2996.33,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,996.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3675.49,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $3,675.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2550.07,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,550.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2876.47,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,876.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2876.47,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,876.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2476.96,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,476.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2876.47,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,876.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2876.47,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,876.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 10 X 13 5954113,C1781,HCPCS,278,RC,10049911,CDM,,,,both,,,3995.1000,2636.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2397.06,,,,,,,1941.6200,3995.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,995.10 in Billed Charges for Rev 278 Proc C1781 = $2,397.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,AETNA,AETNA HSHS,799.61,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $799.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,AETNA,ALL COMMERCIAL AETNA,1237.79,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,237.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,ANTHEM,ANTHEM POS/HMO,643.65,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $643.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,ANTHEM,ANTHEM PPO,643.65,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $643.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1237.79,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,237.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,CENPATICO,ALL MEDICAID CENPATICO,1237.79,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,237.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1052.12,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,052.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,CIGNA,ALL COMMERCIAL CIGNA,866.45,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $866.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,COFINITY,COFINITY,1237.79,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,237.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1175.90,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,175.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,1039.74,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,039.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,878.83,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $878.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,903.59,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $903.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,601.57,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $601.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1052.12,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,052.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,HUMANA,HUMANA CHOICE CARE PPO,1052.12,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,052.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,903.59,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $903.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1237.79,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,237.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,618.90,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $618.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1039.74,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,039.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,928.34,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $928.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1138.77,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $1,138.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,790.08,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $790.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,891.21,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $891.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,891.21,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $891.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,767.43,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $767.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,891.21,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $891.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,891.21,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $891.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 4 X 6 5954460,C1781,HCPCS,278,RC,10049701,CDM,,,,both,,,1237.7900,816.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,742.67,,,,,,,601.5700,1237.7900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,237.79 in Billed Charges for Rev 278 Proc C1781 = $742.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,AETNA,AETNA HSHS,3677.24,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $3,677.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,AETNA,ALL COMMERCIAL AETNA,5692.32,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $5,692.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,ANTHEM,ANTHEM POS/HMO,2960.01,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,960.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,ANTHEM,ANTHEM PPO,2960.01,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,960.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5692.32,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $5,692.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,CENPATICO,ALL MEDICAID CENPATICO,5692.32,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $5,692.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4838.47,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,838.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,CIGNA,ALL COMMERCIAL CIGNA,3984.62,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $3,984.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,COFINITY,COFINITY,5692.32,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $5,692.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5407.70,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $5,407.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,4781.55,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,781.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4041.55,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,041.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4155.39,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,155.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,2766.47,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,766.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4838.47,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,838.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,HUMANA,HUMANA CHOICE CARE HMO,2846.16,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,846.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,HUMANA,HUMANA CHOICE CARE PPO,4838.47,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,838.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,HUMANA,HUMANA NATIIONAL POS HMO,2846.16,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,846.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4155.39,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,155.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,5692.32,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $5,692.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2846.16,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,846.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4781.55,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,781.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4269.24,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,269.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5236.93,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $5,236.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2846.16,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,846.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2846.16,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,846.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,PREVEA HEALTH NETWORK,PREVEA360,2846.16,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,846.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2846.16,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $2,846.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3633.41,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $3,633.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4098.47,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,098.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4098.47,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,098.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3529.24,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $3,529.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4098.47,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,098.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4098.47,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $4,098.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 13X10IN,C1781,HCPCS,278,RC,10052747,CDM,,,,both,,,5692.3200,3756.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3415.39,,,,,,,2766.4700,5692.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,692.32 in Billed Charges for Rev 278 Proc C1781 = $3,415.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,AETNA,AETNA HSHS,2936.30,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,936.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,AETNA,ALL COMMERCIAL AETNA,4545.36,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $4,545.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,ANTHEM,ANTHEM POS/HMO,2363.59,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,363.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,ANTHEM,ANTHEM PPO,2363.59,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,363.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4545.36,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $4,545.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,CENPATICO,ALL MEDICAID CENPATICO,4545.36,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $4,545.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3863.56,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,863.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,CIGNA,ALL COMMERCIAL CIGNA,3181.75,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,181.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,COFINITY,COFINITY,4545.36,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $4,545.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4318.09,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $4,318.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,3818.10,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,818.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3227.21,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,227.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3318.11,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,318.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,2209.05,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,209.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3863.56,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,863.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,HUMANA,HUMANA CHOICE CARE HMO,2272.68,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,272.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,HUMANA,HUMANA CHOICE CARE PPO,3863.56,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,863.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,HUMANA,HUMANA NATIIONAL POS HMO,2272.68,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,272.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3318.11,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,318.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,4545.36,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $4,545.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2272.68,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,272.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3818.10,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,818.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3409.02,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,409.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4181.73,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $4,181.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2901.30,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,901.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3272.66,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,272.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3272.66,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,272.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2818.12,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,818.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3272.66,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,272.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3272.66,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $3,272.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 8X10IN,C1781,HCPCS,278,RC,10052751,CDM,,,,both,,,4545.3600,2999.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2727.22,,,,,,,2209.0500,4545.3600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,545.36 in Billed Charges for Rev 278 Proc C1781 = $2,727.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,AETNA,AETNA HSHS,549.45,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $549.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,AETNA,ALL COMMERCIAL AETNA,850.54,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $850.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,850.54,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $850.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,CENPATICO,ALL MEDICAID CENPATICO,850.54,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $850.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,722.96,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $722.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,CIGNA,ALL COMMERCIAL CIGNA,595.38,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $595.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,COFINITY,COFINITY,850.54,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $850.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,808.01,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $808.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,714.45,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $714.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,603.88,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $603.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,620.89,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $620.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,413.36,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $413.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,722.96,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $722.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,HUMANA,HUMANA CHOICE CARE PPO,722.96,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $722.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,620.89,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $620.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,850.54,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $850.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,425.27,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $425.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,714.45,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $714.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,637.91,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $637.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,782.50,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $782.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,542.90,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $542.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,612.39,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $612.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,612.39,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $612.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,527.33,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $527.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,612.39,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $612.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,612.39,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $612.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VICRYL KNITTED 6 X 6,C1781,HCPCS,278,RC,10012294,CDM,,,,both,,,850.5400,561.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,510.32,,,,,,,413.3600,850.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $850.54 in Billed Charges for Rev 278 Proc C1781 = $510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,AETNA,AETNA HSHS,196.37,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $196.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,AETNA,ALL COMMERCIAL AETNA,303.98,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $303.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,303.98,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $303.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,CENPATICO,ALL MEDICAID CENPATICO,303.98,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $303.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,258.38,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $258.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,CIGNA,ALL COMMERCIAL CIGNA,212.79,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $212.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,COFINITY,COFINITY,303.98,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $303.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,288.78,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $288.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,HEALTH CARE ALLIANCE,THE ALLIANCE,255.34,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $255.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,215.83,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $215.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,221.91,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $221.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,HSHS EMPLOYEES,HSHS EMPLOYEES,147.73,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $147.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,258.38,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $258.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,HUMANA,HUMANA CHOICE CARE PPO,258.38,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $258.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,221.91,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $221.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,LIVE360,LIVE360 HSHS HEALTHY PLAN,303.98,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $303.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,151.99,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $151.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,255.34,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $255.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,227.99,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $227.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,279.66,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $279.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,194.03,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $194.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,218.87,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $218.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,218.87,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $218.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,188.47,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $188.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,218.87,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $218.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,218.87,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $218.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10045485,CDM,,,,both,,,303.9800,200.6300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,182.39,,,,,,,147.7300,303.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $303.98 in Billed Charges for Rev 278 Proc C1713 = $182.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,AETNA,AETNA HSHS,145.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $145.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,AETNA,ALL COMMERCIAL AETNA,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,CENPATICO,ALL MEDICAID CENPATICO,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,CIGNA,ALL COMMERCIAL CIGNA,157.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,COFINITY,COFINITY,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,213.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $213.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,159.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $159.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,109.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $109.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE PPO,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,112.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,168.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,207.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,143.62,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $143.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,139.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $139.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10035203,CDM,,,,both,,,225.0000,148.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,135.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $225.00 in Billed Charges for Rev 278 Proc C1713 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,AETNA,AETNA HSHS,109.01,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $109.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,AETNA,ALL COMMERCIAL AETNA,168.75,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,168.75,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,CENPATICO,ALL MEDICAID CENPATICO,168.75,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,143.44,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $143.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,CIGNA,ALL COMMERCIAL CIGNA,118.13,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $118.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,COFINITY,COFINITY,168.75,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,160.31,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $160.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,141.75,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $141.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,119.81,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $119.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,123.19,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $123.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,82.01,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $82.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,143.44,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $143.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,HUMANA,HUMANA CHOICE CARE PPO,143.44,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $143.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,123.19,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $123.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,168.75,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,84.38,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $84.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,141.75,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $141.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,126.56,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $126.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,155.25,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $155.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,107.71,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $107.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,121.50,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $121.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,121.50,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $121.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,104.63,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $104.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,121.50,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $121.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,121.50,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $121.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10046732,CDM,,,,both,,,168.7500,111.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,101.25,,,,,,,82.0100,168.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $168.75 in Billed Charges for Rev 278 Proc C1713 = $101.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,AETNA,AETNA HSHS,562.50,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $562.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,AETNA,ALL COMMERCIAL AETNA,870.75,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $870.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,870.75,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $870.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,CENPATICO,ALL MEDICAID CENPATICO,870.75,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $870.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,740.14,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $740.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,CIGNA,ALL COMMERCIAL CIGNA,609.53,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $609.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,COFINITY,COFINITY,870.75,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $870.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,827.21,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $827.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,731.43,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $731.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,618.23,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $618.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,635.65,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $635.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,423.18,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $423.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,740.14,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $740.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,HUMANA,HUMANA CHOICE CARE PPO,740.14,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $740.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,635.65,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $635.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,870.75,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $870.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,435.38,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $435.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,731.43,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $731.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,653.06,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $653.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,801.09,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $801.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,555.80,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $555.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,626.94,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $626.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,626.94,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $626.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,539.87,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $539.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,626.94,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $626.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,626.94,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $626.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10002756,CDM,,,,both,,,870.7500,574.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,522.45,,,,,,,423.1800,870.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $870.75 in Billed Charges for Rev 278 Proc C1713 = $522.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,AETNA,AETNA HSHS,167.88,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $167.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,AETNA,ALL COMMERCIAL AETNA,259.88,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,259.88,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,CENPATICO,ALL MEDICAID CENPATICO,259.88,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,220.90,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $220.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,CIGNA,ALL COMMERCIAL CIGNA,181.92,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $181.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,COFINITY,COFINITY,259.88,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,246.89,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $246.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,218.30,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $218.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,184.51,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $184.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,189.71,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $189.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,126.30,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $126.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,220.90,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $220.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,HUMANA,HUMANA CHOICE CARE PPO,220.90,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $220.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,189.71,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $189.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,259.88,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,129.94,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $129.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,218.30,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $218.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,194.91,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $194.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,239.09,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $239.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,165.88,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $165.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,187.11,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $187.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,187.11,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $187.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,161.13,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $161.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,187.11,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $187.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,187.11,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $187.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STEP DRILL FOR 3.0 KNOTLESS SUTURE TAK,C1713,HCPCS,278,RC,10074278,CDM,,,,both,,,259.8800,171.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,155.93,,,,,,,126.3000,259.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $259.88 in Billed Charges for Rev 278 Proc C1713 = $155.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,AETNA,AETNA HSHS,480.77,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $480.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,AETNA,ALL COMMERCIAL AETNA,744.22,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $744.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,744.22,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $744.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,CENPATICO,ALL MEDICAID CENPATICO,744.22,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $744.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,632.59,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $632.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,CIGNA,ALL COMMERCIAL CIGNA,520.95,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $520.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,COFINITY,COFINITY,744.22,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $744.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,707.01,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $707.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,625.14,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $625.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,528.40,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $528.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,543.28,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $543.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,361.69,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $361.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,632.59,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $632.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,HUMANA,HUMANA CHOICE CARE PPO,632.59,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $632.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,543.28,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $543.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,744.22,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $744.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,372.11,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $372.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,625.14,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $625.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,558.17,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $558.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,684.68,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $684.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,475.04,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $475.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,535.84,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $535.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,535.84,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $535.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,461.42,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $461.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,535.84,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $535.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,535.84,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $535.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR 4.5 FOOTPRINT,C1713,HCPCS,278,RC,10053783,CDM,,,,both,,,744.2200,491.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,446.53,,,,,,,361.6900,744.2200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $744.22 in Billed Charges for Rev 278 Proc C1713 = $446.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,AETNA,AETNA HSHS,580.64,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $580.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,AETNA,ALL COMMERCIAL AETNA,898.83,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $898.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,898.83,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $898.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,CENPATICO,ALL MEDICAID CENPATICO,898.83,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $898.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,764.01,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $764.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,CIGNA,ALL COMMERCIAL CIGNA,629.18,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $629.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,COFINITY,COFINITY,898.83,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $898.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,853.89,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $853.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,755.02,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $755.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,638.17,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $638.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,656.15,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $656.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,436.83,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $436.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,764.01,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $764.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,HUMANA,HUMANA CHOICE CARE PPO,764.01,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $764.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,656.15,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $656.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,898.83,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $898.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,449.42,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $449.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,755.02,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $755.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,674.12,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $674.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,826.92,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $826.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,573.72,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $573.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,647.16,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $647.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,647.16,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $647.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,557.27,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $557.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,647.16,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $647.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,647.16,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $647.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE ANCHOR NANOTACK WITH FLEX INSERTER 1.4MM,C1713,HCPCS,278,RC,OML0443,CDM,,,,both,,,898.8300,593.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,539.30,,,,,,,436.8300,898.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $898.83 in Billed Charges for Rev 278 Proc C1713 = $539.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,AETNA,AETNA HSHS,734.76,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $734.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,AETNA,ALL COMMERCIAL AETNA,1137.40,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $1,137.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,ANTHEM,ANTHEM POS/HMO,591.45,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $591.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,ANTHEM,ANTHEM PPO,591.45,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $591.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1137.40,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $1,137.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,CENPATICO,ALL MEDICAID CENPATICO,1137.40,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $1,137.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,966.79,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $966.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,CIGNA,ALL COMMERCIAL CIGNA,796.18,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $796.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,COFINITY,COFINITY,1137.40,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $1,137.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1080.53,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $1,080.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,955.42,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $955.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,807.55,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $807.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,830.30,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $830.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,552.78,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $552.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,966.79,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $966.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,HUMANA,HUMANA CHOICE CARE PPO,966.79,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $966.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,830.30,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $830.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1137.40,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $1,137.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,568.70,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $568.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,955.42,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $955.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,853.05,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $853.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1046.41,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $1,046.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,726.00,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $726.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,818.93,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $818.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,818.93,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $818.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,705.19,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $705.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,818.93,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $818.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,818.93,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $818.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10093930,CDM,,,,both,,,1137.4000,750.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,682.44,,,,,,,552.7800,1137.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,137.40 in Billed Charges for Rev 278 Proc C1713 = $682.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,AETNA,AETNA HSHS,144.92,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $144.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,AETNA,ALL COMMERCIAL AETNA,224.33,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $224.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,224.33,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $224.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,CENPATICO,ALL MEDICAID CENPATICO,224.33,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $224.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,190.68,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $190.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,CIGNA,ALL COMMERCIAL CIGNA,157.03,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $157.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,COFINITY,COFINITY,224.33,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $224.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,213.11,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $213.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,188.44,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $188.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,159.27,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $159.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,163.76,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $163.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,109.02,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $109.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,190.68,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $190.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,HUMANA,HUMANA CHOICE CARE PPO,190.68,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $190.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,163.76,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $163.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,224.33,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $224.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,112.17,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $112.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,188.44,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $188.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,168.25,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $168.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,206.38,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $206.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,143.19,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $143.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,161.52,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $161.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,161.52,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $161.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,139.08,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $139.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,161.52,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $161.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,161.52,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $161.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SUTURE TAPE XBRAID TT CTX WHITE/BLACK,C1713,HCPCS,278,RC,10088476,CDM,,,,both,,,224.3300,148.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,134.60,,,,,,,109.0200,224.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $224.33 in Billed Charges for Rev 278 Proc C1713 = $134.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,AETNA,AETNA HSHS,1250.66,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,250.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,AETNA,ALL COMMERCIAL AETNA,1936.00,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,ANTHEM,ANTHEM POS/HMO,1006.72,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,006.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,ANTHEM,ANTHEM PPO,1006.72,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,006.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1936.00,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,CENPATICO,ALL MEDICAID CENPATICO,1936.00,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1645.60,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,645.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,CIGNA,ALL COMMERCIAL CIGNA,1355.20,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,355.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,COFINITY,COFINITY,1936.00,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1839.20,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,839.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,1626.24,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,626.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1374.56,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,374.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1413.28,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,413.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,940.90,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $940.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1645.60,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,645.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,HUMANA,HUMANA CHOICE CARE PPO,1645.60,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,645.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1413.28,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,413.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1936.00,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,968.00,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $968.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1626.24,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,626.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1452.00,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1781.12,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,781.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1235.75,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,235.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1393.92,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,393.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1393.92,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,393.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1200.32,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,200.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1393.92,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,393.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1393.92,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,393.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIX N TACK SWIVLOCK FIBERLINK SUTURETAPE BIOCMPS,C1713,HCPCS,278,RC,10088656,CDM,,,,both,,,1936.0000,1277.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1161.60,,,,,,,940.9000,1936.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,936.00 in Billed Charges for Rev 278 Proc C1713 = $1,161.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,AETNA,AETNA HSHS,4056.82,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,056.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,AETNA,ALL COMMERCIAL AETNA,6279.90,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $6,279.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,ANTHEM,ANTHEM POS/HMO,3265.55,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,265.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,ANTHEM,ANTHEM PPO,3265.55,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,265.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6279.90,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $6,279.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,CENPATICO,ALL MEDICAID CENPATICO,6279.90,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $6,279.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5337.92,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $5,337.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,CIGNA,ALL COMMERCIAL CIGNA,4395.93,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,395.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,COFINITY,COFINITY,6279.90,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $6,279.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5965.91,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $5,965.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,5275.12,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $5,275.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4458.73,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,458.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4584.33,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,584.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,3052.03,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,052.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5337.92,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $5,337.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,HUMANA,HUMANA CHOICE CARE HMO,3139.95,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,139.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,HUMANA,HUMANA CHOICE CARE PPO,5337.92,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $5,337.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,HUMANA,HUMANA NATIIONAL POS HMO,3139.95,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,139.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4584.33,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,584.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,6279.90,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $6,279.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3139.95,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,139.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5275.12,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $5,275.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4709.93,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,709.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5777.51,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $5,777.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3139.95,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,139.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3139.95,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,139.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,PREVEA HEALTH NETWORK,PREVEA360,3139.95,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,139.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3139.95,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,139.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4008.46,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,008.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4521.53,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,521.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4521.53,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,521.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3893.54,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,893.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4521.53,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,521.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4521.53,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $4,521.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION ARTHREX SPEEDBRIDGE FIBERTAK,C1713,HCPCS,278,RC,ASC228,CDM,,,,both,,,6279.9000,4144.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3767.94,,,,,,,3052.0300,6279.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,279.90 in Billed Charges for Rev 278 Proc C1713 = $3,767.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,AETNA,AETNA HSHS,1133.41,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,133.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,AETNA,ALL COMMERCIAL AETNA,1754.50,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,754.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,ANTHEM,ANTHEM POS/HMO,912.34,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $912.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,ANTHEM,ANTHEM PPO,912.34,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $912.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1754.50,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,754.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,CENPATICO,ALL MEDICAID CENPATICO,1754.50,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,754.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1491.33,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,491.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,CIGNA,ALL COMMERCIAL CIGNA,1228.15,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,228.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,COFINITY,COFINITY,1754.50,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,754.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1666.78,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,666.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,1473.78,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,473.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1245.70,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,245.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1280.79,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,280.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,852.69,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $852.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1491.33,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,491.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,HUMANA,HUMANA CHOICE CARE PPO,1491.33,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,491.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1280.79,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,280.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1754.50,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,754.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,877.25,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $877.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1473.78,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,473.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1315.88,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,315.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1614.14,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,614.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1119.90,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,119.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1263.24,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,263.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1263.24,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,263.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1087.79,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,087.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1263.24,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,263.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1263.24,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,263.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SYSTEM FIXATION SWIVELOCK BIOCOMPOSITE L19.1 MM OD4.75 MM SE,C1713,HCPCS,278,RC,10083423,CDM,,,,both,,,1754.5000,1157.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1052.70,,,,,,,852.6900,1754.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,754.50 in Billed Charges for Rev 278 Proc C1713 = $1,052.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,AETNA,AETNA HSHS,2337.16,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,337.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,AETNA,ALL COMMERCIAL AETNA,3617.90,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,617.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,ANTHEM,ANTHEM POS/HMO,1881.31,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $1,881.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,ANTHEM,ANTHEM PPO,1881.31,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $1,881.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3617.90,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,617.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,CENPATICO,ALL MEDICAID CENPATICO,3617.90,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,617.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3075.22,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,075.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,CIGNA,ALL COMMERCIAL CIGNA,2532.53,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,532.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,COFINITY,COFINITY,3617.90,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,617.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3437.01,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,437.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,3039.04,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,039.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2568.71,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,568.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2641.07,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,641.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,1758.30,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $1,758.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3075.22,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,075.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,HUMANA,HUMANA CHOICE CARE HMO,1808.95,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $1,808.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,HUMANA,HUMANA CHOICE CARE PPO,3075.22,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,075.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,HUMANA,HUMANA NATIIONAL POS HMO,1808.95,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $1,808.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2641.07,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,641.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,3617.90,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,617.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1808.95,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $1,808.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3039.04,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,039.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2713.43,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,713.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3328.47,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $3,328.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2309.31,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,309.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2604.89,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,604.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2604.89,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,604.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2243.10,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,243.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2604.89,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,604.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2604.89,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,604.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10079203,CDM,,,,both,,,3617.9000,2387.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2170.74,,,,,,,1758.3000,3617.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,617.90 in Billed Charges for Rev 278 Proc C1713 = $2,170.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,AETNA,AETNA HSHS,430.56,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $430.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,AETNA,ALL COMMERCIAL AETNA,666.50,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $666.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,666.50,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $666.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,CENPATICO,ALL MEDICAID CENPATICO,666.50,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $666.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,566.53,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $566.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,CIGNA,ALL COMMERCIAL CIGNA,466.55,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $466.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,COFINITY,COFINITY,666.50,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $666.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,633.18,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $633.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,HEALTH CARE ALLIANCE,THE ALLIANCE,559.86,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $559.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,473.22,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $473.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,486.55,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $486.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,HSHS EMPLOYEES,HSHS EMPLOYEES,323.92,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $323.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,566.53,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $566.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,HUMANA,HUMANA CHOICE CARE PPO,566.53,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $566.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,486.55,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $486.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,LIVE360,LIVE360 HSHS HEALTHY PLAN,666.50,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $666.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,333.25,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $333.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,559.86,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $559.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,499.88,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $499.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,613.18,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $613.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,425.43,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $425.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,479.88,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $479.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,479.88,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $479.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,413.23,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $413.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,479.88,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $479.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,479.88,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $479.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10058937,CDM,,,,both,,,666.5000,439.8900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,399.90,,,,,,,323.9200,666.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $666.50 in Billed Charges for Rev 278 Proc C1713 = $399.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,AETNA,AETNA HSHS,531.74,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $531.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,AETNA,ALL COMMERCIAL AETNA,823.13,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $823.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,823.13,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $823.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,CENPATICO,ALL MEDICAID CENPATICO,823.13,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $823.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,699.66,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $699.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,CIGNA,ALL COMMERCIAL CIGNA,576.19,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $576.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,COFINITY,COFINITY,823.13,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $823.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,781.97,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $781.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,691.43,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $691.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,584.42,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $584.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,600.88,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $600.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,400.04,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $400.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,699.66,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $699.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,HUMANA,HUMANA CHOICE CARE PPO,699.66,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $699.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,600.88,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $600.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,823.13,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $823.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,411.57,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $411.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,691.43,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $691.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,617.35,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $617.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,757.28,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $757.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,525.40,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $525.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,592.65,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $592.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,592.65,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $592.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,510.34,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $510.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,592.65,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $592.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,592.65,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $592.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TAP SYNTHES 7.3 CANNULATED CONICAL LOCKING SCREW,C1713,HCPCS,278,RC,10002716,CDM,,,,both,,,823.1300,543.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,493.88,,,,,,,400.0400,823.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $823.13 in Billed Charges for Rev 278 Proc C1713 = $493.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,AETNA,AETNA HSHS,109.88,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $109.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,AETNA,ALL COMMERCIAL AETNA,170.10,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $170.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,170.10,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $170.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,CENPATICO,ALL MEDICAID CENPATICO,170.10,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $170.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,144.59,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $144.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,CIGNA,ALL COMMERCIAL CIGNA,119.07,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $119.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,COFINITY,COFINITY,170.10,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $170.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,161.60,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $161.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,142.88,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $142.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,120.77,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $120.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,124.17,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $124.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,82.67,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $82.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,144.59,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $144.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,HUMANA,HUMANA CHOICE CARE PPO,144.59,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $144.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,124.17,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $124.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,170.10,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $170.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,85.05,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $85.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,142.88,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $142.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,127.58,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $127.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,156.49,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $156.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,108.57,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $108.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,122.47,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $122.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,122.47,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $122.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,105.46,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $105.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,122.47,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $122.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,122.47,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $122.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE 16 HOLE BENDING 4.5 MM RECONSTRUCTION PLATE,C1713,HCPCS,278,RC,10001465,CDM,,,,both,,,170.1000,112.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,102.06,,,,,,,82.6700,170.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $170.10 in Billed Charges for Rev 278 Proc C1713 = $102.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,AETNA,AETNA HSHS,101.58,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $101.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,AETNA,ALL COMMERCIAL AETNA,157.25,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $157.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,157.25,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $157.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,CENPATICO,ALL MEDICAID CENPATICO,157.25,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $157.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,133.66,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $133.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,CIGNA,ALL COMMERCIAL CIGNA,110.08,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $110.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,COFINITY,COFINITY,157.25,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $157.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,149.39,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $149.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,132.09,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $132.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,111.65,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $111.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,114.79,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $114.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,76.42,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $76.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,133.66,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $133.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,HUMANA,HUMANA CHOICE CARE PPO,133.66,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $133.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,114.79,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $114.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,157.25,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $157.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,78.63,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $78.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,132.09,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $132.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,117.94,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $117.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,144.67,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $144.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,100.37,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $100.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,113.22,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $113.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,113.22,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $113.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,97.50,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $97.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,113.22,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $113.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,113.22,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $113.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TEMPLATE SYNTHES MTRX-MAND 1.5MM 3X3 H STRT,C1713,HCPCS,278,RC,10040200,CDM,,,,both,,,157.2500,103.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,94.35,,,,,,,76.4200,157.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $157.25 in Billed Charges for Rev 278 Proc C1713 = $94.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,AETNA,AETNA HSHS,281.11,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $281.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,AETNA,ALL COMMERCIAL AETNA,435.16,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $435.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,435.16,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $435.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,CENPATICO,ALL MEDICAID CENPATICO,435.16,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $435.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,369.89,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $369.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,CIGNA,ALL COMMERCIAL CIGNA,304.61,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $304.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,COFINITY,COFINITY,435.16,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $435.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,413.40,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $413.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,365.53,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $365.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,308.96,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $308.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,317.67,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $317.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,211.49,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $211.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,369.89,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $369.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,HUMANA,HUMANA CHOICE CARE PPO,369.89,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $369.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,317.67,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $317.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,435.16,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $435.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,217.58,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $217.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,365.53,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $365.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,326.37,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $326.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,400.35,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $400.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,277.76,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $277.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,313.32,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $313.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,313.32,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $313.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,269.80,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $269.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,313.32,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $313.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,313.32,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $313.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TIGHTROPE ABS ACL ARTHREX,C1713,HCPCS,278,RC,10053867,CDM,,,,both,,,435.1600,287.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,261.10,,,,,,,211.4900,435.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $435.16 in Billed Charges for Rev 278 Proc C1713 = $261.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,AETNA,AETNA HSHS,1922.64,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,922.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,AETNA,ALL COMMERCIAL AETNA,2976.22,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,976.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,ANTHEM,ANTHEM POS/HMO,1547.63,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,547.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,ANTHEM,ANTHEM PPO,1547.63,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,547.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2976.22,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,976.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,CENPATICO,ALL MEDICAID CENPATICO,2976.22,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,976.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2529.79,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,529.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,CIGNA,ALL COMMERCIAL CIGNA,2083.35,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,083.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,COFINITY,COFINITY,2976.22,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,976.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2827.41,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,827.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,HEALTH CARE ALLIANCE,THE ALLIANCE,2500.02,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,500.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2113.12,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,113.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2172.64,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,172.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,HSHS EMPLOYEES,HSHS EMPLOYEES,1446.44,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,446.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2529.79,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,529.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,HUMANA,HUMANA CHOICE CARE HMO,1488.11,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,488.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,HUMANA,HUMANA CHOICE CARE PPO,2529.79,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,529.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,HUMANA,HUMANA NATIIONAL POS HMO,1488.11,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,488.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2172.64,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,172.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,LIVE360,LIVE360 HSHS HEALTHY PLAN,2976.22,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,976.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1488.11,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,488.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2500.02,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,500.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2232.17,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,232.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2738.12,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,738.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1899.72,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,899.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2142.88,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,142.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2142.88,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,142.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1845.26,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,845.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2142.88,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,142.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2142.88,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $2,142.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10077212,CDM,,,,both,,,2976.2200,1964.3100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1785.73,,,,,,,1446.4400,2976.2200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,976.22 in Billed Charges for Rev 278 Proc C1713 = $1,785.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,AETNA,AETNA HSHS,34.41,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $34.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,AETNA,ALL COMMERCIAL AETNA,53.26,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $53.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,53.26,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $53.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,CENPATICO,ALL MEDICAID CENPATICO,53.26,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $53.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,45.27,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $45.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,CIGNA,ALL COMMERCIAL CIGNA,37.28,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $37.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,COFINITY,COFINITY,53.26,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $53.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,50.60,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $50.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,44.74,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $44.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,37.81,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $37.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,38.88,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $38.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,25.88,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $25.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,45.27,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $45.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,HUMANA,HUMANA CHOICE CARE PPO,45.27,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $45.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,38.88,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $38.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,53.26,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $53.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.63,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $26.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,44.74,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $44.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,39.95,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $39.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,49.00,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,34.00,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $34.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,38.35,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $38.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,38.35,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $38.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,33.02,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $33.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,38.35,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $38.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,38.35,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $38.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 10.0MM,C1713,HCPCS,278,RC,10026128,CDM,,,,both,,,53.2600,35.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.96,,,,,,,25.8800,53.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $53.26 in Billed Charges for Rev 278 Proc C1713 = $31.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,AETNA,AETNA HSHS,36.83,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $36.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,AETNA,ALL COMMERCIAL AETNA,57.02,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $57.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,57.02,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $57.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,CENPATICO,ALL MEDICAID CENPATICO,57.02,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $57.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,48.47,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $48.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,CIGNA,ALL COMMERCIAL CIGNA,39.91,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $39.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,COFINITY,COFINITY,57.02,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $57.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,54.17,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $54.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,HEALTH CARE ALLIANCE,THE ALLIANCE,47.90,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $47.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,40.48,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $40.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,41.62,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $41.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,HSHS EMPLOYEES,HSHS EMPLOYEES,27.71,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $27.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,48.47,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $48.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,HUMANA,HUMANA CHOICE CARE PPO,48.47,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $48.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,41.62,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $41.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,LIVE360,LIVE360 HSHS HEALTHY PLAN,57.02,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $57.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,28.51,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $28.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,47.90,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $47.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,42.77,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $42.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,52.46,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $52.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,36.40,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $36.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,41.05,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $41.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,41.05,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $41.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,35.35,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $35.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,41.05,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $41.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,41.05,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $41.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 13.0MM,C1713,HCPCS,278,RC,10046444,CDM,,,,both,,,57.0200,37.6300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,34.21,,,,,,,27.7100,57.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.02 in Billed Charges for Rev 278 Proc C1713 = $34.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,AETNA,AETNA HSHS,158.23,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $158.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,AETNA,ALL COMMERCIAL AETNA,244.94,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $244.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,244.94,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $244.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,CENPATICO,ALL MEDICAID CENPATICO,244.94,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $244.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,208.20,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $208.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,CIGNA,ALL COMMERCIAL CIGNA,171.46,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $171.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,COFINITY,COFINITY,244.94,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $244.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,232.69,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $232.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,205.75,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $205.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,173.91,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $173.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,178.81,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $178.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,119.04,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $119.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,208.20,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $208.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,HUMANA,HUMANA CHOICE CARE PPO,208.20,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $208.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,178.81,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $178.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,244.94,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $244.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,122.47,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $122.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,205.75,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $205.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,183.71,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $183.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,225.34,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $225.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,156.35,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $156.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,176.36,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $176.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,176.36,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $176.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,151.86,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $151.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,176.36,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $176.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,176.36,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $176.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WASHER SYNTHES 5.5 SPIKED 13.5MM,C1713,HCPCS,278,RC,10006346,CDM,,,,both,,,244.9400,161.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,146.96,,,,,,,119.0400,244.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.94 in Billed Charges for Rev 278 Proc C1713 = $146.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,AETNA,AETNA HSHS,21.79,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $21.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,AETNA,ALL COMMERCIAL AETNA,33.73,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $33.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,33.73,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $33.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,CENPATICO,ALL MEDICAID CENPATICO,33.73,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $33.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,28.67,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $28.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,CIGNA,ALL COMMERCIAL CIGNA,23.61,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $23.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,COFINITY,COFINITY,33.73,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $33.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,32.04,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $32.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,28.33,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $28.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,23.95,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $23.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,24.62,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $24.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,16.39,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $16.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,28.67,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $28.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,HUMANA,HUMANA CHOICE CARE PPO,28.67,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $28.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,24.62,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $24.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,33.73,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $33.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.87,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $16.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,28.33,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $28.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,25.30,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $25.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,31.03,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $31.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,21.53,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $21.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,24.29,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $24.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,24.29,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $24.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,20.91,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $20.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,24.29,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $24.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,24.29,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $24.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078551,CDM,,,,both,,,33.7300,22.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,20.24,,,,,,,16.3900,33.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.73 in Billed Charges for Rev 278 Proc C1713 = $20.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,AETNA,AETNA HSHS,13.64,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $13.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,AETNA,ALL COMMERCIAL AETNA,21.11,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $21.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,21.11,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $21.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,CENPATICO,ALL MEDICAID CENPATICO,21.11,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $21.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.94,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $17.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,CIGNA,ALL COMMERCIAL CIGNA,14.78,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,COFINITY,COFINITY,21.11,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $21.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,20.05,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $20.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,17.73,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $17.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.99,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $14.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15.41,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $15.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,10.26,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $10.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.94,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $17.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,HUMANA,HUMANA CHOICE CARE PPO,17.94,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $17.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15.41,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $15.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,21.11,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $21.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.56,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $10.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.73,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $17.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.83,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,19.42,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $19.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.47,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $13.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15.20,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $15.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15.20,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $15.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13.09,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $13.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15.20,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $15.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15.20,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $15.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10078552,CDM,,,,both,,,21.1100,13.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.67,,,,,,,10.2600,21.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.11 in Billed Charges for Rev 278 Proc C1713 = $12.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,AETNA,AETNA HSHS,94.48,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $94.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,AETNA,ALL COMMERCIAL AETNA,146.25,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $146.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,146.25,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $146.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,CENPATICO,ALL MEDICAID CENPATICO,146.25,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $146.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.31,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $124.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,CIGNA,ALL COMMERCIAL CIGNA,102.38,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $102.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,COFINITY,COFINITY,146.25,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $146.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.94,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $138.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,HEALTH CARE ALLIANCE,THE ALLIANCE,122.85,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $122.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.84,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $103.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.76,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $106.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,HSHS EMPLOYEES,HSHS EMPLOYEES,71.08,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $71.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.31,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $124.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,HUMANA,HUMANA CHOICE CARE PPO,124.31,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $124.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.76,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $106.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,LIVE360,LIVE360 HSHS HEALTHY PLAN,146.25,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $146.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.13,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $73.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.85,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $122.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.69,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $109.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,134.55,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $134.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.35,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $93.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.30,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $105.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.30,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $105.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.68,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $90.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.30,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $105.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.30,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $105.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE FIXATION .035IN KIRSCHNER TITANIUM,C1713,HCPCS,278,RC,10043761,CDM,,,,both,,,146.2500,96.5300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.75,,,,,,,71.0800,146.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.25 in Billed Charges for Rev 278 Proc C1713 = $87.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,AETNA,AETNA HSHS,60.79,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $60.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,AETNA,ALL COMMERCIAL AETNA,94.10,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $94.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,94.10,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $94.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,CENPATICO,ALL MEDICAID CENPATICO,94.10,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $94.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.99,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $79.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,CIGNA,ALL COMMERCIAL CIGNA,65.87,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $65.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,COFINITY,COFINITY,94.10,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $94.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,89.40,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $89.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,79.04,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $79.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.81,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $66.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,68.69,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $68.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,45.73,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $45.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.99,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $79.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,HUMANA,HUMANA CHOICE CARE PPO,79.99,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $79.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,68.69,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $68.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,94.10,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $94.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,47.05,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $47.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,79.04,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $79.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,70.58,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $70.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,86.57,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $86.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,60.06,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $60.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,67.75,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $67.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,67.75,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $67.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.34,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $58.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,67.75,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $67.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,67.75,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $67.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10017190,CDM,,,,both,,,94.1000,62.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,56.46,,,,,,,45.7300,94.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $94.10 in Billed Charges for Rev 278 Proc C1713 = $56.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,AETNA,AETNA HSHS,18.72,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,AETNA,ALL COMMERCIAL AETNA,28.98,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $28.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,28.98,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $28.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,CENPATICO,ALL MEDICAID CENPATICO,28.98,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $28.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,24.63,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $24.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,CIGNA,ALL COMMERCIAL CIGNA,20.29,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $20.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,COFINITY,COFINITY,28.98,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $28.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,27.53,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $27.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,HEALTH CARE ALLIANCE,THE ALLIANCE,24.34,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $24.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,20.58,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,21.16,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $21.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,HSHS EMPLOYEES,HSHS EMPLOYEES,14.08,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $14.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,24.63,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $24.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,HUMANA,HUMANA CHOICE CARE PPO,24.63,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $24.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,21.16,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $21.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,LIVE360,LIVE360 HSHS HEALTHY PLAN,28.98,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $28.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,14.49,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $14.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,24.34,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $24.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,21.74,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $21.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,26.66,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $26.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,18.50,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $18.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,20.87,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $20.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,20.87,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $20.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.97,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $17.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,20.87,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $20.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,20.87,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $20.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .028,C1713,HCPCS,278,RC,10056242,CDM,,,,both,,,28.9800,19.1300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,17.39,,,,,,,14.0800,28.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $28.98 in Billed Charges for Rev 278 Proc C1713 = $17.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,AETNA,AETNA HSHS,12.08,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $12.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,AETNA,ALL COMMERCIAL AETNA,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,CENPATICO,ALL MEDICAID CENPATICO,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15.90,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,CIGNA,ALL COMMERCIAL CIGNA,13.09,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $13.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,COFINITY,COFINITY,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17.77,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $17.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,15.71,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $15.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.28,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13.65,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $13.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,9.09,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $9.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15.90,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,HUMANA,HUMANA CHOICE CARE PPO,15.90,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13.65,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $13.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.35,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $9.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15.71,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $15.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.03,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,17.20,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $17.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.94,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $11.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.46,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.46,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.59,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $11.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.46,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.46,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE KIRSCHNER .045 X 4 PLAIN,C1713,HCPCS,278,RC,10056243,CDM,,,,both,,,18.7000,12.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.22,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.70 in Billed Charges for Rev 278 Proc C1713 = $11.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,AETNA,AETNA HSHS,185.47,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $185.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,AETNA,ALL COMMERCIAL AETNA,287.10,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $287.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,287.10,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $287.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,CENPATICO,ALL MEDICAID CENPATICO,287.10,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $287.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,244.04,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $244.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,CIGNA,ALL COMMERCIAL CIGNA,200.97,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $200.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,COFINITY,COFINITY,287.10,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $287.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,272.75,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $272.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,HEALTH CARE ALLIANCE,THE ALLIANCE,241.16,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $241.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,203.84,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $203.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,209.58,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $209.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,HSHS EMPLOYEES,HSHS EMPLOYEES,139.53,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $139.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,244.04,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $244.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,HUMANA,HUMANA CHOICE CARE PPO,244.04,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $244.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,209.58,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $209.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,LIVE360,LIVE360 HSHS HEALTHY PLAN,287.10,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $287.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,143.55,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $143.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,241.16,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $241.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,215.33,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $215.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,264.13,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $264.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,183.26,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $183.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,206.71,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $206.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,206.71,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $206.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,178.00,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $178.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,206.71,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $206.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,206.71,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $206.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SPOOL 28GA,C1713,HCPCS,278,RC,10025803,CDM,,,,both,,,287.1000,189.4900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,172.26,,,,,,,139.5300,287.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $287.10 in Billed Charges for Rev 278 Proc C1713 = $172.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,AETNA,AETNA HSHS,10.99,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $10.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,AETNA,ALL COMMERCIAL AETNA,17.01,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $17.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17.01,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $17.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,CENPATICO,ALL MEDICAID CENPATICO,17.01,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $17.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.46,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $14.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,CIGNA,ALL COMMERCIAL CIGNA,11.91,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $11.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,COFINITY,COFINITY,17.01,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $17.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16.16,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $16.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,14.29,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $14.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12.08,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $12.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.42,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $12.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,8.27,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $8.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.46,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $14.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,HUMANA,HUMANA CHOICE CARE PPO,14.46,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $14.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.42,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $12.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,17.01,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $17.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.51,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $8.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.29,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $14.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.76,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $12.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.65,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $15.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.86,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $10.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.25,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.25,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.55,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.25,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.25,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.60MM CERCLAGE 175MM,C1713,HCPCS,278,RC,70416401,CDM,,,,both,,,17.0100,11.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.21,,,,,,,8.2700,17.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.01 in Billed Charges for Rev 278 Proc C1713 = $10.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,AETNA,AETNA HSHS,12.51,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,AETNA,ALL COMMERCIAL AETNA,19.37,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $19.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,19.37,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $19.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,CENPATICO,ALL MEDICAID CENPATICO,19.37,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $19.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,16.46,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $16.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,CIGNA,ALL COMMERCIAL CIGNA,13.56,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $13.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,COFINITY,COFINITY,19.37,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $19.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,18.40,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $18.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,16.27,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $16.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.75,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $13.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.14,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $14.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,9.41,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $9.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,16.46,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $16.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,HUMANA,HUMANA CHOICE CARE PPO,16.46,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $16.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.14,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $14.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,19.37,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $19.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.69,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $9.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,16.27,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $16.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.53,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $14.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,17.82,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $17.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.36,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $12.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.95,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.95,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.01,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $12.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.95,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.95,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 0.80MM CERCLAGE 200MM,C1713,HCPCS,278,RC,70419072,CDM,,,,both,,,19.3700,12.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.62,,,,,,,9.4100,19.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.37 in Billed Charges for Rev 278 Proc C1713 = $11.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,AETNA,AETNA HSHS,60.59,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $60.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,AETNA,ALL COMMERCIAL AETNA,93.80,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $93.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,93.80,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $93.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,CENPATICO,ALL MEDICAID CENPATICO,93.80,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $93.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.73,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $79.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,CIGNA,ALL COMMERCIAL CIGNA,65.66,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $65.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,COFINITY,COFINITY,93.80,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $93.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,89.11,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $89.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,HEALTH CARE ALLIANCE,THE ALLIANCE,78.79,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $78.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.60,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $66.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,68.47,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $68.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,HSHS EMPLOYEES,HSHS EMPLOYEES,45.59,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $45.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.73,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $79.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,HUMANA,HUMANA CHOICE CARE PPO,79.73,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $79.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,68.47,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $68.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,LIVE360,LIVE360 HSHS HEALTHY PLAN,93.80,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $93.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.90,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $46.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.79,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $78.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,70.35,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $70.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,86.30,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $86.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,59.87,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $59.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,67.54,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $67.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,67.54,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $67.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.16,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $58.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,67.54,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $67.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,67.54,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $67.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10074864,CDM,,,,both,,,93.8000,61.9100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,56.28,,,,,,,45.5900,93.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.80 in Billed Charges for Rev 278 Proc C1713 = $56.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,AETNA,AETNA HSHS,63.75,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,AETNA,ALL COMMERCIAL AETNA,98.69,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $98.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,98.69,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $98.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,CENPATICO,ALL MEDICAID CENPATICO,98.69,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $98.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,83.89,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $83.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,CIGNA,ALL COMMERCIAL CIGNA,69.08,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $69.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,COFINITY,COFINITY,98.69,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $98.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,93.76,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $93.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,82.90,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $82.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,70.07,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $70.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,72.04,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $72.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,47.96,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $47.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,83.89,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $83.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,HUMANA,HUMANA CHOICE CARE PPO,83.89,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $83.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,72.04,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $72.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,98.69,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $98.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,49.35,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $49.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,82.90,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $82.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,74.02,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $74.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,90.79,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $90.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,62.99,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $62.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,71.06,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $71.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,71.06,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $71.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,61.19,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $61.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,71.06,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $71.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,71.06,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $71.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 1.6 COMPRESSION 30MM X 150MM,C1713,HCPCS,278,RC,10084078,CDM,,,,both,,,98.6900,65.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,59.21,,,,,,,47.9600,98.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $98.69 in Billed Charges for Rev 278 Proc C1713 = $59.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,AETNA,AETNA HSHS,44.42,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $44.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,AETNA,ALL COMMERCIAL AETNA,68.76,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $68.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,68.76,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $68.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,CENPATICO,ALL MEDICAID CENPATICO,68.76,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $68.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.45,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $58.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,CIGNA,ALL COMMERCIAL CIGNA,48.13,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $48.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,COFINITY,COFINITY,68.76,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $68.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.32,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $65.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,57.76,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $57.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.82,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $48.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.19,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $50.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,33.42,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $33.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.45,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $58.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,HUMANA,HUMANA CHOICE CARE PPO,58.45,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $58.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.19,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $50.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,68.76,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $68.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.38,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $34.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.76,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $57.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.57,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $51.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.26,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $63.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.89,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $43.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.51,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $49.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.51,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $49.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.63,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $42.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.51,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $49.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.51,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $49.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 GUIDE 240MM,C1713,HCPCS,278,RC,10007977,CDM,,,,both,,,68.7600,45.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.26,,,,,,,33.4200,68.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.76 in Billed Charges for Rev 278 Proc C1713 = $41.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,AETNA,AETNA HSHS,13.35,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $13.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,AETNA,ALL COMMERCIAL AETNA,20.66,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $20.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.66,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $20.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,CENPATICO,ALL MEDICAID CENPATICO,20.66,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $20.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.56,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $17.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,CIGNA,ALL COMMERCIAL CIGNA,14.46,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $14.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,COFINITY,COFINITY,20.66,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $20.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.63,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $19.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,17.35,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $17.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.67,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $14.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15.08,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $15.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,10.04,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $10.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.56,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $17.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,HUMANA,HUMANA CHOICE CARE PPO,17.56,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $17.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15.08,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $15.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.66,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $20.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.33,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $10.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.35,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $17.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.50,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,19.01,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $19.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.19,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $13.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.88,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $14.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.88,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $14.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.81,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $12.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.88,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $14.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.88,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $14.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WIRE SYNTHES 2.0 TITANIUM,C1713,HCPCS,278,RC,10051744,CDM,,,,both,,,20.6600,13.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.40,,,,,,,10.0400,20.6600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.66 in Billed Charges for Rev 278 Proc C1713 = $12.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,AETNA,AETNA HSHS,78.35,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $78.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,AETNA,ALL COMMERCIAL AETNA,121.28,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $121.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,121.28,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $121.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,CENPATICO,ALL MEDICAID CENPATICO,121.28,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $121.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,103.09,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $103.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,CIGNA,ALL COMMERCIAL CIGNA,84.90,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $84.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,COFINITY,COFINITY,121.28,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $121.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,115.22,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $115.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,101.88,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $101.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,86.11,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $86.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,88.53,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $88.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,58.94,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $58.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,103.09,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $103.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,HUMANA,HUMANA CHOICE CARE PPO,103.09,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $103.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,88.53,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $88.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,121.28,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $121.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,60.64,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $60.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,101.88,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $101.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,90.96,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $90.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,111.58,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $111.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.41,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $77.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.32,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $87.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.32,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $87.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.19,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $75.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.32,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $87.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.32,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $87.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,10084003,CDM,,,,both,,,121.2800,80.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,72.77,,,,,,,58.9400,121.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $121.28 in Billed Charges for Rev 278 Proc C1713 = $72.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,AETNA,AETNA HSHS,870.37,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $870.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,AETNA,ALL COMMERCIAL AETNA,1347.32,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,347.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,ANTHEM,ANTHEM POS/HMO,700.61,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $700.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,ANTHEM,ANTHEM PPO,700.61,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $700.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1347.32,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,347.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,CENPATICO,ALL MEDICAID CENPATICO,1347.32,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,347.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1145.22,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,145.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,CIGNA,ALL COMMERCIAL CIGNA,943.12,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $943.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,COFINITY,COFINITY,1347.32,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,347.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1279.95,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,279.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,1131.75,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,131.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,956.60,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $956.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,983.54,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $983.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,654.80,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $654.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1145.22,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,145.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,HUMANA,HUMANA CHOICE CARE PPO,1145.22,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,145.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,983.54,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $983.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1347.32,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,347.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,673.66,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $673.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1131.75,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,131.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1010.49,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,010.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1239.53,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $1,239.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,859.99,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $859.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,970.07,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $970.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,970.07,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $970.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,835.34,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $835.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,970.07,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $970.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,970.07,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $970.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH SURG 7X5.5IN GROIN 2 LYR MFIL SELF XPD MEM,C1781,HCPCS,278,RC,10054156,CDM,,,,both,,,1347.3200,889.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,808.39,,,,,,,654.8000,1347.3200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,347.32 in Billed Charges for Rev 278 Proc C1781 = $808.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,AETNA,AETNA HSHS,803.85,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $803.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,AETNA,ALL COMMERCIAL AETNA,1244.35,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,244.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,ANTHEM,ANTHEM POS/HMO,647.06,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $647.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,ANTHEM,ANTHEM PPO,647.06,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $647.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1244.35,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,244.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,CENPATICO,ALL MEDICAID CENPATICO,1244.35,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,244.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1057.70,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,057.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,CIGNA,ALL COMMERCIAL CIGNA,871.05,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $871.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,COFINITY,COFINITY,1244.35,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,244.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1182.13,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,182.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,1045.25,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,045.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,883.49,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $883.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,908.38,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $908.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,604.75,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $604.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1057.70,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,057.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,HUMANA,HUMANA CHOICE CARE PPO,1057.70,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,057.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,908.38,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $908.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1244.35,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,244.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,622.18,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $622.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1045.25,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,045.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,933.26,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $933.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1144.80,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $1,144.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,794.27,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $794.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,895.93,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $895.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,895.93,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $895.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,771.50,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $771.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,895.93,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $895.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,895.93,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $895.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHEET MEDPOR ULTRA THIN 50X46X0.85,C1781,HCPCS,278,RC,10049238,CDM,,,,both,,,1244.3500,821.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,746.61,,,,,,,604.7500,1244.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,244.35 in Billed Charges for Rev 278 Proc C1781 = $746.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,AETNA,AETNA HSHS,244.07,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $244.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,AETNA,ALL COMMERCIAL AETNA,377.82,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $377.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,377.82,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $377.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,CENPATICO,ALL MEDICAID CENPATICO,377.82,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $377.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,321.15,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $321.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,CIGNA,ALL COMMERCIAL CIGNA,264.47,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $264.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,COFINITY,COFINITY,377.82,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $377.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,358.93,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $358.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,317.37,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $317.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,268.25,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $268.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,275.81,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $275.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,183.62,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $183.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,321.15,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $321.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,HUMANA,HUMANA CHOICE CARE PPO,321.15,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $321.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,275.81,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $275.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,377.82,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $377.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,188.91,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $188.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,317.37,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $317.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,283.37,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $283.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,347.59,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $347.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,241.16,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $241.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,272.03,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $272.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,272.03,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $272.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,234.25,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $234.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,272.03,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $272.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,272.03,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $272.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH ECHELON FLEX 60GUARD SEAM WL GORE BIOABSORBABLE BLUE GOLD,C1781,HCPCS,278,RC,10051172,CDM,,,,both,,,377.8200,249.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,226.69,,,,,,,183.6200,377.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $377.82 in Billed Charges for Rev 278 Proc C1781 = $226.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,AETNA,AETNA HSHS,2382.58,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,382.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,AETNA,ALL COMMERCIAL AETNA,3688.20,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,688.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,ANTHEM,ANTHEM POS/HMO,1917.86,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $1,917.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,ANTHEM,ANTHEM PPO,1917.86,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $1,917.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3688.20,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,688.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,CENPATICO,ALL MEDICAID CENPATICO,3688.20,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,688.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3134.97,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,134.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,CIGNA,ALL COMMERCIAL CIGNA,2581.74,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,581.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,COFINITY,COFINITY,3688.20,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,688.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3503.79,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,503.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,3098.09,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,098.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2618.62,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,618.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2692.39,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,692.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,1792.47,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $1,792.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3134.97,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,134.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,HUMANA,HUMANA CHOICE CARE HMO,1844.10,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $1,844.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,HUMANA,HUMANA CHOICE CARE PPO,3134.97,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,134.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,HUMANA,HUMANA NATIIONAL POS HMO,1844.10,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $1,844.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2692.39,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,692.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,3688.20,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,688.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1844.10,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $1,844.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3098.09,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,098.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2766.15,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,766.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3393.14,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $3,393.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2354.18,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,354.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2655.50,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,655.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2655.50,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,655.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2286.68,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,286.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2655.50,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,655.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2655.50,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,655.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 10X30CM,C1781,HCPCS,278,RC,10068242,CDM,,,,both,,,3688.2000,2434.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2212.92,,,,,,,1792.4700,3688.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,688.20 in Billed Charges for Rev 278 Proc C1781 = $2,212.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,AETNA,AETNA HSHS,3182.58,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,182.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,AETNA,ALL COMMERCIAL AETNA,4926.60,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,ANTHEM,ANTHEM POS/HMO,2561.83,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $2,561.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,ANTHEM,ANTHEM PPO,2561.83,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $2,561.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4926.60,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,CENPATICO,ALL MEDICAID CENPATICO,4926.60,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4187.61,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,187.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,CIGNA,ALL COMMERCIAL CIGNA,3448.62,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,448.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,COFINITY,COFINITY,4926.60,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4680.27,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,680.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,4138.34,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,138.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3497.89,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,497.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3596.42,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,596.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,2394.33,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $2,394.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4187.61,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,187.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,HUMANA,HUMANA CHOICE CARE HMO,2463.30,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $2,463.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,HUMANA,HUMANA CHOICE CARE PPO,4187.61,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,187.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,HUMANA,HUMANA NATIIONAL POS HMO,2463.30,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $2,463.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3596.42,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,596.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,4926.60,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,926.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2463.30,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $2,463.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4138.34,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,138.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3694.95,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,694.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4532.47,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $4,532.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3144.65,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,144.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3547.15,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,547.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3547.15,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,547.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3054.49,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,054.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3547.15,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,547.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3547.15,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $3,547.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X20CM,C1781,HCPCS,278,RC,10068243,CDM,,,,both,,,4926.6000,3251.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2955.96,,,,,,,2394.3300,4926.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,926.60 in Billed Charges for Rev 278 Proc C1781 = $2,955.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,AETNA,AETNA HSHS,4754.69,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $4,754.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,AETNA,ALL COMMERCIAL AETNA,7360.20,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $7,360.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,ANTHEM,ANTHEM POS/HMO,3827.30,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,827.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,ANTHEM,ANTHEM PPO,3827.30,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,827.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7360.20,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $7,360.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,CENPATICO,ALL MEDICAID CENPATICO,7360.20,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $7,360.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6256.17,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $6,256.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,CIGNA,ALL COMMERCIAL CIGNA,5152.14,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,152.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,COFINITY,COFINITY,7360.20,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $7,360.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6992.19,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $6,992.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,6182.57,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $6,182.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5225.74,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,225.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5372.95,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,372.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,3577.06,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,577.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6256.17,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $6,256.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,HUMANA,HUMANA CHOICE CARE HMO,3680.10,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,680.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,HUMANA,HUMANA CHOICE CARE PPO,6256.17,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $6,256.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,HUMANA,HUMANA NATIIONAL POS HMO,3680.10,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,680.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5372.95,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,372.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,7360.20,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $7,360.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3680.10,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,680.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6182.57,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $6,182.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5520.15,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,520.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6771.38,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $6,771.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3680.10,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,680.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3680.10,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,680.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,PREVEA HEALTH NETWORK,PREVEA360,3680.10,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,680.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3680.10,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,680.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4698.02,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $4,698.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5299.34,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,299.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3429.85,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,429.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,UNITED HEALTHCARE,UHC ONEIDA NATION,3429.85,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,429.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,UNITED HEALTHCARE,UNITED HEALTHCARE,3429.85,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $3,429.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5299.34,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,299.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4563.32,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $4,563.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5299.34,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,299.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5299.34,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $5,299.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 20X30CM,C1781,HCPCS,278,RC,10068244,CDM,,,,both,,,7360.2000,4857.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4416.12,,,,,,,3429.8500,7360.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,360.20 in Billed Charges for Rev 278 Proc C1781 = $4,416.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,AETNA,AETNA HSHS,584.73,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $584.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,AETNA,ALL COMMERCIAL AETNA,905.15,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $905.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,905.15,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $905.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,CENPATICO,ALL MEDICAID CENPATICO,905.15,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $905.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,769.38,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $769.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,CIGNA,ALL COMMERCIAL CIGNA,633.61,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $633.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,COFINITY,COFINITY,905.15,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $905.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,859.89,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $859.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,760.33,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $760.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,642.66,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $642.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,660.76,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $660.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,439.90,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $439.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,769.38,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $769.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,HUMANA,HUMANA CHOICE CARE PPO,769.38,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $769.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,660.76,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $660.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,905.15,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $905.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,452.58,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $452.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,760.33,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $760.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,678.86,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $678.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,832.74,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $832.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,577.76,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $577.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,651.71,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $651.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,651.71,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $651.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,561.19,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $561.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,651.71,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $651.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,651.71,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $651.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 8X8CM,C1781,HCPCS,278,RC,10068240,CDM,,,,both,,,905.1500,597.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,543.09,,,,,,,439.9000,905.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $905.15 in Billed Charges for Rev 278 Proc C1781 = $543.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,AETNA,AETNA HSHS,1002.50,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,002.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,AETNA,ALL COMMERCIAL AETNA,1551.85,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,551.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,ANTHEM,ANTHEM POS/HMO,806.96,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $806.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,ANTHEM,ANTHEM PPO,806.96,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $806.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1551.85,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,551.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,CENPATICO,ALL MEDICAID CENPATICO,1551.85,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,551.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1319.07,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,319.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,CIGNA,ALL COMMERCIAL CIGNA,1086.30,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,086.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,COFINITY,COFINITY,1551.85,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,551.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1474.26,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,474.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,1303.55,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,303.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1101.81,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,101.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1132.85,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,132.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,754.20,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $754.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1319.07,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,319.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,HUMANA,HUMANA CHOICE CARE PPO,1319.07,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,319.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1132.85,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,132.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1551.85,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,551.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,775.93,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $775.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1303.55,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,303.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1163.89,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,163.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1427.70,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,427.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,990.55,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $990.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1117.33,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,117.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1117.33,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,117.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,962.15,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $962.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1117.33,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,117.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1117.33,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $1,117.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE BIO-A REINFORCEMENT 9X15CM,C1781,HCPCS,278,RC,10068241,CDM,,,,both,,,1551.8500,1024.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,931.11,,,,,,,754.2000,1551.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,551.85 in Billed Charges for Rev 278 Proc C1781 = $931.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,AETNA,AETNA HSHS,597.23,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $597.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,AETNA,ALL COMMERCIAL AETNA,924.50,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $924.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,924.50,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $924.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,CENPATICO,ALL MEDICAID CENPATICO,924.50,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $924.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,785.83,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $785.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,CIGNA,ALL COMMERCIAL CIGNA,647.15,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $647.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,COFINITY,COFINITY,924.50,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $924.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,878.28,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $878.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,776.58,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $776.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,656.40,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $656.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,674.89,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $674.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,449.31,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $449.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,785.83,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $785.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,HUMANA,HUMANA CHOICE CARE PPO,785.83,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $785.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,674.89,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $674.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,924.50,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $924.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,462.25,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $462.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,776.58,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $776.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,693.38,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $693.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,850.54,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $850.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,590.11,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $590.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,665.64,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $665.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,665.64,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $665.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,573.19,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $573.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,665.64,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $665.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,665.64,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $665.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATH HICKMAN SUBCUTANEOUS PORT SM,C1788,HCPCS,278,RC,70402315,CDM,,,,both,,,924.5000,610.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,554.70,,,,,,,449.3100,924.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $924.50 in Billed Charges for Rev 278 Proc C1788 = $554.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,AETNA,AETNA HSHS,239.83,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $239.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,AETNA,ALL COMMERCIAL AETNA,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,CENPATICO,ALL MEDICAID CENPATICO,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,315.56,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $315.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,CIGNA,ALL COMMERCIAL CIGNA,259.88,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,COFINITY,COFINITY,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,352.69,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $352.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,HEALTH CARE ALLIANCE,THE ALLIANCE,311.85,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $311.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,263.59,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $263.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,271.01,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $271.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,HSHS EMPLOYEES,HSHS EMPLOYEES,180.43,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $180.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,315.56,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $315.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,HUMANA,HUMANA CHOICE CARE PPO,315.56,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $315.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,271.01,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $271.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,LIVE360,LIVE360 HSHS HEALTHY PLAN,371.25,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $371.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,185.63,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $185.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,311.85,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $311.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,278.44,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $278.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,341.55,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $341.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,236.97,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $236.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,267.30,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,267.30,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,230.18,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $230.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,267.30,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,267.30,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER BARD PORT 8 FR (0605420),C1788,HCPCS,278,RC,10000509,CDM,,,,both,,,371.2500,245.0300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,222.75,,,,,,,180.4300,371.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $371.25 in Billed Charges for Rev 278 Proc C1788 = $222.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,AETNA,AETNA HSHS,728.37,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $728.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,AETNA,ALL COMMERCIAL AETNA,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,ANTHEM,ANTHEM POS/HMO,586.30,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $586.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,ANTHEM,ANTHEM PPO,586.30,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $586.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,CENPATICO,ALL MEDICAID CENPATICO,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,958.38,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $958.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,CIGNA,ALL COMMERCIAL CIGNA,789.25,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $789.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,COFINITY,COFINITY,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1071.13,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $1,071.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,947.10,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $947.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,800.53,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $800.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,823.08,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $823.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,547.97,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $547.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,958.38,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $958.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,HUMANA,HUMANA CHOICE CARE PPO,958.38,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $958.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,823.08,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $823.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1127.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $1,127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,563.75,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $563.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,947.10,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $947.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,845.63,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $845.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1037.30,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $1,037.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,719.68,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $719.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,811.80,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $811.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,811.80,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $811.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,699.05,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $699.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,811.80,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $811.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,811.80,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $811.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT BARD POWERPORT WITH 8FR. CATHETER,C1788,HCPCS,278,RC,10020232,CDM,,,,both,,,1127.5000,744.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,676.50,,,,,,,547.9700,1127.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,127.50 in Billed Charges for Rev 278 Proc C1788 = $676.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,AETNA,AETNA HSHS,1386.96,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,386.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,AETNA,ALL COMMERCIAL AETNA,2147.00,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $2,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,ANTHEM,ANTHEM POS/HMO,1116.44,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,116.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,ANTHEM,ANTHEM PPO,1116.44,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,116.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2147.00,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $2,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,CENPATICO,ALL MEDICAID CENPATICO,2147.00,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $2,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1824.95,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,824.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,CIGNA,ALL COMMERCIAL CIGNA,1502.90,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,502.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,COFINITY,COFINITY,2147.00,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $2,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2039.65,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $2,039.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,1803.48,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,803.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1524.37,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,524.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1567.31,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,567.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,1043.44,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,043.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1824.95,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,824.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,HUMANA,HUMANA CHOICE CARE PPO,1824.95,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,824.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1567.31,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,567.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2147.00,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $2,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1073.50,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,073.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1803.48,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,803.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1610.25,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,610.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1975.24,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,975.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1370.43,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,370.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1545.84,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,545.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1545.84,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,545.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1331.14,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,331.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1545.84,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,545.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1545.84,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,545.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,10051985,CDM,,,,both,,,2147.0000,1417.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1288.20,,,,,,,1043.4400,2147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,147.00 in Billed Charges for Rev 278 Proc C1789 = $1,288.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,AETNA,AETNA HSHS,13316.35,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $13,316.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,AETNA,ALL COMMERCIAL AETNA,20613.54,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $20,613.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,ANTHEM,ANTHEM POS/HMO,10719.04,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,719.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,ANTHEM,ANTHEM PPO,10719.04,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,719.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20613.54,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $20,613.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,CENPATICO,ALL MEDICAID CENPATICO,20613.54,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $20,613.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17521.51,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $17,521.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,CIGNA,ALL COMMERCIAL CIGNA,14429.48,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $14,429.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,COFINITY,COFINITY,20613.54,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $20,613.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19582.86,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $19,582.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,17315.37,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $17,315.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14635.61,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $14,635.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15047.88,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $15,047.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,10018.18,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,018.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17521.51,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $17,521.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,HUMANA,HUMANA CHOICE CARE HMO,10306.77,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,HUMANA,HUMANA CHOICE CARE PPO,17521.51,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $17,521.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,HUMANA,HUMANA NATIIONAL POS HMO,10306.77,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15047.88,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $15,047.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,20613.54,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $20,613.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10306.77,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17315.37,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $17,315.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15460.16,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $15,460.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18964.46,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $18,964.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10306.77,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10306.77,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,PREVEA HEALTH NETWORK,PREVEA360,10306.77,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10306.77,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $10,306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13157.62,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $13,157.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14841.75,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $14,841.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9605.91,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $9,605.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,9605.91,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $9,605.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,9605.91,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $9,605.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14841.75,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $14,841.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12780.39,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $12,780.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14841.75,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $14,841.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14841.75,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $14,841.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP MS AMS 700 CX 21 X 12MM,C1813,HCPCS,278,RC,10022011,CDM,,,,both,,,20613.5400,13604.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12368.12,,,,,,,9605.9100,20613.5400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $20,613.54 in Billed Charges for Rev 278 Proc C1813 = $12,368.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,AETNA,AETNA HSHS,550.98,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $550.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,AETNA,ALL COMMERCIAL AETNA,852.91,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $852.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,852.91,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $852.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,CENPATICO,ALL MEDICAID CENPATICO,852.91,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $852.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,724.97,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $724.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,CIGNA,ALL COMMERCIAL CIGNA,597.04,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $597.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,COFINITY,COFINITY,852.91,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $852.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,810.26,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $810.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,716.44,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $716.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,605.57,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $605.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,622.62,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $622.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,414.51,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $414.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,724.97,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $724.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,HUMANA,HUMANA CHOICE CARE PPO,724.97,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $724.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,622.62,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $622.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,852.91,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $852.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,426.46,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $426.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,716.44,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $716.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,639.68,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $639.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,784.68,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $784.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,544.41,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $544.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,614.10,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $614.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,614.10,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $614.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,528.80,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $528.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,614.10,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $614.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,614.10,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $614.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OIL SILICONE ADATOSIL 5000,C1814,HCPCS,278,RC,10031618,CDM,,,,both,,,852.9100,562.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,511.75,,,,,,,414.5100,852.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $852.91 in Billed Charges for Rev 278 Proc C1814 = $511.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,AETNA,AETNA HSHS,4395.38,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,395.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,AETNA,ALL COMMERCIAL AETNA,6804.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $6,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,ANTHEM,ANTHEM POS/HMO,3538.08,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,538.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,ANTHEM,ANTHEM PPO,3538.08,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,538.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6804.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $6,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,CENPATICO,ALL MEDICAID CENPATICO,6804.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $6,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5783.40,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $5,783.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,CIGNA,ALL COMMERCIAL CIGNA,4762.80,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,762.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,COFINITY,COFINITY,6804.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $6,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6463.80,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $6,463.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,5715.36,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $5,715.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4830.84,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,830.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4966.92,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,966.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,3306.74,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,306.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5783.40,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $5,783.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,HUMANA,HUMANA CHOICE CARE HMO,3402.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,HUMANA,HUMANA CHOICE CARE PPO,5783.40,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $5,783.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,HUMANA,HUMANA NATIIONAL POS HMO,3402.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4966.92,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,966.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,6804.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $6,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3402.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5715.36,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $5,715.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5103.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $5,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6259.68,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $6,259.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3402.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3402.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,PREVEA HEALTH NETWORK,PREVEA360,3402.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3402.00,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4342.99,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,342.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4898.88,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,898.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3170.66,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,170.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,3170.66,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,170.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,3170.66,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $3,170.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4898.88,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,898.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4218.48,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,218.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4898.88,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,898.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4898.88,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,898.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10054205,CDM,,,,both,,,6804.0000,4490.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4082.40,,,,,,,3170.6600,6804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,804.00 in Billed Charges for Rev 278 Proc C1874 = $4,082.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,AETNA,AETNA HSHS,2558.16,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,558.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,AETNA,ALL COMMERCIAL AETNA,3960.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,960.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,ANTHEM,ANTHEM POS/HMO,2059.20,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,059.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,ANTHEM,ANTHEM PPO,2059.20,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,059.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3960.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,960.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,CENPATICO,ALL MEDICAID CENPATICO,3960.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,960.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3366.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,366.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,CIGNA,ALL COMMERCIAL CIGNA,2772.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,772.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,COFINITY,COFINITY,3960.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,960.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3762.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,762.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,3326.40,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,326.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2811.60,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,811.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2890.80,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,890.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,1924.56,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $1,924.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3366.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,366.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,HUMANA,HUMANA CHOICE CARE HMO,1980.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $1,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,HUMANA,HUMANA CHOICE CARE PPO,3366.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,366.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,HUMANA,HUMANA NATIIONAL POS HMO,1980.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $1,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2890.80,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,890.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3960.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,960.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1980.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $1,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3326.40,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,326.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2970.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,970.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3643.20,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $3,643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2527.67,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,527.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2851.20,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,851.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2851.20,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,851.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2455.20,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,455.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2851.20,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,851.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2851.20,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,851.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10065051,CDM,,,,both,,,3960.0000,2613.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2376.00,,,,,,,1924.5600,3960.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,960.00 in Billed Charges for Rev 278 Proc C1874 = $2,376.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,AETNA,AETNA HSHS,2441.88,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,441.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,AETNA,ALL COMMERCIAL AETNA,3780.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,780.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,ANTHEM,ANTHEM POS/HMO,1965.60,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $1,965.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,ANTHEM,ANTHEM PPO,1965.60,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $1,965.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3780.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,780.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,CENPATICO,ALL MEDICAID CENPATICO,3780.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,780.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3213.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,213.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,CIGNA,ALL COMMERCIAL CIGNA,2646.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,646.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,COFINITY,COFINITY,3780.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,780.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3591.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,591.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,3175.20,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,175.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2683.80,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,683.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2759.40,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,759.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,1837.08,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $1,837.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3213.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,213.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,HUMANA,HUMANA CHOICE CARE HMO,1890.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $1,890.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,HUMANA,HUMANA CHOICE CARE PPO,3213.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,213.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,HUMANA,HUMANA NATIIONAL POS HMO,1890.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $1,890.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2759.40,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,759.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3780.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,780.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1890.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $1,890.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3175.20,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,175.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2835.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,835.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3477.60,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $3,477.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2412.77,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,412.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2721.60,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,721.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2721.60,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,721.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2343.60,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,343.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2721.60,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,721.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2721.60,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,721.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10022950,CDM,,,,both,,,3780.0000,2494.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2268.00,,,,,,,1837.0800,3780.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,780.00 in Billed Charges for Rev 278 Proc C1874 = $2,268.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,AETNA,AETNA HSHS,3850.03,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $3,850.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,AETNA,ALL COMMERCIAL AETNA,5959.80,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,959.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,ANTHEM,ANTHEM POS/HMO,3099.10,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $3,099.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,ANTHEM,ANTHEM PPO,3099.10,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $3,099.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5959.80,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,959.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,CENPATICO,ALL MEDICAID CENPATICO,5959.80,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,959.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5065.83,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,065.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,CIGNA,ALL COMMERCIAL CIGNA,4171.86,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,171.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,COFINITY,COFINITY,5959.80,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,959.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5661.81,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,661.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,5006.23,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,006.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4231.46,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,231.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4350.65,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,350.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,2896.46,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $2,896.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5065.83,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,065.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,HUMANA,HUMANA CHOICE CARE HMO,2979.90,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $2,979.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,HUMANA,HUMANA CHOICE CARE PPO,5065.83,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,065.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,HUMANA,HUMANA NATIIONAL POS HMO,2979.90,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $2,979.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4350.65,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,350.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,5959.80,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,959.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2979.90,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $2,979.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5006.23,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,006.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4469.85,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,469.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5483.02,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $5,483.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2979.90,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $2,979.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2979.90,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $2,979.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,PREVEA HEALTH NETWORK,PREVEA360,2979.90,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $2,979.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2979.90,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $2,979.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3804.14,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $3,804.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4291.06,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,291.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4291.06,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,291.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3695.08,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $3,695.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4291.06,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,291.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4291.06,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $4,291.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10075614,CDM,,,,both,,,5959.8000,3933.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3575.88,,,,,,,2896.4600,5959.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,959.80 in Billed Charges for Rev 278 Proc C1874 = $3,575.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,AETNA,AETNA HSHS,4261.66,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,261.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,AETNA,ALL COMMERCIAL AETNA,6597.00,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $6,597.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,ANTHEM,ANTHEM POS/HMO,3430.44,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,430.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,ANTHEM,ANTHEM PPO,3430.44,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,430.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6597.00,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $6,597.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,CENPATICO,ALL MEDICAID CENPATICO,6597.00,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $6,597.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5607.45,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $5,607.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,CIGNA,ALL COMMERCIAL CIGNA,4617.90,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,617.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,COFINITY,COFINITY,6597.00,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $6,597.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6267.15,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $6,267.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,5541.48,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $5,541.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4683.87,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,683.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4815.81,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,815.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,3206.14,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,206.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5607.45,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $5,607.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,HUMANA,HUMANA CHOICE CARE HMO,3298.50,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,298.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,HUMANA,HUMANA CHOICE CARE PPO,5607.45,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $5,607.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,HUMANA,HUMANA NATIIONAL POS HMO,3298.50,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,298.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4815.81,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,815.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,6597.00,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $6,597.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3298.50,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,298.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5541.48,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $5,541.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4947.75,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,947.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6069.24,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $6,069.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3298.50,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,298.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3298.50,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,298.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,PREVEA HEALTH NETWORK,PREVEA360,3298.50,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,298.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3298.50,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,298.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4210.87,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,210.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4749.84,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,749.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4749.84,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,749.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4090.14,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,090.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4749.84,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,749.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4749.84,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $4,749.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT VIABAHN VBX  7MMX79MMX135CM,C1874,HCPCS,278,RC,10073591,CDM,,,,both,,,6597.0000,4354.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3958.20,,,,,,,3206.1400,6597.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,597.00 in Billed Charges for Rev 278 Proc C1874 = $3,958.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,AETNA,AETNA HSHS,1209.83,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,209.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,AETNA,ALL COMMERCIAL AETNA,1872.80,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,872.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,ANTHEM,ANTHEM POS/HMO,973.86,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $973.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,ANTHEM,ANTHEM PPO,973.86,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $973.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1872.80,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,872.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,CENPATICO,ALL MEDICAID CENPATICO,1872.80,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,872.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1591.88,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,591.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,CIGNA,ALL COMMERCIAL CIGNA,1310.96,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,310.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,COFINITY,COFINITY,1872.80,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,872.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1779.16,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,779.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,1573.15,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,573.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1329.69,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,329.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1367.14,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,367.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,910.18,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $910.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1591.88,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,591.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,HUMANA,HUMANA CHOICE CARE PPO,1591.88,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,591.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1367.14,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,367.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1872.80,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,872.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,936.40,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $936.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1573.15,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,573.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1404.60,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,404.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1722.98,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,722.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1195.41,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,195.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1348.42,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,348.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1348.42,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,348.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1161.14,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,161.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1348.42,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,348.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1348.42,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,348.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,70405013,CDM,,,,both,,,1872.8000,1236.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1123.68,,,,,,,910.1800,1872.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,872.80 in Billed Charges for Rev 278 Proc C1876 = $1,123.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,AETNA,AETNA HSHS,169.74,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $169.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,AETNA,ALL COMMERCIAL AETNA,262.76,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $262.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,262.76,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $262.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,CENPATICO,ALL MEDICAID CENPATICO,262.76,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $262.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,223.35,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $223.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,CIGNA,ALL COMMERCIAL CIGNA,183.93,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $183.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,COFINITY,COFINITY,262.76,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $262.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,249.62,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $249.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,220.72,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $220.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,186.56,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $186.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,191.81,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $191.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,127.70,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $127.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,223.35,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $223.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,HUMANA,HUMANA CHOICE CARE PPO,223.35,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $223.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,191.81,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $191.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,262.76,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $262.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,131.38,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $131.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,220.72,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $220.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,197.07,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $197.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,241.74,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $241.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,167.72,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $167.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,189.19,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $189.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,189.19,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $189.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,162.91,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $162.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,189.19,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $189.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,189.19,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $189.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POST SYNTHES 11MM 30 DEG OUTRIGGER MR SAFE,C1889,HCPCS,278,RC,10050160,CDM,,,,both,,,262.7600,173.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,157.66,,,,,,,127.7000,262.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $262.76 in Billed Charges for Rev 278 Proc C1889 = $157.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,AETNA,AETNA HSHS,1158.76,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,AETNA,ALL COMMERCIAL AETNA,1793.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,793.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,ANTHEM,ANTHEM POS/HMO,932.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $932.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,ANTHEM,ANTHEM PPO,932.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $932.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1793.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,793.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,CENPATICO,ALL MEDICAID CENPATICO,1793.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,793.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1524.69,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,524.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,CIGNA,ALL COMMERCIAL CIGNA,1255.63,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,255.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,COFINITY,COFINITY,1793.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,793.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1704.06,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,704.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,1506.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,506.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1273.56,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,273.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1309.44,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,309.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,871.76,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $871.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1524.69,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,524.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,HUMANA,HUMANA CHOICE CARE PPO,1524.69,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,524.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1309.44,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,309.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1793.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,793.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,896.88,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $896.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1506.75,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,506.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1345.31,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,345.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1650.25,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,650.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1144.95,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,144.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1291.50,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,291.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1291.50,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,291.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1112.13,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,112.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1291.50,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,291.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1291.50,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,291.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SEALANT PROGEL (PGPS002),C1889,HCPCS,278,RC,10059654,CDM,,,,both,,,1793.7500,1183.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1076.25,,,,,,,871.7600,1793.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,793.75 in Billed Charges for Rev 278 Proc C1889 = $1,076.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,AETNA,AETNA HSHS,79.22,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $79.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,AETNA,ALL COMMERCIAL AETNA,122.63,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $122.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,122.63,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $122.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,CENPATICO,ALL MEDICAID CENPATICO,122.63,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $122.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,104.24,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $104.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,CIGNA,ALL COMMERCIAL CIGNA,85.84,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $85.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,COFINITY,COFINITY,122.63,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $122.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,116.50,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $116.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,103.01,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $103.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,87.07,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $87.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.52,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $89.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,59.60,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $59.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,104.24,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $104.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,HUMANA,HUMANA CHOICE CARE PPO,104.24,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $104.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.52,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $89.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,122.63,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $122.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.32,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,103.01,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $103.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,91.97,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $91.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,112.82,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $112.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,78.27,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $78.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,88.29,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $88.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,88.29,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $88.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,76.03,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $76.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,88.29,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $88.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,88.29,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $88.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT FIRLIFT-KLUGE 8 FR X 30,C2617,HCPCS,278,RC,10003557,CDM,,,,both,,,122.6300,80.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.58,,,,,,,59.6000,122.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $122.63 in Billed Charges for Rev 278 Proc C2617 = $73.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,AETNA,AETNA HSHS,130.82,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $130.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,AETNA,ALL COMMERCIAL AETNA,202.50,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $202.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,202.50,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $202.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,CENPATICO,ALL MEDICAID CENPATICO,202.50,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $202.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,172.13,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $172.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,CIGNA,ALL COMMERCIAL CIGNA,141.75,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $141.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,COFINITY,COFINITY,202.50,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $202.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,192.38,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $192.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,170.10,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $170.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,143.78,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $143.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,147.83,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $147.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,98.42,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $98.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,172.13,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $172.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,HUMANA,HUMANA CHOICE CARE PPO,172.13,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $172.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,147.83,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $147.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,202.50,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $202.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,101.25,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $101.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,170.10,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $170.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,151.88,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $151.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,186.30,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $186.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,129.26,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $129.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,145.80,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $145.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,145.80,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $145.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,125.55,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $125.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,145.80,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $145.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,145.80,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $145.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10070919,CDM,,,,both,,,202.5000,133.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,121.50,,,,,,,98.4200,202.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $202.50 in Billed Charges for Rev 278 Proc C2617 = $121.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,AETNA,AETNA HSHS,202.31,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $202.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,AETNA,ALL COMMERCIAL AETNA,313.18,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $313.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,313.18,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $313.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,CENPATICO,ALL MEDICAID CENPATICO,313.18,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $313.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,266.20,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $266.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,CIGNA,ALL COMMERCIAL CIGNA,219.23,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $219.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,COFINITY,COFINITY,313.18,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $313.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,297.52,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $297.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,263.07,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $263.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,222.36,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $222.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,228.62,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $228.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,152.21,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $152.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,266.20,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $266.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,HUMANA,HUMANA CHOICE CARE PPO,266.20,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $266.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,228.62,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $228.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,313.18,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $313.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,156.59,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $156.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,263.07,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $263.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,234.89,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $234.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,288.13,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $288.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,199.90,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $199.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,225.49,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $225.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,225.49,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $225.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,194.17,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $194.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,225.49,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $225.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,225.49,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $225.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70401933,CDM,,,,both,,,313.1800,206.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,187.91,,,,,,,152.2100,313.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $313.18 in Billed Charges for Rev 278 Proc C2617 = $187.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,AETNA,AETNA HSHS,281.76,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $281.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,AETNA,ALL COMMERCIAL AETNA,436.16,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $436.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,436.16,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $436.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,CENPATICO,ALL MEDICAID CENPATICO,436.16,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $436.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,370.74,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $370.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,CIGNA,ALL COMMERCIAL CIGNA,305.31,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $305.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,COFINITY,COFINITY,436.16,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $436.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,414.35,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $414.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,366.37,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $366.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,309.67,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $309.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,318.40,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $318.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,211.97,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $211.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,370.74,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $370.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,HUMANA,HUMANA CHOICE CARE PPO,370.74,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $370.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,318.40,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $318.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,436.16,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $436.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,218.08,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $218.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,366.37,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $366.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,327.12,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $327.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,401.27,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $401.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,278.40,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $278.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,314.04,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $314.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,314.04,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $314.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,270.42,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $270.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,314.04,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $314.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,314.04,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $314.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS URETERAL BOSTON SCIENTIFIC 6FR X 26CM,C2617,HCPCS,278,RC,10013943,CDM,,,,both,,,436.1600,287.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,261.70,,,,,,,211.9700,436.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.16 in Billed Charges for Rev 278 Proc C2617 = $261.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,AETNA,AETNA HSHS,287.33,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $287.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,AETNA,ALL COMMERCIAL AETNA,444.78,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $444.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,444.78,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $444.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,CENPATICO,ALL MEDICAID CENPATICO,444.78,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $444.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,378.06,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $378.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,CIGNA,ALL COMMERCIAL CIGNA,311.35,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $311.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,COFINITY,COFINITY,444.78,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $444.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,422.54,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $422.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,373.62,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $373.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,315.79,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $315.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,324.69,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $324.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,216.16,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $216.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,378.06,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $378.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,HUMANA,HUMANA CHOICE CARE PPO,378.06,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $378.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,324.69,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $324.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,444.78,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $444.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,222.39,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $222.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,373.62,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $373.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,333.59,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $333.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,409.20,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $409.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,283.90,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $283.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,320.24,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $320.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,320.24,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $320.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,275.76,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $275.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,320.24,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $320.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,320.24,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $320.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10055419,CDM,,,,both,,,444.7800,293.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,266.87,,,,,,,216.1600,444.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $444.78 in Billed Charges for Rev 278 Proc C2617 = $266.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,AETNA,AETNA HSHS,145.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $145.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,AETNA,ALL COMMERCIAL AETNA,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,CENPATICO,ALL MEDICAID CENPATICO,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,CIGNA,ALL COMMERCIAL CIGNA,157.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,COFINITY,COFINITY,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,213.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $213.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,159.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $159.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,109.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $109.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE PPO,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,112.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,168.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,207.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,143.62,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $143.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,139.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $139.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10052061,CDM,,,,both,,,225.0000,148.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,135.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $225.00 in Billed Charges for Rev 278 Proc C2617 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,AETNA,AETNA HSHS,367.71,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $367.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,AETNA,ALL COMMERCIAL AETNA,569.21,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $569.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,569.21,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $569.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,CENPATICO,ALL MEDICAID CENPATICO,569.21,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $569.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,483.83,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $483.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,CIGNA,ALL COMMERCIAL CIGNA,398.45,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $398.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,COFINITY,COFINITY,569.21,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $569.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,540.75,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $540.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,478.14,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $478.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,404.14,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $404.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,415.52,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $415.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,276.64,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $276.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,483.83,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $483.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,HUMANA,HUMANA CHOICE CARE PPO,483.83,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $483.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,415.52,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $415.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,569.21,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $569.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,284.61,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $284.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,478.14,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $478.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,426.91,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $426.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,523.67,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $523.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,363.33,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $363.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,409.83,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $409.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,409.83,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $409.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,352.91,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $352.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,409.83,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $409.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,409.83,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $409.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10004027,CDM,,,,both,,,569.2100,375.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,341.53,,,,,,,276.6400,569.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $569.21 in Billed Charges for Rev 278 Proc C2617 = $341.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,AETNA,AETNA HSHS,2202.86,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,202.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,AETNA,ALL COMMERCIAL AETNA,3410.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $3,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,ANTHEM,ANTHEM POS/HMO,1773.20,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $1,773.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,ANTHEM,ANTHEM PPO,1773.20,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $1,773.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3410.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $3,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,CENPATICO,ALL MEDICAID CENPATICO,3410.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $3,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2898.50,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,898.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,CIGNA,ALL COMMERCIAL CIGNA,2387.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,387.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,COFINITY,COFINITY,3410.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $3,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3239.50,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $3,239.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,2864.40,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,864.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2421.10,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,421.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2489.30,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,489.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,1657.26,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $1,657.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2898.50,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,898.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,HUMANA,HUMANA CHOICE CARE HMO,1705.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $1,705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,HUMANA,HUMANA CHOICE CARE PPO,2898.50,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,898.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,HUMANA,HUMANA NATIIONAL POS HMO,1705.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $1,705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2489.30,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,489.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3410.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $3,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1705.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $1,705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2864.40,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,864.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2557.50,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,557.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3137.20,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $3,137.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2176.60,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,176.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2455.20,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,455.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2455.20,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,455.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2114.20,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,114.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2455.20,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,455.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2455.20,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,455.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROPEL CONTOUR MOMETASONE FUROATE,C2625,HCPCS,278,RC,10075932,CDM,,,,both,,,3410.0000,2250.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2046.00,,,,,,,1657.2600,3410.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,410.00 in Billed Charges for Rev 278 Proc C2625 = $2,046.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,AETNA,AETNA HSHS,11224.51,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $11,224.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,AETNA,ALL COMMERCIAL AETNA,17375.40,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $17,375.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,ANTHEM,ANTHEM POS/HMO,9035.21,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $9,035.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,ANTHEM,ANTHEM PPO,9035.21,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $9,035.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17375.40,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $17,375.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,CENPATICO,ALL MEDICAID CENPATICO,17375.40,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $17,375.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14769.09,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $14,769.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,CIGNA,ALL COMMERCIAL CIGNA,12162.78,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $12,162.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,COFINITY,COFINITY,17375.40,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $17,375.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16506.63,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $16,506.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,14595.34,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $14,595.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12336.53,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $12,336.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12684.04,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $12,684.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,8444.44,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,444.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14769.09,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $14,769.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,HUMANA,HUMANA CHOICE CARE HMO,8687.70,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,687.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,HUMANA,HUMANA CHOICE CARE PPO,14769.09,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $14,769.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,HUMANA,HUMANA NATIIONAL POS HMO,8687.70,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,687.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12684.04,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $12,684.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,17375.40,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $17,375.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8687.70,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,687.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14595.34,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $14,595.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13031.55,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $13,031.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15985.37,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $15,985.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8687.70,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,687.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8687.70,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,687.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,PREVEA HEALTH NETWORK,PREVEA360,8687.70,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,687.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8687.70,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,687.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11090.72,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $11,090.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12510.29,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $12,510.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8096.94,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,096.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,8096.94,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,096.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,8096.94,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $8,096.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12510.29,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $12,510.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10772.75,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $10,772.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12510.29,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $12,510.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12510.29,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $12,510.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077474,CDM,,,,both,,,17375.4000,11467.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10425.24,,,,,,,8096.9400,17375.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $17,375.40 in Billed Charges for Rev 278 Proc C2625 = $10,425.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,AETNA,AETNA HSHS,8130.30,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $8,130.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,AETNA,ALL COMMERCIAL AETNA,12585.60,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $12,585.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,ANTHEM,ANTHEM POS/HMO,6544.51,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,544.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,ANTHEM,ANTHEM PPO,6544.51,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,544.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12585.60,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $12,585.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,CENPATICO,ALL MEDICAID CENPATICO,12585.60,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $12,585.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10697.76,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $10,697.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,CIGNA,ALL COMMERCIAL CIGNA,8809.92,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $8,809.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,COFINITY,COFINITY,12585.60,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $12,585.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11956.32,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $11,956.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,10571.90,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $10,571.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8935.78,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $8,935.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9187.49,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $9,187.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,6116.60,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,116.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10697.76,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $10,697.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,HUMANA,HUMANA CHOICE CARE HMO,6292.80,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,292.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,HUMANA,HUMANA CHOICE CARE PPO,10697.76,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $10,697.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,HUMANA,HUMANA NATIIONAL POS HMO,6292.80,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,292.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9187.49,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $9,187.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,12585.60,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $12,585.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6292.80,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,292.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10571.90,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $10,571.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9439.20,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $9,439.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11578.75,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $11,578.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6292.80,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,292.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6292.80,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,292.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,PREVEA HEALTH NETWORK,PREVEA360,6292.80,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,292.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6292.80,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $6,292.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8033.39,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $8,033.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9061.63,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $9,061.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5864.89,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $5,864.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,5864.89,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $5,864.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,5864.89,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $5,864.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9061.63,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $9,061.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7803.07,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $7,803.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9061.63,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $9,061.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9061.63,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $9,061.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 15MM 3MM 3.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075025,CDM,,,,both,,,12585.6000,8306.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7551.36,,,,,,,5864.8900,12585.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $12,585.60 in Billed Charges for Rev 278 Proc C2625 = $7,551.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,AETNA,AETNA HSHS,9514.31,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $9,514.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,AETNA,ALL COMMERCIAL AETNA,14728.03,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $14,728.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,ANTHEM,ANTHEM POS/HMO,7658.58,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,658.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,ANTHEM,ANTHEM PPO,7658.58,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,658.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14728.03,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $14,728.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,CENPATICO,ALL MEDICAID CENPATICO,14728.03,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $14,728.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12518.83,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $12,518.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,CIGNA,ALL COMMERCIAL CIGNA,10309.62,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $10,309.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,COFINITY,COFINITY,14728.03,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $14,728.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13991.63,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $13,991.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,12371.55,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $12,371.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10456.90,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $10,456.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10751.46,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $10,751.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,7157.82,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,157.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12518.83,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $12,518.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,HUMANA,HUMANA CHOICE CARE HMO,7364.02,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,HUMANA,HUMANA CHOICE CARE PPO,12518.83,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $12,518.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,HUMANA,HUMANA NATIIONAL POS HMO,7364.02,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10751.46,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $10,751.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,14728.03,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $14,728.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7364.02,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12371.55,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $12,371.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11046.02,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $11,046.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13549.79,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $13,549.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7364.02,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7364.02,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,PREVEA HEALTH NETWORK,PREVEA360,7364.02,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7364.02,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $7,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9400.90,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $9,400.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10604.18,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $10,604.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6863.26,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $6,863.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,6863.26,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $6,863.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,6863.26,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $6,863.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10604.18,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $10,604.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9131.38,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $9,131.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10604.18,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $10,604.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10604.18,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $10,604.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10077473,CDM,,,,both,,,14728.0300,9720.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8836.82,,,,,,,6863.2600,14728.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $14,728.03 in Billed Charges for Rev 278 Proc C2625 = $8,836.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,AETNA,AETNA HSHS,8008.79,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $8,008.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,AETNA,ALL COMMERCIAL AETNA,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,ANTHEM,ANTHEM POS/HMO,6446.70,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,446.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,ANTHEM,ANTHEM PPO,6446.70,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,446.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,CENPATICO,ALL MEDICAID CENPATICO,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10537.88,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $10,537.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,CIGNA,ALL COMMERCIAL CIGNA,8678.25,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $8,678.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,COFINITY,COFINITY,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11777.63,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $11,777.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,10413.90,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $10,413.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8802.23,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $8,802.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9050.18,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $9,050.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,6025.19,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,025.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10537.88,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $10,537.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,HUMANA,HUMANA CHOICE CARE HMO,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,HUMANA,HUMANA CHOICE CARE PPO,10537.88,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $10,537.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,HUMANA,HUMANA NATIIONAL POS HMO,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9050.18,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $9,050.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,12397.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $12,397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10413.90,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $10,413.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9298.13,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $9,298.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11405.70,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $11,405.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,PREVEA HEALTH NETWORK,PREVEA360,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6198.75,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $6,198.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7913.32,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $7,913.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8926.20,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $8,926.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5777.24,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $5,777.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,UNITED HEALTHCARE,UHC ONEIDA NATION,5777.24,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $5,777.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,UNITED HEALTHCARE,UNITED HEALTHCARE,5777.24,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $5,777.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8926.20,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $8,926.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7686.45,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $7,686.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8926.20,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $8,926.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8926.20,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $8,926.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT INTRCRAN 21MM 4MM 4.5MM NRFRM ATLS EXCLS SL-10 XT-17,C2625,HCPCS,278,RC,10075028,CDM,,,,both,,,12397.5000,8182.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7438.50,,,,,,,5777.2400,12397.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $12,397.50 in Billed Charges for Rev 278 Proc C2625 = $7,438.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,AETNA,AETNA HSHS,2451.57,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,451.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,AETNA,ALL COMMERCIAL AETNA,3795.00,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,795.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,ANTHEM,ANTHEM POS/HMO,1973.40,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $1,973.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,ANTHEM,ANTHEM PPO,1973.40,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $1,973.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3795.00,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,795.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,CENPATICO,ALL MEDICAID CENPATICO,3795.00,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,795.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3225.75,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,225.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,CIGNA,ALL COMMERCIAL CIGNA,2656.50,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,656.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,COFINITY,COFINITY,3795.00,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,795.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3605.25,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,605.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,3187.80,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,187.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2694.45,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,694.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2770.35,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,770.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,1844.37,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $1,844.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3225.75,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,225.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,HUMANA,HUMANA CHOICE CARE HMO,1897.50,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $1,897.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,HUMANA,HUMANA CHOICE CARE PPO,3225.75,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,225.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,HUMANA,HUMANA NATIIONAL POS HMO,1897.50,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $1,897.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2770.35,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,770.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3795.00,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,795.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1897.50,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $1,897.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3187.80,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,187.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2846.25,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,846.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3491.40,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $3,491.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2422.35,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,422.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2732.40,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,732.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2732.40,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,732.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2352.90,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,352.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2732.40,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,732.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2732.40,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,732.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/DEL SY",C2625,HCPCS,278,RC,10064785,CDM,,,,both,,,3795.0000,2504.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2277.00,,,,,,,1844.3700,3795.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,795.00 in Billed Charges for Rev 278 Proc C2625 = $2,277.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,AETNA,AETNA HSHS,2490.63,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,490.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,AETNA,AETNA MEDICARE,120.88,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,AETNA,ALL COMMERCIAL AETNA,3855.47,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,855.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,120.88,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,ANTHEM,ANTHEM POS/HMO,86.70,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q4104 * Qty 1 = $51.00 at 170% = $86.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,ANTHEM,ANTHEM PPO,107.10,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q4104 * Qty 1 = $51.00 at 210% = $107.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3855.47,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,855.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,CENPATICO,ALL MEDICAID CENPATICO,3855.47,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,855.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3277.15,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,277.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,CIGNA,ALL COMMERCIAL CIGNA,2698.83,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,698.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,COFINITY,COFINITY,3855.47,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,855.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3662.70,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,662.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,3238.59,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,238.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2737.38,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,737.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2814.49,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,814.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,1873.76,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $1,873.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3277.15,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,277.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HUMANA,HUMANA CHOICE CARE HMO,84.20,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $84.20 from Fee Schedule 005543_170 for Rev 636 Proc Q4104 * Qty 1 = $84.20 at 100% = $84.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HUMANA,HUMANA CHOICE CARE PPO,3277.15,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,277.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HUMANA,HUMANA MEDICARE ADVANTAGE,120.88,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,HUMANA,HUMANA NATIIONAL POS HMO,84.20,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $84.20 from Fee Schedule 005543_170 for Rev 636 Proc Q4104 * Qty 1 = $84.20 at 100% = $84.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2814.49,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,814.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,3855.47,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,855.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,120.88,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,MOLINA HEALTHCARE,MOLINA MEDICARE,120.88,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1927.74,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $1,927.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3238.59,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,238.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,NAPHCARE,ALL COMMERICAL NAPHCARE,271.97,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2891.60,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,891.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3547.03,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $3,547.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,91.29,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q4104 * Qty 1 = $51.00 at 179% = $91.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,91.29,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q4104 * Qty 1 = $51.00 at 179% = $91.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,PREVEA HEALTH NETWORK,PREVEA360,91.29,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q4104 * Qty 1 = $51.00 at 179% = $91.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,91.29,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q4104 * Qty 1 = $51.00 at 179% = $91.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2460.95,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,460.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,122.09,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2775.94,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,775.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,209.78,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $209.78 from Fee Schedule UHC_31190C for Rev 636 Proc Q4104 * Qty 1 = $209.78 at 100% = $209.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,209.78,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $209.78 from Fee Schedule UHC_31190C for Rev 636 Proc Q4104 * Qty 1 = $209.78 at 100% = $209.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,120.88,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,209.78,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $209.78 from Fee Schedule UHC_31190C for Rev 636 Proc Q4104 * Qty 1 = $209.78 at 100% = $209.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,UNITY HEALTH PLAN,UNITY HOSPICE,120.88,,,,,,,84.2000,3855.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2775.94,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,775.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2390.39,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,390.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2775.94,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,775.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2775.94,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,775.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRESSING MATRIX WOUND INTEGRA 2IN X 2IN,Q4104,HCPCS,636,RC,10010299,CDM,,,,both,,,3855.4700,2544.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2313.28,,,,,,,84.2000,3855.4700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,855.47 in Billed Charges for Rev 636 Proc Q4104 = $2,313.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,AETNA,AETNA HSHS,4732.60,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $4,732.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,AETNA,ALL COMMERCIAL AETNA,7326.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $7,326.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,ANTHEM,ANTHEM POS/HMO,3809.52,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,809.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,ANTHEM,ANTHEM PPO,3809.52,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,809.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7326.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $7,326.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,CENPATICO,ALL MEDICAID CENPATICO,7326.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $7,326.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6227.10,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $6,227.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,CIGNA,ALL COMMERCIAL CIGNA,5128.20,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,128.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,COFINITY,COFINITY,7326.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $7,326.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6959.70,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $6,959.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,6153.84,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $6,153.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5201.46,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,201.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5347.98,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,347.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,3560.44,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,560.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6227.10,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $6,227.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,HUMANA,HUMANA CHOICE CARE HMO,3663.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,663.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,HUMANA,HUMANA CHOICE CARE PPO,6227.10,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $6,227.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,HUMANA,HUMANA NATIIONAL POS HMO,3663.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,663.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5347.98,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,347.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,7326.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $7,326.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3663.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,663.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6153.84,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $6,153.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5494.50,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,494.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6739.92,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $6,739.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3663.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,663.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3663.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,663.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,PREVEA HEALTH NETWORK,PREVEA360,3663.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,663.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3663.00,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,663.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4676.19,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $4,676.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5274.72,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,274.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3413.92,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,413.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,3413.92,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,413.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,3413.92,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $3,413.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5274.72,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,274.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4542.12,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $4,542.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5274.72,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,274.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5274.72,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $5,274.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 3X6CM AMNION CORD,Q4112,HCPCS,278,RC,10077210,CDM,,,,both,,,7326.0000,4835.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4395.60,,,,,,,3413.9200,7326.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,326.00 in Billed Charges for Rev 278 Proc Q4112 = $4,395.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,AETNA,AETNA HSHS,680.56,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $680.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,AETNA,ALL COMMERCIAL AETNA,1053.50,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $1,053.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,ANTHEM,ANTHEM POS/HMO,547.82,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $547.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,ANTHEM,ANTHEM PPO,547.82,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $547.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1053.50,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $1,053.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,CENPATICO,ALL MEDICAID CENPATICO,1053.50,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $1,053.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,895.48,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $895.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,CIGNA,ALL COMMERCIAL CIGNA,737.45,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $737.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,COFINITY,COFINITY,1053.50,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $1,053.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1000.83,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $1,000.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,HEALTH CARE ALLIANCE,THE ALLIANCE,884.94,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $884.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,747.99,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $747.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,769.06,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $769.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,HSHS EMPLOYEES,HSHS EMPLOYEES,512.00,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $512.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,895.48,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $895.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,HUMANA,HUMANA CHOICE CARE PPO,895.48,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $895.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,769.06,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $769.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1053.50,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $1,053.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,526.75,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $526.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,884.94,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $884.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,790.13,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $790.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,969.22,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $969.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,672.45,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $672.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,758.52,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,758.52,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,653.17,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $653.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,758.52,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,758.52,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $758.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
OCULAR IMPLANT,L8610,HCPCS,278,RC,10016190,CDM,,,,both,,,1053.5000,695.3100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,632.10,,,,,,,512.0000,1053.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,053.50 in Billed Charges for Rev 278 Proc L8610 = $632.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,AETNA,AETNA HSHS,69.46,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $69.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,AETNA,ALL COMMERCIAL AETNA,107.53,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $107.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,107.53,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $107.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,CENPATICO,ALL MEDICAID CENPATICO,107.53,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $107.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,91.40,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $91.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,CIGNA,ALL COMMERCIAL CIGNA,75.27,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $75.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,COFINITY,COFINITY,107.53,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $107.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,102.15,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $102.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,90.33,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $90.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,76.35,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $76.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,78.50,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $78.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,52.26,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $52.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,91.40,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $91.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,HUMANA,HUMANA CHOICE CARE PPO,91.40,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $91.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,78.50,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $78.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,107.53,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $107.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.77,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $53.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,90.33,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $90.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,80.65,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $80.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,98.93,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $98.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,68.64,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $68.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,77.42,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $77.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,77.42,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $77.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,66.67,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $66.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,77.42,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $77.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,77.42,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $77.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 4X2.5MM SILICONE OVAL STERILE,L8610,HCPCS,278,RC,10073765,CDM,,,,both,,,107.5300,70.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,64.52,,,,,,,52.2600,107.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $107.53 in Billed Charges for Rev 278 Proc L8610 = $64.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,AETNA,AETNA HSHS,216.57,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $216.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,AETNA,ALL COMMERCIAL AETNA,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,CENPATICO,ALL MEDICAID CENPATICO,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,284.96,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $284.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,CIGNA,ALL COMMERCIAL CIGNA,234.68,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $234.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,COFINITY,COFINITY,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,318.49,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $318.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,281.61,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $281.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,238.03,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $238.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,244.73,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $244.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,162.93,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $162.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,284.96,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $284.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,HUMANA,HUMANA CHOICE CARE PPO,284.96,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $284.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,244.73,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $244.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,335.25,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,167.63,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $167.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,281.61,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $281.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,251.44,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $251.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,308.43,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $308.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,213.99,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $213.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,241.38,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $241.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,241.38,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $241.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,207.86,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $207.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,241.38,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $241.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,241.38,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $241.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PISTON OSSICULAR 4MM .6MM EAR STAPES PLATINUM FLUOROPLASTIC RIBBON LOOP,L8613,HCPCS,278,RC,10025499,CDM,,,,both,,,335.2500,221.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,201.15,,,,,,,162.9300,335.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $335.25 in Billed Charges for Rev 278 Proc L8613 = $201.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,AETNA,AETNA HSHS,437.50,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $437.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,AETNA,ALL COMMERCIAL AETNA,677.25,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $677.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,677.25,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $677.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,CENPATICO,ALL MEDICAID CENPATICO,677.25,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $677.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,575.66,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $575.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,CIGNA,ALL COMMERCIAL CIGNA,474.08,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $474.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,COFINITY,COFINITY,677.25,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $677.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,643.39,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $643.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,568.89,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $568.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,480.85,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $480.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,494.39,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $494.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,329.14,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $329.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,575.66,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $575.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,HUMANA,HUMANA CHOICE CARE PPO,575.66,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $575.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,494.39,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $494.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,677.25,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $677.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,338.63,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $338.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,568.89,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $568.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,507.94,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $507.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,623.07,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $623.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,432.29,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $432.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,487.62,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $487.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,487.62,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $487.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,419.90,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $419.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,487.62,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $487.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,487.62,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $487.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR 2X2X1.2MM 1MM APLBM SM DNS INCDSTP HA,L8613,HCPCS,278,RC,10033561,CDM,,,,both,,,677.2500,446.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,406.35,,,,,,,329.1400,677.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $677.25 in Billed Charges for Rev 278 Proc L8613 = $406.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,AETNA,AETNA HSHS,481.95,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $481.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,AETNA,ALL COMMERCIAL AETNA,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,CENPATICO,ALL MEDICAID CENPATICO,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,634.14,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $634.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,CIGNA,ALL COMMERCIAL CIGNA,522.24,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $522.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,COFINITY,COFINITY,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,708.75,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $708.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,626.68,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $626.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,529.70,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $529.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,544.62,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $544.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,362.58,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $362.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,634.14,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $634.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,HUMANA,HUMANA CHOICE CARE PPO,634.14,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $634.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,544.62,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $544.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,746.05,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $746.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,373.03,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $373.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,626.68,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $626.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,559.54,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $559.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,686.37,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $686.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,476.20,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $476.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,537.16,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,537.16,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,462.55,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $462.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,537.16,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,537.16,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $537.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS STAPES WEHRS DOUBLE NOTCH,L8613,HCPCS,278,RC,10055410,CDM,,,,both,,,746.0500,492.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,447.63,,,,,,,362.5800,746.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $746.05 in Billed Charges for Rev 278 Proc L8613 = $447.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,AETNA,AETNA HSHS,1059.44,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,059.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,AETNA,ALL COMMERCIAL AETNA,1640.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,ANTHEM,ANTHEM POS/HMO,852.80,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $852.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,ANTHEM,ANTHEM PPO,852.80,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $852.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1640.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,CENPATICO,ALL MEDICAID CENPATICO,1640.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1394.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,CIGNA,ALL COMMERCIAL CIGNA,1148.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,148.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,COFINITY,COFINITY,1640.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1558.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,1377.60,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,377.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1164.40,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,164.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1197.20,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,197.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,797.04,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $797.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1394.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,HUMANA,HUMANA CHOICE CARE PPO,1394.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1197.20,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,197.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1640.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,820.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $820.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1377.60,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,377.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1230.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,230.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1508.80,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,508.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1046.81,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,046.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1180.80,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1180.80,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1016.80,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,016.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1180.80,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1180.80,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $1,180.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE EAR SHAH MINI GROMET,L8613,HCPCS,278,RC,10000222,CDM,,,,both,,,1640.0000,1082.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,984.00,,,,,,,797.0400,1640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,640.00 in Billed Charges for Rev 278 Proc L8613 = $984.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,AETNA,AETNA HSHS,954.82,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $954.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,AETNA,ALL COMMERCIAL AETNA,1478.05,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,478.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,ANTHEM,ANTHEM POS/HMO,768.59,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $768.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,ANTHEM,ANTHEM PPO,768.59,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $768.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1478.05,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,478.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,CENPATICO,ALL MEDICAID CENPATICO,1478.05,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,478.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1256.34,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,256.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,COFINITY,COFINITY,1478.05,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,478.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1404.15,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,404.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,1241.56,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,241.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1049.42,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,049.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1078.98,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,078.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,718.33,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $718.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1256.34,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,256.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,HUMANA,HUMANA CHOICE CARE PPO,1256.34,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,256.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1078.98,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,078.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1478.05,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,478.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,739.03,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $739.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1241.56,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,241.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1108.54,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,108.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1359.81,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,359.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,943.44,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $943.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1064.20,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,064.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1064.20,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,064.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,916.39,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $916.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1064.20,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,064.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1064.20,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $1,064.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CATH RELIEVA SOLO PRO SINUS BALLOON 7 X 24,C1726,HCPCS,278,RC,70405293,CDM,,,,both,,,1478.0500,975.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,886.83,,,,,,,718.3300,1478.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,478.05 in Billed Charges for Rev 278 Proc C1726 = $886.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,AETNA,AETNA HSHS,37.79,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $37.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,AETNA,ALL COMMERCIAL AETNA,58.50,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,58.50,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,CENPATICO,ALL MEDICAID CENPATICO,58.50,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,49.73,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $49.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,COFINITY,COFINITY,58.50,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,55.58,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $55.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,49.14,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $49.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,41.54,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $41.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,42.71,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $42.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,28.43,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $28.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,49.73,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $49.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,HUMANA,HUMANA CHOICE CARE PPO,49.73,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $49.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,42.71,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $42.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,58.50,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,29.25,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $29.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,49.14,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $49.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,43.88,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $43.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,53.82,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $53.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,37.34,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $37.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,42.12,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $42.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,42.12,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $42.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,36.27,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $36.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,42.12,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $42.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,42.12,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $42.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONN SHNT 1.6CM 1.9MM 1.1MM STRT CSF THR PDNZ NYL STER,C1729,HCPCS,278,RC,10004857,CDM,,,,both,,,58.5000,38.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,35.10,,,,,,,28.4300,58.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $58.50 in Billed Charges for Rev 278 Proc C1729 = $35.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,AETNA,AETNA HSHS,461.46,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $461.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,AETNA,ALL COMMERCIAL AETNA,714.34,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $714.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,714.34,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $714.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,CENPATICO,ALL MEDICAID CENPATICO,714.34,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $714.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,607.19,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $607.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,CIGNA,ALL COMMERCIAL CIGNA,500.04,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $500.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,COFINITY,COFINITY,714.34,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $714.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,678.62,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $678.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,600.05,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $600.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,507.18,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $507.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,521.47,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $521.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,347.17,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $347.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,607.19,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $607.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,HUMANA,HUMANA CHOICE CARE PPO,607.19,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $607.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,521.47,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $521.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,714.34,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $714.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,357.17,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $357.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,600.05,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $600.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,535.76,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $535.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,657.19,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $657.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,455.96,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $455.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,514.32,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $514.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,514.32,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $514.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,442.89,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $442.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,514.32,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $514.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,514.32,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $514.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CATHETER PERITONEAL ARES ANTIMICROBIAL,C1750,HCPCS,278,RC,10068081,CDM,,,,both,,,714.3400,471.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,428.60,,,,,,,347.1700,714.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $714.34 in Billed Charges for Rev 278 Proc C1750 = $428.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,AETNA,AETNA HSHS,1044.99,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,044.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,AETNA,ALL COMMERCIAL AETNA,1617.63,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,617.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,ANTHEM,ANTHEM POS/HMO,841.17,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $841.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,ANTHEM,ANTHEM PPO,841.17,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $841.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1617.63,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,617.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,CENPATICO,ALL MEDICAID CENPATICO,1617.63,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,617.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1374.99,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,374.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,CIGNA,ALL COMMERCIAL CIGNA,1132.34,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,132.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,COFINITY,COFINITY,1617.63,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,617.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1536.75,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,536.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,1358.81,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,358.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1148.52,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,148.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1180.87,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,180.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,786.17,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $786.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1374.99,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,374.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,HUMANA,HUMANA CHOICE CARE PPO,1374.99,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,374.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1180.87,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,180.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1617.63,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,617.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,808.82,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $808.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1358.81,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,358.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1213.22,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,213.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1488.22,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,488.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1032.53,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,032.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1164.69,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,164.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1164.69,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,164.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1002.93,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,002.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1164.69,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,164.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1164.69,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $1,164.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
WEDGE ILLIAC CREST 13-15X14-20MM,C1762,HCPCS,278,RC,10074988,CDM,,,,both,,,1617.6300,1067.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,970.58,,,,,,,786.1700,1617.6300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,617.63 in Billed Charges for Rev 278 Proc C1762 = $970.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,AETNA,AETNA HSHS,2976.93,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,976.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,AETNA,ALL COMMERCIAL AETNA,4608.25,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $4,608.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,ANTHEM,ANTHEM POS/HMO,2396.29,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,396.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,ANTHEM,ANTHEM PPO,2396.29,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,396.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4608.25,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $4,608.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,CENPATICO,ALL MEDICAID CENPATICO,4608.25,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $4,608.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3917.01,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,917.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,CIGNA,ALL COMMERCIAL CIGNA,3225.78,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,225.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,COFINITY,COFINITY,4608.25,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $4,608.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4377.84,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $4,377.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,3870.93,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,870.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3271.86,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,271.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3364.02,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,2239.61,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,239.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3917.01,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,917.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,HUMANA,HUMANA CHOICE CARE HMO,2304.13,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,304.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,HUMANA,HUMANA CHOICE CARE PPO,3917.01,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,917.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,HUMANA,HUMANA NATIIONAL POS HMO,2304.13,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,304.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3364.02,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,364.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,4608.25,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $4,608.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2304.13,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,304.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3870.93,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,870.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3456.19,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,456.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4239.59,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $4,239.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2941.45,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,941.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3317.94,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,317.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3317.94,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,317.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2857.12,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,857.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3317.94,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,317.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3317.94,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $3,317.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BIOINDUCTIVE IMPLANT W/ ARTHROSCOPIC DELIVERY SYSTEM LARGE,C1763,HCPCS,278,RC,10090013,CDM,,,,both,,,4608.2500,3041.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2764.95,,,,,,,2239.6100,4608.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,608.25 in Billed Charges for Rev 278 Proc C1763 = $2,764.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,AETNA,AETNA HSHS,1659.14,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,659.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,AETNA,ALL COMMERCIAL AETNA,2568.33,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,568.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,ANTHEM,ANTHEM POS/HMO,1335.53,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,335.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,ANTHEM,ANTHEM PPO,1335.53,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,335.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2568.33,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,568.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,CENPATICO,ALL MEDICAID CENPATICO,2568.33,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,568.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2183.08,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,183.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,CIGNA,ALL COMMERCIAL CIGNA,1797.83,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,797.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,COFINITY,COFINITY,2568.33,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,568.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2439.91,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,439.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,2157.40,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,157.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1823.51,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,823.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1874.88,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,874.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,1248.21,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,248.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2183.08,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,183.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,HUMANA,HUMANA CHOICE CARE HMO,1284.17,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,284.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,HUMANA,HUMANA CHOICE CARE PPO,2183.08,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,183.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,HUMANA,HUMANA NATIIONAL POS HMO,1284.17,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,284.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1874.88,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,874.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2568.33,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,568.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1284.17,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,284.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2157.40,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,157.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1926.25,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,926.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2362.86,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $2,362.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1639.37,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,639.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1849.20,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,849.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1849.20,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,849.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1592.36,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,592.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1849.20,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,849.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1849.20,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,849.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 12X16CM,C1763,HCPCS,278,RC,10069601,CDM,,,,both,,,2568.3300,1695.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1541.00,,,,,,,1248.2100,2568.3300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,568.33 in Billed Charges for Rev 278 Proc C1763 = $1,541.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,AETNA,AETNA HSHS,584.92,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $584.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,AETNA,ALL COMMERCIAL AETNA,905.45,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $905.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,905.45,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $905.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,CENPATICO,ALL MEDICAID CENPATICO,905.45,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $905.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,769.63,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $769.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,CIGNA,ALL COMMERCIAL CIGNA,633.82,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $633.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,COFINITY,COFINITY,905.45,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $905.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,860.18,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $860.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,760.58,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $760.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,642.87,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $642.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,660.98,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $660.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,440.05,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $440.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,769.63,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $769.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,HUMANA,HUMANA CHOICE CARE PPO,769.63,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $769.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,660.98,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $660.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,905.45,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $905.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,452.73,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $452.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,760.58,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $760.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,679.09,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $679.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,833.01,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $833.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,577.95,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $577.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,651.92,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $651.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,651.92,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $651.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,561.38,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $561.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,651.92,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $651.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,651.92,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $651.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BP SUTUREABLE 6X8CM,C1763,HCPCS,278,RC,10069600,CDM,,,,both,,,905.4500,597.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,543.27,,,,,,,440.0500,905.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $905.45 in Billed Charges for Rev 278 Proc C1763 = $543.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,AETNA,AETNA HSHS,449.81,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $449.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,AETNA,ALL COMMERCIAL AETNA,696.30,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $696.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,696.30,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $696.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,CENPATICO,ALL MEDICAID CENPATICO,696.30,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $696.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,591.86,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $591.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,CIGNA,ALL COMMERCIAL CIGNA,487.41,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $487.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,COFINITY,COFINITY,696.30,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $696.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,661.49,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $661.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,584.89,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $584.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,494.37,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $494.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,508.30,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $508.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,338.40,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,591.86,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $591.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,HUMANA,HUMANA CHOICE CARE PPO,591.86,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $591.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,508.30,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $508.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,696.30,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $696.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,348.15,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $348.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,584.89,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $584.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,522.23,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $522.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,640.60,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $640.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,444.45,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $444.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,501.34,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $501.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,501.34,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $501.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,431.71,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $431.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,501.34,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $501.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,501.34,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $501.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT DURAGEN MATRIX 1 X 1,C1763,HCPCS,278,RC,10018006,CDM,,,,both,,,696.3000,459.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,417.78,,,,,,,338.4000,696.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $696.30 in Billed Charges for Rev 278 Proc C1763 = $417.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,AETNA,AETNA HSHS,2781.42,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,781.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,AETNA,ALL COMMERCIAL AETNA,4305.60,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $4,305.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,ANTHEM,ANTHEM POS/HMO,2238.91,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,238.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,ANTHEM,ANTHEM PPO,2238.91,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,238.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4305.60,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $4,305.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,CENPATICO,ALL MEDICAID CENPATICO,4305.60,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $4,305.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3659.76,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,659.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,CIGNA,ALL COMMERCIAL CIGNA,3013.92,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,013.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,COFINITY,COFINITY,4305.60,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $4,305.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4090.32,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $4,090.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,3616.70,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,616.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3056.98,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,056.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3143.09,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,143.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,2092.52,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,092.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3659.76,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,659.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,HUMANA,HUMANA CHOICE CARE HMO,2152.80,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,152.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,HUMANA,HUMANA CHOICE CARE PPO,3659.76,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,659.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,HUMANA,HUMANA NATIIONAL POS HMO,2152.80,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,152.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3143.09,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,143.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,4305.60,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $4,305.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2152.80,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,152.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3616.70,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,616.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3229.20,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,229.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3961.15,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,961.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2748.26,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,748.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3100.03,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,100.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3100.03,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,100.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2669.47,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,669.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3100.03,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,100.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3100.03,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $3,100.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MATRIX TISS 10X10CM STRATTICE PORC DERM RECON FIRM 100SQ CM,C1763,HCPCS,278,RC,10043327,CDM,,,,both,,,4305.6000,2841.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2583.36,,,,,,,2092.5200,4305.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,305.60 in Billed Charges for Rev 278 Proc C1763 = $2,583.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,AETNA,AETNA HSHS,667.95,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $667.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,AETNA,ALL COMMERCIAL AETNA,1033.98,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $1,033.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,ANTHEM,ANTHEM POS/HMO,537.67,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $537.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,ANTHEM,ANTHEM PPO,537.67,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $537.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1033.98,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $1,033.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,CENPATICO,ALL MEDICAID CENPATICO,1033.98,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $1,033.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,878.88,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $878.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,CIGNA,ALL COMMERCIAL CIGNA,723.79,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $723.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,COFINITY,COFINITY,1033.98,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $1,033.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,982.28,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $982.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,868.54,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $868.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,734.13,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $734.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,754.81,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $754.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,502.51,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $502.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,878.88,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $878.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,HUMANA,HUMANA CHOICE CARE PPO,878.88,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $878.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,754.81,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $754.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1033.98,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $1,033.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,516.99,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $516.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,868.54,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $868.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,775.49,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $775.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,951.26,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $951.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,659.99,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $659.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,744.47,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $744.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,744.47,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $744.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,641.07,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $641.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,744.47,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $744.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,744.47,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $744.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 2 X 2,C1763,HCPCS,278,RC,10018005,CDM,,,,both,,,1033.9800,682.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,620.39,,,,,,,502.5100,1033.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,033.98 in Billed Charges for Rev 278 Proc C1763 = $620.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,AETNA,AETNA HSHS,1248.88,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,248.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,AETNA,ALL COMMERCIAL AETNA,1933.25,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,933.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,ANTHEM,ANTHEM POS/HMO,1005.29,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,005.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,ANTHEM,ANTHEM PPO,1005.29,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,005.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1933.25,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,933.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,CENPATICO,ALL MEDICAID CENPATICO,1933.25,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,933.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1643.26,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,643.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,CIGNA,ALL COMMERCIAL CIGNA,1353.28,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,353.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,COFINITY,COFINITY,1933.25,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,933.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1836.59,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,836.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,HEALTH CARE ALLIANCE,THE ALLIANCE,1623.93,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,623.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1372.61,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,372.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1411.27,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,411.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,HSHS EMPLOYEES,HSHS EMPLOYEES,939.56,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $939.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1643.26,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,643.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,HUMANA,HUMANA CHOICE CARE PPO,1643.26,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,643.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1411.27,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,411.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1933.25,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,933.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,966.63,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $966.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1623.93,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,623.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1449.94,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,449.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1778.59,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,778.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1233.99,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,233.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1391.94,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,391.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1391.94,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,391.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1198.62,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,198.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1391.94,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,391.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1391.94,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,391.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN 3 X 3,C1763,HCPCS,278,RC,10031418,CDM,,,,both,,,1933.2500,1275.9500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1159.95,,,,,,,939.5600,1933.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,933.25 in Billed Charges for Rev 278 Proc C1763 = $1,159.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,AETNA,AETNA HSHS,663.80,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $663.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,AETNA,ALL COMMERCIAL AETNA,1027.56,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $1,027.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,ANTHEM,ANTHEM POS/HMO,534.33,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $534.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,ANTHEM,ANTHEM PPO,534.33,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $534.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1027.56,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $1,027.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,CENPATICO,ALL MEDICAID CENPATICO,1027.56,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $1,027.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,873.43,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $873.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,CIGNA,ALL COMMERCIAL CIGNA,719.29,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $719.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,COFINITY,COFINITY,1027.56,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $1,027.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,976.18,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $976.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,863.15,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $863.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,729.57,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $729.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,750.12,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $750.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,499.39,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $499.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,873.43,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $873.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,HUMANA,HUMANA CHOICE CARE PPO,873.43,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $873.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,750.12,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $750.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1027.56,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $1,027.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,513.78,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $513.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,863.15,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $863.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,770.67,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $770.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,945.36,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $945.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,655.89,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $655.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,739.84,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $739.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,739.84,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $739.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,637.09,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $637.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,739.84,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $739.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,739.84,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $739.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE DURAGEN MATRIX 1 X 3,C1763,HCPCS,278,RC,10031417,CDM,,,,both,,,1027.5600,678.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,616.54,,,,,,,499.3900,1027.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,027.56 in Billed Charges for Rev 278 Proc C1763 = $616.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,AETNA,AETNA HSHS,1244.56,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,244.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,AETNA,ALL COMMERCIAL AETNA,1926.57,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,926.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,ANTHEM,ANTHEM POS/HMO,1001.82,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,001.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,ANTHEM,ANTHEM PPO,1001.82,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,001.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1926.57,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,926.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,CENPATICO,ALL MEDICAID CENPATICO,1926.57,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,926.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1637.58,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,637.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,COFINITY,COFINITY,1926.57,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,926.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1830.24,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,830.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,1618.32,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,618.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1367.86,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,367.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1406.40,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,406.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,936.31,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $936.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1637.58,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,637.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,HUMANA,HUMANA CHOICE CARE PPO,1637.58,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,637.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1406.40,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,406.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1926.57,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,926.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,963.29,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $963.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1618.32,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,618.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1444.93,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,444.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1772.44,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,772.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1229.73,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,229.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1387.13,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,387.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1387.13,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,387.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1194.47,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,194.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1387.13,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,387.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1387.13,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,387.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"BARRIER SEPRAFILM 3 X 5, PROCEDURE PACK",C1765,HCPCS,278,RC,10005378,CDM,,,,both,,,1926.5700,1271.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1155.94,,,,,,,936.3100,1926.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,926.57 in Billed Charges for Rev 278 Proc C1765 = $1,155.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,AETNA,AETNA HSHS,33293.29,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $33,293.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,AETNA,ALL COMMERCIAL AETNA,51537.60,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $51,537.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,ANTHEM,ANTHEM POS/HMO,26799.55,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $26,799.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,ANTHEM,ANTHEM PPO,26799.55,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $26,799.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,51537.60,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $51,537.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,CENPATICO,ALL MEDICAID CENPATICO,51537.60,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $51,537.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,43806.96,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $43,806.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,CIGNA,ALL COMMERCIAL CIGNA,36076.32,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $36,076.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,COFINITY,COFINITY,51537.60,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $51,537.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,48960.72,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $48,960.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,43291.58,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $43,291.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,36591.70,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $36,591.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,37622.45,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $37,622.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,25047.27,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $25,047.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,43806.96,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $43,806.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,HUMANA,HUMANA CHOICE CARE HMO,25768.80,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $25,768.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,HUMANA,HUMANA CHOICE CARE PPO,43806.96,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $43,806.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,HUMANA,HUMANA NATIIONAL POS HMO,25768.80,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $25,768.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,37622.45,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $37,622.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,51537.60,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $51,537.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,25768.80,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $25,768.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,43291.58,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $43,291.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,38653.20,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $38,653.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,47414.59,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $47,414.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,25768.80,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $25,768.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,25768.80,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $25,768.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,PREVEA HEALTH NETWORK,PREVEA360,25768.80,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $25,768.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,25768.80,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $25,768.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,32896.45,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $32,896.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,37107.07,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $37,107.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,24016.52,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $24,016.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,24016.52,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $24,016.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,24016.52,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $24,016.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,37107.07,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $37,107.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,31953.31,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $31,953.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,37107.07,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $37,107.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,37107.07,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $37,107.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR MEDTRONIC VNS THERAPY PULSE (MODEL 106),C1767,HCPCS,278,RC,10053819,CDM,,,,both,,,51537.6000,34014.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,30922.56,,,,,,,24016.5200,51537.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $51,537.60 in Billed Charges for Rev 278 Proc C1767 = $30,922.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,AETNA,AETNA HSHS,45255.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $45,255.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,AETNA,ALL COMMERCIAL AETNA,70054.76,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $70,054.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,ANTHEM,ANTHEM POS/HMO,36428.48,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $36,428.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,ANTHEM,ANTHEM PPO,36428.48,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $36,428.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,70054.76,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $70,054.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,CENPATICO,ALL MEDICAID CENPATICO,70054.76,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $70,054.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,59546.55,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $59,546.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,CIGNA,ALL COMMERCIAL CIGNA,49038.33,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $49,038.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,COFINITY,COFINITY,70054.76,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $70,054.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,66552.02,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $66,552.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,58846.00,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $58,846.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,49738.88,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $49,738.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,51139.97,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $51,139.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,34046.61,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $34,046.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,59546.55,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $59,546.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,HUMANA,HUMANA CHOICE CARE HMO,35027.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $35,027.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,HUMANA,HUMANA CHOICE CARE PPO,59546.55,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $59,546.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,HUMANA,HUMANA NATIIONAL POS HMO,35027.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $35,027.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,51139.97,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $51,139.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,70054.76,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $70,054.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35027.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $35,027.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,58846.00,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $58,846.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,52541.07,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $52,541.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,64450.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $64,450.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,35027.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $35,027.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,35027.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $35,027.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,PREVEA HEALTH NETWORK,PREVEA360,35027.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $35,027.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,35027.38,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $35,027.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44715.95,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $44,715.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,50439.43,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $50,439.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32645.52,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $32,645.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,32645.52,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $32,645.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,32645.52,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $32,645.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,50439.43,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $50,439.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,43433.95,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $43,433.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,50439.43,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $50,439.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,50439.43,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $50,439.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GENERATOR SENTIVA VAGAL NERVE STIM MODEL 1000,C1767,HCPCS,278,RC,10074966,CDM,,,,both,,,70054.7600,46236.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42032.86,,,,,,,32645.5200,70054.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $70,054.76 in Billed Charges for Rev 278 Proc C1767 = $42,032.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,AETNA,AETNA HSHS,526.39,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $526.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,AETNA,ALL COMMERCIAL AETNA,814.85,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $814.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,814.85,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $814.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,CENPATICO,ALL MEDICAID CENPATICO,814.85,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $814.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,692.62,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $692.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,CIGNA,ALL COMMERCIAL CIGNA,570.40,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $570.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,COFINITY,COFINITY,814.85,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $814.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,774.11,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $774.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,684.47,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $684.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,578.54,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $578.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,594.84,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $594.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,396.02,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $396.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,692.62,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $692.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,HUMANA,HUMANA CHOICE CARE PPO,692.62,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $692.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,594.84,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $594.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,814.85,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $814.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,407.43,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $407.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,684.47,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $684.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,611.14,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $611.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,749.66,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $749.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,520.12,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $520.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,586.69,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $586.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,586.69,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $586.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,505.21,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $505.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,586.69,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $586.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,586.69,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $586.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT  XENOSURE BIOLOGIC PATCH 2 X 9CM,C1768,HCPCS,278,RC,10038858,CDM,,,,both,,,814.8500,537.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,488.91,,,,,,,396.0200,814.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $814.85 in Billed Charges for Rev 278 Proc C1768 = $488.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,AETNA,AETNA HSHS,1681.54,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,681.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,AETNA,ALL COMMERCIAL AETNA,2603.00,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,603.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,ANTHEM,ANTHEM POS/HMO,1353.56,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,353.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,ANTHEM,ANTHEM PPO,1353.56,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,353.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2603.00,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,603.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,CENPATICO,ALL MEDICAID CENPATICO,2603.00,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,603.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2212.55,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,212.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,CIGNA,ALL COMMERCIAL CIGNA,1822.10,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,822.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,COFINITY,COFINITY,2603.00,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,603.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2472.85,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,472.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,2186.52,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,186.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1848.13,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,848.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1900.19,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,900.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,1265.06,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,265.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2212.55,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,212.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,HUMANA,HUMANA CHOICE CARE HMO,1301.50,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,301.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,HUMANA,HUMANA CHOICE CARE PPO,2212.55,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,212.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,HUMANA,HUMANA NATIIONAL POS HMO,1301.50,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,301.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1900.19,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,900.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2603.00,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,603.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1301.50,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,301.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2186.52,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,186.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1952.25,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,952.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2394.76,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $2,394.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1661.49,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,661.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1874.16,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,874.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1874.16,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,874.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1613.86,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,613.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1874.16,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,874.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1874.16,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,874.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT ACUSEAL WL GORE 6X40,C1768,HCPCS,278,RC,10065686,CDM,,,,both,,,2603.0000,1717.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1561.80,,,,,,,1265.0600,2603.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,603.00 in Billed Charges for Rev 278 Proc C1768 = $1,561.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,AETNA,AETNA HSHS,949.66,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $949.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,AETNA,ALL COMMERCIAL AETNA,1470.06,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,470.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,ANTHEM,ANTHEM POS/HMO,764.43,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $764.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,ANTHEM,ANTHEM PPO,764.43,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $764.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1470.06,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,470.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,CENPATICO,ALL MEDICAID CENPATICO,1470.06,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,470.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1249.55,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,249.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,CIGNA,ALL COMMERCIAL CIGNA,1029.04,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,029.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,COFINITY,COFINITY,1470.06,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,470.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1396.56,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,396.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,1234.85,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,234.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1043.74,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,043.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1073.14,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,073.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,714.45,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $714.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1249.55,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,249.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,HUMANA,HUMANA CHOICE CARE PPO,1249.55,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,249.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1073.14,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,073.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1470.06,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,470.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,735.03,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $735.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1234.85,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,234.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1102.55,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,102.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1352.46,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,352.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,938.34,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $938.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1058.44,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,058.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1058.44,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,058.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,911.44,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $911.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1058.44,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,058.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1058.44,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $1,058.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BARD IMPRA STEPPED CENTREFLEX 4 X 7,C1768,HCPCS,278,RC,10003875,CDM,,,,both,,,1470.0600,970.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,882.04,,,,,,,714.4500,1470.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,470.06 in Billed Charges for Rev 278 Proc C1768 = $882.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,AETNA,AETNA HSHS,783.13,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $783.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,AETNA,ALL COMMERCIAL AETNA,1212.27,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,212.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,ANTHEM,ANTHEM POS/HMO,630.38,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $630.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,ANTHEM,ANTHEM PPO,630.38,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $630.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1212.27,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,212.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,CENPATICO,ALL MEDICAID CENPATICO,1212.27,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,212.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1030.43,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,030.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,CIGNA,ALL COMMERCIAL CIGNA,848.59,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $848.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,COFINITY,COFINITY,1212.27,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,212.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1151.66,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,151.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,1018.31,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,018.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,860.71,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $860.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,884.96,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $884.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,589.16,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $589.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1030.43,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,030.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,HUMANA,HUMANA CHOICE CARE PPO,1030.43,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,030.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,884.96,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $884.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1212.27,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,212.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,606.14,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $606.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1018.31,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,018.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,909.20,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $909.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1115.29,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $1,115.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,773.79,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $773.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,872.83,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $872.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,872.83,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $872.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,751.61,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $751.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,872.83,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $872.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,872.83,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $872.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10043445,CDM,,,,both,,,1212.2700,800.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,727.36,,,,,,,589.1600,1212.2700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,212.27 in Billed Charges for Rev 278 Proc C1768 = $727.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,AETNA,AETNA HSHS,1766.54,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,766.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,AETNA,ALL COMMERCIAL AETNA,2734.58,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,734.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,ANTHEM,ANTHEM POS/HMO,1421.98,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,421.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,ANTHEM,ANTHEM PPO,1421.98,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,421.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2734.58,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,734.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,CENPATICO,ALL MEDICAID CENPATICO,2734.58,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,734.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2324.39,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,324.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,CIGNA,ALL COMMERCIAL CIGNA,1914.21,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,914.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,COFINITY,COFINITY,2734.58,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,734.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2597.85,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,597.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,2297.05,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,297.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1941.55,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,941.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1996.24,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,996.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,1329.01,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,329.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2324.39,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,324.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,HUMANA,HUMANA CHOICE CARE HMO,1367.29,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,367.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,HUMANA,HUMANA CHOICE CARE PPO,2324.39,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,324.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,HUMANA,HUMANA NATIIONAL POS HMO,1367.29,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,367.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1996.24,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,996.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2734.58,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,734.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1367.29,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,367.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2297.05,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,297.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2050.94,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,050.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2515.81,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $2,515.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1745.48,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,745.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1968.90,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,968.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1968.90,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,968.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1695.44,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,695.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1968.90,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,968.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1968.90,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,968.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT DISTAFLO 6MM X 50CM FLEX SM BEAD,C1768,HCPCS,278,RC,10007524,CDM,,,,both,,,2734.5800,1804.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1640.75,,,,,,,1329.0100,2734.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,734.58 in Billed Charges for Rev 278 Proc C1768 = $1,640.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,AETNA,AETNA HSHS,2037.48,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,037.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,AETNA,ALL COMMERCIAL AETNA,3154.00,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $3,154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,ANTHEM,ANTHEM POS/HMO,1640.08,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $1,640.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,ANTHEM,ANTHEM PPO,1640.08,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $1,640.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3154.00,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $3,154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,CENPATICO,ALL MEDICAID CENPATICO,3154.00,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $3,154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2680.90,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,680.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,CIGNA,ALL COMMERCIAL CIGNA,2207.80,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,207.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,COFINITY,COFINITY,3154.00,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $3,154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2996.30,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,996.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,2649.36,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,649.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2239.34,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,239.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2302.42,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,302.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,1532.84,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $1,532.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2680.90,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,680.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,HUMANA,HUMANA CHOICE CARE HMO,1577.00,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $1,577.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,HUMANA,HUMANA CHOICE CARE PPO,2680.90,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,680.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,HUMANA,HUMANA NATIIONAL POS HMO,1577.00,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $1,577.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2302.42,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,302.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3154.00,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $3,154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1577.00,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $1,577.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2649.36,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,649.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2365.50,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,365.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2901.68,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,901.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2013.20,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,013.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2270.88,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,270.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2270.88,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,270.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1955.48,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $1,955.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2270.88,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,270.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2270.88,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $2,270.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10012316,CDM,,,,both,,,3154.0000,2081.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1892.40,,,,,,,1532.8400,3154.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,154.00 in Billed Charges for Rev 278 Proc C1768 = $1,892.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,AETNA,AETNA HSHS,995.87,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $995.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,AETNA,ALL COMMERCIAL AETNA,1541.60,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,541.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,ANTHEM,ANTHEM POS/HMO,801.63,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $801.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,ANTHEM,ANTHEM PPO,801.63,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $801.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1541.60,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,541.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,CENPATICO,ALL MEDICAID CENPATICO,1541.60,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,541.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1310.36,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,310.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,CIGNA,ALL COMMERCIAL CIGNA,1079.12,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,079.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,COFINITY,COFINITY,1541.60,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,541.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1464.52,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,464.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,1294.94,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,294.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1094.54,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,094.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1125.37,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,125.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,749.22,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $749.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1310.36,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,310.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,HUMANA,HUMANA CHOICE CARE PPO,1310.36,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,310.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1125.37,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,125.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1541.60,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,541.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,770.80,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $770.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1294.94,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,294.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1156.20,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,156.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1418.27,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,418.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,984.00,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $984.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1109.95,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,109.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1109.95,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,109.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,955.79,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $955.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1109.95,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,109.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1109.95,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $1,109.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10071120,CDM,,,,both,,,1541.6000,1017.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,924.96,,,,,,,749.2200,1541.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,541.60 in Billed Charges for Rev 278 Proc C1768 = $924.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,AETNA,AETNA HSHS,766.77,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $766.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,AETNA,ALL COMMERCIAL AETNA,1186.95,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,186.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,ANTHEM,ANTHEM POS/HMO,617.21,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $617.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,ANTHEM,ANTHEM PPO,617.21,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $617.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1186.95,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,186.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,CENPATICO,ALL MEDICAID CENPATICO,1186.95,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,186.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1008.91,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,008.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,CIGNA,ALL COMMERCIAL CIGNA,830.87,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $830.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,COFINITY,COFINITY,1186.95,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,186.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1127.60,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,127.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,997.04,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $997.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,842.73,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $842.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,866.47,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $866.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,576.86,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $576.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1008.91,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,008.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,HUMANA,HUMANA CHOICE CARE PPO,1008.91,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,008.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,866.47,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $866.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1186.95,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,186.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,593.48,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $593.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,997.04,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $997.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,890.21,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $890.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1091.99,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $1,091.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,757.63,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $757.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,854.60,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $854.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,854.60,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $854.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,735.91,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $735.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,854.60,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $854.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,854.60,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $854.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE STRAIGHT 26MMX30CM,C1768,HCPCS,278,RC,70200847,CDM,,,,both,,,1186.9500,783.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,712.17,,,,,,,576.8600,1186.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,186.95 in Billed Charges for Rev 278 Proc C1768 = $712.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,AETNA,AETNA HSHS,1742.91,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,742.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,AETNA,ALL COMMERCIAL AETNA,2698.00,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,698.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,ANTHEM,ANTHEM POS/HMO,1402.96,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,402.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,ANTHEM,ANTHEM PPO,1402.96,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,402.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2698.00,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,698.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,CENPATICO,ALL MEDICAID CENPATICO,2698.00,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,698.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2293.30,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,293.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,CIGNA,ALL COMMERCIAL CIGNA,1888.60,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,888.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,COFINITY,COFINITY,2698.00,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,698.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2563.10,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,563.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,2266.32,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,266.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1915.58,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,915.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1969.54,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,969.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,1311.23,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,311.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2293.30,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,293.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,HUMANA,HUMANA CHOICE CARE HMO,1349.00,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,349.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,HUMANA,HUMANA CHOICE CARE PPO,2293.30,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,293.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,HUMANA,HUMANA NATIIONAL POS HMO,1349.00,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,349.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1969.54,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,969.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2698.00,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,698.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1349.00,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,349.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2266.32,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,266.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2023.50,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,023.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2482.16,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $2,482.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1722.13,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,722.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1942.56,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,942.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1942.56,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,942.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1672.76,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,672.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1942.56,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,942.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1942.56,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,942.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10064879,CDM,,,,both,,,2698.0000,1780.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1618.80,,,,,,,1311.2300,2698.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,698.00 in Billed Charges for Rev 278 Proc C1768 = $1,618.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,AETNA,AETNA HSHS,917.74,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $917.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,AETNA,ALL COMMERCIAL AETNA,1420.65,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,420.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,ANTHEM,ANTHEM POS/HMO,738.74,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $738.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,ANTHEM,ANTHEM PPO,738.74,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $738.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1420.65,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,420.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,CENPATICO,ALL MEDICAID CENPATICO,1420.65,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,420.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1207.55,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,207.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,CIGNA,ALL COMMERCIAL CIGNA,994.46,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $994.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,COFINITY,COFINITY,1420.65,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,420.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1349.62,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,349.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,HEALTH CARE ALLIANCE,THE ALLIANCE,1193.35,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,193.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1008.66,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,008.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1037.07,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,037.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,HSHS EMPLOYEES,HSHS EMPLOYEES,690.44,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $690.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1207.55,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,207.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,HUMANA,HUMANA CHOICE CARE PPO,1207.55,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,207.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1037.07,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,037.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1420.65,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,420.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,710.33,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $710.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1193.35,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,193.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1065.49,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,065.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1307.00,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,307.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,906.80,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $906.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1022.87,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,022.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1022.87,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,022.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,880.80,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $880.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1022.87,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,022.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1022.87,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $1,022.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GELWEAVE TERUMO STRAIGHT 12MM X 30CM,C1768,HCPCS,278,RC,10070523,CDM,,,,both,,,1420.6500,937.6300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,852.39,,,,,,,690.4400,1420.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,420.65 in Billed Charges for Rev 278 Proc C1768 = $852.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,AETNA,AETNA HSHS,1607.89,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,607.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,AETNA,ALL COMMERCIAL AETNA,2489.00,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,489.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,ANTHEM,ANTHEM POS/HMO,1294.28,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,294.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,ANTHEM,ANTHEM PPO,1294.28,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,294.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2489.00,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,489.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,CENPATICO,ALL MEDICAID CENPATICO,2489.00,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,489.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2115.65,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,115.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,CIGNA,ALL COMMERCIAL CIGNA,1742.30,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,742.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,COFINITY,COFINITY,2489.00,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,489.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2364.55,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,364.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,2090.76,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,090.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1767.19,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,767.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1816.97,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,816.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,1209.65,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,209.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2115.65,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,115.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,HUMANA,HUMANA CHOICE CARE PPO,2115.65,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,115.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1816.97,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,816.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2489.00,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,489.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1244.50,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,244.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2090.76,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,090.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1866.75,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,866.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2289.88,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $2,289.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1588.73,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,588.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1792.08,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,792.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1792.08,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,792.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1543.18,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,543.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1792.08,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,792.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1792.08,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,792.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE PROPATEN THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10022524,CDM,,,,both,,,2489.0000,1642.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1493.40,,,,,,,1209.6500,2489.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,489.00 in Billed Charges for Rev 278 Proc C1768 = $1,493.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,AETNA,AETNA HSHS,2594.21,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,594.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,AETNA,ALL COMMERCIAL AETNA,4015.80,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $4,015.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,ANTHEM,ANTHEM POS/HMO,2088.22,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,088.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,ANTHEM,ANTHEM PPO,2088.22,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,088.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4015.80,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $4,015.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,CENPATICO,ALL MEDICAID CENPATICO,4015.80,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $4,015.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3413.43,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $3,413.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,CIGNA,ALL COMMERCIAL CIGNA,2811.06,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,811.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,COFINITY,COFINITY,4015.80,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $4,015.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3815.01,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $3,815.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,3373.27,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $3,373.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2851.22,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,851.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2931.53,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,931.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,1951.68,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $1,951.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3413.43,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $3,413.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,HUMANA,HUMANA CHOICE CARE HMO,2007.90,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,007.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,HUMANA,HUMANA CHOICE CARE PPO,3413.43,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $3,413.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,HUMANA,HUMANA NATIIONAL POS HMO,2007.90,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,007.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2931.53,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,931.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,4015.80,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $4,015.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2007.90,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,007.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3373.27,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $3,373.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3011.85,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $3,011.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3694.54,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $3,694.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2563.29,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,563.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2891.38,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,891.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2891.38,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,891.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2489.80,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,489.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2891.38,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,891.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2891.38,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,891.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX RINGED AXILLOBIFEMORAL,C1768,HCPCS,278,RC,10048967,CDM,,,,both,,,4015.8000,2650.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2409.48,,,,,,,1951.6800,4015.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,015.80 in Billed Charges for Rev 278 Proc C1768 = $2,409.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,AETNA,AETNA HSHS,1137.57,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,137.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,AETNA,ALL COMMERCIAL AETNA,1760.95,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,760.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,ANTHEM,ANTHEM POS/HMO,915.69,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $915.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,ANTHEM,ANTHEM PPO,915.69,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $915.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1760.95,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,760.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,CENPATICO,ALL MEDICAID CENPATICO,1760.95,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,760.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1496.81,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,496.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,CIGNA,ALL COMMERCIAL CIGNA,1232.67,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,232.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,COFINITY,COFINITY,1760.95,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,760.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1672.90,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,672.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,1479.20,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,479.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1250.27,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,250.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1285.49,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,285.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,855.82,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $855.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1496.81,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,496.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,HUMANA,HUMANA CHOICE CARE PPO,1496.81,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,496.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1285.49,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,285.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1760.95,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,760.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,880.48,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $880.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1479.20,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,479.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1320.71,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,320.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1620.07,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,620.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1124.01,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,124.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1267.88,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,267.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1267.88,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,267.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1091.79,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,091.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1267.88,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,267.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1267.88,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,267.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026252,CDM,,,,both,,,1760.9500,1162.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1056.57,,,,,,,855.8200,1760.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,760.95 in Billed Charges for Rev 278 Proc C1768 = $1,056.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,AETNA,AETNA HSHS,684.66,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $684.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,AETNA,ALL COMMERCIAL AETNA,1059.85,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $1,059.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,ANTHEM,ANTHEM POS/HMO,551.12,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $551.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,ANTHEM,ANTHEM PPO,551.12,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $551.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1059.85,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $1,059.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,CENPATICO,ALL MEDICAID CENPATICO,1059.85,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $1,059.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,900.87,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $900.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,CIGNA,ALL COMMERCIAL CIGNA,741.90,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $741.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,COFINITY,COFINITY,1059.85,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $1,059.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1006.86,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $1,006.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,890.27,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $890.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,752.49,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $752.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,773.69,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $773.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,515.09,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $515.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,900.87,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $900.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,HUMANA,HUMANA CHOICE CARE PPO,900.87,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $900.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,773.69,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $773.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1059.85,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $1,059.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,529.93,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $529.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,890.27,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $890.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,794.89,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $794.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,975.06,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $975.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,676.50,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $676.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,763.09,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $763.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,763.09,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $763.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,657.11,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $657.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,763.09,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $763.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,763.09,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $763.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORE-TEX THIN WALL 6MM X 40CM,C1768,HCPCS,278,RC,10000116,CDM,,,,both,,,1059.8500,699.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,635.91,,,,,,,515.0900,1059.8500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,059.85 in Billed Charges for Rev 278 Proc C1768 = $635.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,AETNA,AETNA HSHS,913.77,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $913.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,AETNA,ALL COMMERCIAL AETNA,1414.50,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,414.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,ANTHEM,ANTHEM POS/HMO,735.54,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $735.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,ANTHEM,ANTHEM PPO,735.54,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $735.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1414.50,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,414.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,CENPATICO,ALL MEDICAID CENPATICO,1414.50,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,414.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1202.33,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,202.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,CIGNA,ALL COMMERCIAL CIGNA,990.15,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $990.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,COFINITY,COFINITY,1414.50,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,414.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1343.78,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,343.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,1188.18,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,188.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1004.30,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,004.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1032.59,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,032.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,687.45,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $687.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1202.33,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,202.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,HUMANA,HUMANA CHOICE CARE PPO,1202.33,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,202.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1032.59,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,032.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1414.50,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,414.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,707.25,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $707.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1188.18,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,188.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1060.88,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,060.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1301.34,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,301.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,902.88,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $902.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1018.44,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,018.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1018.44,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,018.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,876.99,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $876.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1018.44,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,018.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1018.44,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $1,018.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 45 ACCESS STND WALL STRETCH 4-7MM,C1768,HCPCS,278,RC,10000126,CDM,,,,both,,,1414.5000,933.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,848.70,,,,,,,687.4500,1414.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,414.50 in Billed Charges for Rev 278 Proc C1768 = $848.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,AETNA,AETNA HSHS,1434.83,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,434.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,AETNA,ALL COMMERCIAL AETNA,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,ANTHEM,ANTHEM POS/HMO,1154.97,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,154.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,ANTHEM,ANTHEM PPO,1154.97,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,154.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,CENPATICO,ALL MEDICAID CENPATICO,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1887.94,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,887.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,CIGNA,ALL COMMERCIAL CIGNA,1554.77,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,554.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,COFINITY,COFINITY,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2110.05,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $2,110.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,1865.72,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,865.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1576.98,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,576.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1621.40,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,621.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,1079.45,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,079.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1887.94,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,887.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,HUMANA,HUMANA CHOICE CARE PPO,1887.94,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,887.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1621.40,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,621.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,2221.10,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $2,221.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1110.55,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,110.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1865.72,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,865.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1665.83,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,665.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2043.41,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $2,043.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1417.73,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,417.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1599.19,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,599.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1599.19,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,599.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1377.08,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,377.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1599.19,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,599.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1599.19,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,599.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX 6 X 70CM TW RING,C1768,HCPCS,278,RC,10000152,CDM,,,,both,,,2221.1000,1465.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1332.66,,,,,,,1079.4500,2221.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,221.10 in Billed Charges for Rev 278 Proc C1768 = $1,332.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,AETNA,AETNA HSHS,1281.92,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,281.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,AETNA,ALL COMMERCIAL AETNA,1984.40,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,984.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,ANTHEM,ANTHEM POS/HMO,1031.89,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,031.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,ANTHEM,ANTHEM PPO,1031.89,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,031.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1984.40,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,984.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,CENPATICO,ALL MEDICAID CENPATICO,1984.40,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,984.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1686.74,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,686.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,CIGNA,ALL COMMERCIAL CIGNA,1389.08,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,389.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,COFINITY,COFINITY,1984.40,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,984.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1885.18,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,885.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,1666.90,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,666.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1408.92,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,408.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1448.61,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,448.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,964.42,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $964.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1686.74,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,686.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,HUMANA,HUMANA CHOICE CARE PPO,1686.74,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,686.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1448.61,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,448.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1984.40,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,984.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,992.20,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $992.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1666.90,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,666.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1488.30,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,488.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1825.65,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,825.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1266.64,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,266.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1428.77,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,428.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1428.77,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,428.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1230.33,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,230.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1428.77,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,428.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1428.77,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,428.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10026257,CDM,,,,both,,,1984.4000,1309.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1190.64,,,,,,,964.4200,1984.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,984.40 in Billed Charges for Rev 278 Proc C1768 = $1,190.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,AETNA,AETNA HSHS,1891.42,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,891.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,AETNA,ALL COMMERCIAL AETNA,2927.90,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,927.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,ANTHEM,ANTHEM POS/HMO,1522.51,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,522.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,ANTHEM,ANTHEM PPO,1522.51,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,522.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2927.90,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,927.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,CENPATICO,ALL MEDICAID CENPATICO,2927.90,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,927.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2488.72,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,488.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,CIGNA,ALL COMMERCIAL CIGNA,2049.53,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,049.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,COFINITY,COFINITY,2927.90,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,927.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2781.51,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,781.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,2459.44,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,459.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2078.81,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,078.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2137.37,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,137.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,1422.96,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,422.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2488.72,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,488.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,HUMANA,HUMANA CHOICE CARE HMO,1463.95,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,463.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,HUMANA,HUMANA CHOICE CARE PPO,2488.72,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,488.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,HUMANA,HUMANA NATIIONAL POS HMO,1463.95,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,463.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2137.37,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,137.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,2927.90,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,927.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1463.95,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,463.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2459.44,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,459.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2195.93,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,195.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2693.67,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,693.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1868.88,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,868.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2108.09,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,108.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2108.09,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,108.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1815.30,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,815.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2108.09,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,108.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2108.09,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $2,108.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX DIALYSIS 6MM X 45 CM,C1768,HCPCS,278,RC,10000154,CDM,,,,both,,,2927.9000,1932.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1756.74,,,,,,,1422.9600,2927.9000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,927.90 in Billed Charges for Rev 278 Proc C1768 = $1,756.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,AETNA,AETNA HSHS,690.28,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $690.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,AETNA,ALL COMMERCIAL AETNA,1068.55,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $1,068.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,ANTHEM,ANTHEM POS/HMO,555.65,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $555.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,ANTHEM,ANTHEM PPO,555.65,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $555.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1068.55,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $1,068.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,CENPATICO,ALL MEDICAID CENPATICO,1068.55,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $1,068.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,908.27,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $908.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,CIGNA,ALL COMMERCIAL CIGNA,747.99,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $747.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,COFINITY,COFINITY,1068.55,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $1,068.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1015.12,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $1,015.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,897.58,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $897.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,758.67,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $758.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,780.04,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $780.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,519.32,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $519.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,908.27,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $908.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,HUMANA,HUMANA CHOICE CARE PPO,908.27,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $908.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,780.04,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $780.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1068.55,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $1,068.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,534.28,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $534.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,897.58,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $897.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,801.41,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $801.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,983.07,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $983.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,682.06,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $682.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,769.36,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $769.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,769.36,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $769.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,662.50,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $662.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,769.36,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $769.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,769.36,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $769.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT GORTEX PATCH 5 X 7.5CM,C1768,HCPCS,278,RC,10002952,CDM,,,,both,,,1068.5500,705.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,641.13,,,,,,,519.3200,1068.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,068.55 in Billed Charges for Rev 278 Proc C1768 = $641.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,AETNA,AETNA HSHS,1107.11,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,107.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,AETNA,ALL COMMERCIAL AETNA,1713.80,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,713.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,ANTHEM,ANTHEM POS/HMO,891.18,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $891.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,ANTHEM,ANTHEM PPO,891.18,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $891.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1713.80,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,713.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,CENPATICO,ALL MEDICAID CENPATICO,1713.80,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,713.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1456.73,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,456.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,CIGNA,ALL COMMERCIAL CIGNA,1199.66,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,199.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,COFINITY,COFINITY,1713.80,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,713.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1628.11,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,628.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,1439.59,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,439.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1216.80,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,216.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1251.07,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,251.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,832.91,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $832.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1456.73,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,456.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,HUMANA,HUMANA CHOICE CARE PPO,1456.73,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,456.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1251.07,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,251.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1713.80,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,713.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,856.90,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $856.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1439.59,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,439.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1285.35,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,285.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1576.70,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,576.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1093.92,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,093.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1233.94,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,233.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1233.94,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,233.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1062.56,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,062.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1233.94,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,233.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1233.94,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,233.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10028872,CDM,,,,both,,,1713.8000,1131.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1028.28,,,,,,,832.9100,1713.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,713.80 in Billed Charges for Rev 278 Proc C1768 = $1,028.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,AETNA,AETNA HSHS,424.91,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $424.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,AETNA,ALL COMMERCIAL AETNA,657.75,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $657.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,657.75,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $657.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,CENPATICO,ALL MEDICAID CENPATICO,657.75,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $657.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,559.09,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $559.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,CIGNA,ALL COMMERCIAL CIGNA,460.43,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $460.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,COFINITY,COFINITY,657.75,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $657.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,624.86,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $624.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,552.51,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $552.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,467.00,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $467.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,480.16,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $480.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,319.67,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $319.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,559.09,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $559.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,HUMANA,HUMANA CHOICE CARE PPO,559.09,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $559.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,480.16,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $480.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,657.75,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $657.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,328.88,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $328.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,552.51,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $552.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,493.31,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $493.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,605.13,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $605.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,419.84,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $419.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,473.58,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $473.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,473.58,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $473.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,407.81,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $407.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,473.58,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $473.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,473.58,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $473.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10059022,CDM,,,,both,,,657.7500,434.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,394.65,,,,,,,319.6700,657.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $657.75 in Billed Charges for Rev 278 Proc C1768 = $394.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,AETNA,AETNA HSHS,160.64,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $160.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,AETNA,ALL COMMERCIAL AETNA,248.67,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $248.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,248.67,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $248.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,CENPATICO,ALL MEDICAID CENPATICO,248.67,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $248.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,211.37,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $211.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,CIGNA,ALL COMMERCIAL CIGNA,174.07,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $174.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,COFINITY,COFINITY,248.67,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $248.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,236.24,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $236.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,208.88,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $208.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,176.56,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $176.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,181.53,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $181.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,120.85,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $120.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,211.37,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $211.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,HUMANA,HUMANA CHOICE CARE PPO,211.37,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $211.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,181.53,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $181.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,248.67,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $248.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,124.34,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $124.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,208.88,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $208.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,186.50,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $186.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,228.78,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $228.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,158.73,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $158.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,179.04,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $179.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,179.04,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $179.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,154.18,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $154.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,179.04,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $179.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,179.04,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $179.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD PATCH,C1768,HCPCS,278,RC,10059113,CDM,,,,both,,,248.6700,164.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,149.20,,,,,,,120.8500,248.6700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $248.67 in Billed Charges for Rev 278 Proc C1768 = $149.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,AETNA,AETNA HSHS,747.54,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $747.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,AETNA,ALL COMMERCIAL AETNA,1157.18,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $1,157.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,ANTHEM,ANTHEM POS/HMO,601.73,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $601.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,ANTHEM,ANTHEM PPO,601.73,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $601.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1157.18,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $1,157.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,CENPATICO,ALL MEDICAID CENPATICO,1157.18,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $1,157.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,983.60,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $983.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,CIGNA,ALL COMMERCIAL CIGNA,810.03,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $810.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,COFINITY,COFINITY,1157.18,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $1,157.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1099.32,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $1,099.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,972.03,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $972.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,821.60,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $821.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,844.74,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $844.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,562.39,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $562.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,983.60,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $983.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,HUMANA,HUMANA CHOICE CARE PPO,983.60,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $983.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,844.74,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $844.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1157.18,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $1,157.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,578.59,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $578.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,972.03,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $972.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,867.89,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $867.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1064.61,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $1,064.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,738.63,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $738.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,833.17,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $833.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,833.17,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $833.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,717.45,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $717.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,833.17,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $833.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,833.17,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $833.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN 16MM STRAIGHT,C1768,HCPCS,278,RC,70404504,CDM,,,,both,,,1157.1800,763.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,694.31,,,,,,,562.3900,1157.1800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,157.18 in Billed Charges for Rev 278 Proc C1768 = $694.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,AETNA,AETNA HSHS,778.12,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $778.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,AETNA,ALL COMMERCIAL AETNA,1204.52,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,204.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,ANTHEM,ANTHEM POS/HMO,626.35,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $626.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,ANTHEM,ANTHEM PPO,626.35,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $626.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1204.52,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,204.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,CENPATICO,ALL MEDICAID CENPATICO,1204.52,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,204.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1023.84,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,023.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,CIGNA,ALL COMMERCIAL CIGNA,843.16,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $843.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,COFINITY,COFINITY,1204.52,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,204.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1144.29,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,144.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,1011.80,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,011.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,855.21,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $855.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,879.30,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $879.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,585.40,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $585.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1023.84,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,023.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,HUMANA,HUMANA CHOICE CARE PPO,1023.84,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,023.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,879.30,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $879.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1204.52,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,204.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,602.26,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $602.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1011.80,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,011.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,903.39,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $903.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1108.16,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $1,108.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,768.85,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $768.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,867.25,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $867.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,867.25,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $867.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,746.80,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $746.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,867.25,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $867.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,867.25,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $867.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042732,CDM,,,,both,,,1204.5200,794.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,722.71,,,,,,,585.4000,1204.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,204.52 in Billed Charges for Rev 278 Proc C1768 = $722.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,AETNA,AETNA HSHS,631.71,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $631.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,AETNA,ALL COMMERCIAL AETNA,977.88,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $977.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,977.88,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $977.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,CENPATICO,ALL MEDICAID CENPATICO,977.88,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $977.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,831.20,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $831.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,CIGNA,ALL COMMERCIAL CIGNA,684.52,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $684.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,COFINITY,COFINITY,977.88,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $977.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,928.99,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $928.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,821.42,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $821.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,694.29,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $694.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,713.85,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $713.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,475.25,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $475.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,831.20,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $831.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,HUMANA,HUMANA CHOICE CARE PPO,831.20,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $831.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,713.85,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $713.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,977.88,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $977.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,488.94,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $488.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,821.42,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $821.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,733.41,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $733.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,899.65,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $899.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,624.18,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $624.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,704.07,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $704.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,704.07,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $704.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,606.29,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $606.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,704.07,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $704.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,704.07,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $704.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT HEMASHIELD WOVEN ATRIUM 26MM X 30CM,C1768,HCPCS,278,RC,10058477,CDM,,,,both,,,977.8800,645.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,586.73,,,,,,,475.2500,977.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $977.88 in Billed Charges for Rev 278 Proc C1768 = $586.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,AETNA,AETNA HSHS,565.72,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $565.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,AETNA,ALL COMMERCIAL AETNA,875.72,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $875.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,875.72,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $875.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,CENPATICO,ALL MEDICAID CENPATICO,875.72,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $875.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,744.36,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $744.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,CIGNA,ALL COMMERCIAL CIGNA,613.00,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $613.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,COFINITY,COFINITY,875.72,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $875.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,831.93,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $831.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,735.60,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $735.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,621.76,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $621.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,639.28,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $639.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,425.60,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $425.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,744.36,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $744.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,HUMANA,HUMANA CHOICE CARE PPO,744.36,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $744.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,639.28,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $639.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,875.72,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $875.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,437.86,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $437.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,735.60,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $735.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,656.79,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $656.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,805.66,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $805.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,558.97,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $558.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,630.52,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $630.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,630.52,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $630.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,542.95,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $542.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,630.52,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $630.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,630.52,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $630.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRAFT, VASCULAR",C1768,HCPCS,278,RC,10042736,CDM,,,,both,,,875.7200,577.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,525.43,,,,,,,425.6000,875.7200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $875.72 in Billed Charges for Rev 278 Proc C1768 = $525.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,AETNA,AETNA HSHS,174.42,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $174.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,AETNA,ALL COMMERCIAL AETNA,270.00,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,270.00,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,CENPATICO,ALL MEDICAID CENPATICO,270.00,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,229.50,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $229.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,CIGNA,ALL COMMERCIAL CIGNA,189.00,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,COFINITY,COFINITY,270.00,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,256.50,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $256.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,226.80,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,191.70,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $191.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,197.10,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $197.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,131.22,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $131.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,229.50,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $229.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,HUMANA,HUMANA CHOICE CARE PPO,229.50,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $229.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,197.10,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $197.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,270.00,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,135.00,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,226.80,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,202.50,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $202.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,248.40,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $248.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,172.34,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $172.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,194.40,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $194.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,194.40,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $194.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,167.40,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $167.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,194.40,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $194.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,194.40,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $194.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC 1 X 6CM,C1768,HCPCS,278,RC,10065676,CDM,,,,both,,,270.0000,178.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,162.00,,,,,,,131.2200,270.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $270.00 in Billed Charges for Rev 278 Proc C1768 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,AETNA,AETNA HSHS,928.33,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $928.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,AETNA,ALL COMMERCIAL AETNA,1437.05,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,437.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,ANTHEM,ANTHEM POS/HMO,747.27,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $747.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,ANTHEM,ANTHEM PPO,747.27,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $747.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1437.05,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,437.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,CENPATICO,ALL MEDICAID CENPATICO,1437.05,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,437.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1221.49,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,221.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,CIGNA,ALL COMMERCIAL CIGNA,1005.94,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,005.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,COFINITY,COFINITY,1437.05,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,437.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1365.20,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,365.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,1207.12,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,207.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1020.31,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,020.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1049.05,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,049.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,698.41,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $698.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1221.49,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,221.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,HUMANA,HUMANA CHOICE CARE PPO,1221.49,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,221.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1049.05,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,049.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1437.05,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,437.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,718.53,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $718.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1207.12,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,207.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1077.79,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,077.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1322.09,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,322.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,917.27,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $917.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1034.68,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,034.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1034.68,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,034.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,890.97,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $890.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1034.68,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,034.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1034.68,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $1,034.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PERIPHERAL VASCULAR XENOSURE BIOLOGIC PATCH,C1768,HCPCS,278,RC,10065683,CDM,,,,both,,,1437.0500,948.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,862.23,,,,,,,698.4100,1437.0500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,437.05 in Billed Charges for Rev 278 Proc C1768 = $862.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,AETNA,AETNA HSHS,3139.56,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,139.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,AETNA,ALL COMMERCIAL AETNA,4860.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,ANTHEM,ANTHEM POS/HMO,2527.20,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $2,527.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,ANTHEM,ANTHEM PPO,2527.20,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $2,527.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4860.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,CENPATICO,ALL MEDICAID CENPATICO,4860.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4131.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,131.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,CIGNA,ALL COMMERCIAL CIGNA,3402.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,COFINITY,COFINITY,4860.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4617.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,617.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,4082.40,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,082.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3450.60,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,450.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3547.80,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,547.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,2361.96,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $2,361.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4131.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,131.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,HUMANA,HUMANA CHOICE CARE HMO,2430.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $2,430.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,HUMANA,HUMANA CHOICE CARE PPO,4131.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,131.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,HUMANA,HUMANA NATIIONAL POS HMO,2430.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $2,430.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3547.80,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,547.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,4860.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2430.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $2,430.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4082.40,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,082.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3645.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4471.20,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $4,471.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3102.14,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,102.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3499.20,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,499.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3499.20,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,499.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3013.20,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,013.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3499.20,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,499.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3499.20,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $3,499.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT PROPATEN THIN WALL REMOVABLE RING 6MM X 70CM,C1768,HCPCS,278,RC,10022344,CDM,,,,both,,,4860.0000,3207.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2916.00,,,,,,,2361.9600,4860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,860.00 in Billed Charges for Rev 278 Proc C1768 = $2,916.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,AETNA,AETNA HSHS,1288.77,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,288.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,AETNA,ALL COMMERCIAL AETNA,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,ANTHEM,ANTHEM POS/HMO,1037.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,037.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,ANTHEM,ANTHEM PPO,1037.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,037.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,CENPATICO,ALL MEDICAID CENPATICO,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1695.75,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,695.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,CIGNA,ALL COMMERCIAL CIGNA,1396.50,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,396.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,COFINITY,COFINITY,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1895.25,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,895.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,1675.80,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,675.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1416.45,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,416.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1456.35,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,456.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,969.57,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $969.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1695.75,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,695.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,HUMANA,HUMANA CHOICE CARE PPO,1695.75,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,695.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1456.35,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,456.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,997.50,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1675.80,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,675.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1496.25,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,496.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1835.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,835.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1273.41,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,273.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1436.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1436.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1236.90,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,236.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1436.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1436.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT HANDLE UROLIFT 2,L8699,HCPCS,278,RC,10090037,CDM,,,,both,,,1995.0000,1316.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1197.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,995.00 in Billed Charges for Rev 278 Proc L8699 = $1,197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,AETNA,AETNA HSHS,47.60,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,AETNA,ALL COMMERCIAL AETNA,73.69,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $73.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,73.69,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $73.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,CENPATICO,ALL MEDICAID CENPATICO,73.69,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $73.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,62.64,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $62.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,CIGNA,ALL COMMERCIAL CIGNA,51.58,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $51.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,COFINITY,COFINITY,73.69,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $73.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,70.01,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $70.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,61.90,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $61.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.32,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $52.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,53.79,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $53.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,35.81,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $35.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,62.64,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $62.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,HUMANA,HUMANA CHOICE CARE PPO,62.64,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $62.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,53.79,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $53.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,73.69,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $73.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,36.85,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $36.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,61.90,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $61.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.27,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $55.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,67.79,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $67.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.04,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $47.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.06,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $53.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.06,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $53.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.69,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $45.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.06,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $53.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.06,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $53.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TUBE VENTILATION 1.14MM ARMSTRONG 1 GROMMET FLUOROPLASTIC BEVEL INNER FLANGE MYRINGOTOMY 140242-ENT,L8699,HCPCS,278,RC,10019723,CDM,,,,both,,,73.6900,48.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.21,,,,,,,35.8100,73.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.69 in Billed Charges for Rev 278 Proc L8699 = $44.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,AETNA,AETNA HSHS,1314.61,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,314.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,AETNA,ALL COMMERCIAL AETNA,2035.00,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $2,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,ANTHEM,ANTHEM POS/HMO,1058.20,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,058.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,ANTHEM,ANTHEM PPO,1058.20,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,058.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2035.00,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $2,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,CENPATICO,ALL MEDICAID CENPATICO,2035.00,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $2,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1729.75,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,729.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,CIGNA,ALL COMMERCIAL CIGNA,1424.50,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,424.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,COFINITY,COFINITY,2035.00,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $2,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1933.25,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,933.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,1709.40,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,709.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1444.85,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,444.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1485.55,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,485.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,989.01,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $989.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1729.75,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,729.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,HUMANA,HUMANA CHOICE CARE PPO,1729.75,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,729.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1485.55,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,485.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2035.00,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $2,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1017.50,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,017.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1709.40,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,709.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1526.25,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,526.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1872.20,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,872.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1298.94,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,298.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1465.20,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,465.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1465.20,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,465.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1261.70,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,261.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1465.20,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,465.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1465.20,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,465.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UROLIFT,L8699,HCPCS,278,RC,10074162,CDM,,,,both,,,2035.0000,1343.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1221.00,,,,,,,989.0100,2035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,035.00 in Billed Charges for Rev 278 Proc L8699 = $1,221.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,AETNA,AETNA HSHS,4112.42,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,112.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,AETNA,ALL COMMERCIAL AETNA,6365.97,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $6,365.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,ANTHEM,ANTHEM POS/HMO,3310.30,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,310.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,ANTHEM,ANTHEM PPO,3310.30,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,310.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6365.97,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $6,365.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,CENPATICO,ALL MEDICAID CENPATICO,6365.97,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $6,365.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5411.07,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $5,411.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,CIGNA,ALL COMMERCIAL CIGNA,4456.18,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,456.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,COFINITY,COFINITY,6365.97,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $6,365.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6047.67,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $6,047.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,5347.41,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $5,347.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4519.84,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,519.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4647.16,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,647.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,3093.86,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,093.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5411.07,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $5,411.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,HUMANA,HUMANA CHOICE CARE HMO,3182.99,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,182.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,HUMANA,HUMANA CHOICE CARE PPO,5411.07,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $5,411.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,HUMANA,HUMANA NATIIONAL POS HMO,3182.99,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,182.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4647.16,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,647.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,6365.97,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $6,365.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3182.99,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,182.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5347.41,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $5,347.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4774.48,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,774.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5856.69,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $5,856.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3182.99,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,182.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3182.99,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,182.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,PREVEA HEALTH NETWORK,PREVEA360,3182.99,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,182.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3182.99,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,182.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4063.40,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,063.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4583.50,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,583.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4583.50,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,583.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3946.90,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,946.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4583.50,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,583.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4583.50,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $4,583.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 10CC,C9359,HCPCS,278,RC,10086706,CDM,,,,both,,,6365.9700,4201.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3819.58,,,,,,,3093.8600,6365.9700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,365.97 in Billed Charges for Rev 278 Proc C9359 = $3,819.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,AETNA,AETNA HSHS,1472.98,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,472.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,AETNA,ALL COMMERCIAL AETNA,2280.15,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $2,280.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,ANTHEM,ANTHEM POS/HMO,1185.68,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,185.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,ANTHEM,ANTHEM PPO,1185.68,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,185.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2280.15,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $2,280.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,CENPATICO,ALL MEDICAID CENPATICO,2280.15,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $2,280.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1938.13,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,938.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,CIGNA,ALL COMMERCIAL CIGNA,1596.11,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,596.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,COFINITY,COFINITY,2280.15,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $2,280.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2166.14,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $2,166.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,1915.33,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,915.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1618.91,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,618.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1664.51,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,664.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,1108.15,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,108.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1938.13,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,938.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,HUMANA,HUMANA CHOICE CARE PPO,1938.13,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,938.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1664.51,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,664.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2280.15,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $2,280.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1140.08,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,140.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1915.33,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,915.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1710.11,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,710.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2097.74,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $2,097.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1455.42,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,455.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1641.71,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,641.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1641.71,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,641.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1413.69,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,413.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1641.71,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,641.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1641.71,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,641.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 3CC,C9359,HCPCS,278,RC,10086704,CDM,,,,both,,,2280.1500,1504.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1368.09,,,,,,,1108.1500,2280.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,280.15 in Billed Charges for Rev 278 Proc C9359 = $1,368.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,AETNA,AETNA HSHS,2306.48,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,306.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,AETNA,ALL COMMERCIAL AETNA,3570.40,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,570.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,ANTHEM,ANTHEM POS/HMO,1856.61,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $1,856.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,ANTHEM,ANTHEM PPO,1856.61,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $1,856.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3570.40,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,570.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,CENPATICO,ALL MEDICAID CENPATICO,3570.40,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,570.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3034.84,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,034.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,CIGNA,ALL COMMERCIAL CIGNA,2499.28,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,499.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,COFINITY,COFINITY,3570.40,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,570.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3391.88,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,391.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,2999.14,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,999.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2534.98,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,534.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2606.39,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,606.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,1735.21,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $1,735.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3034.84,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,034.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,HUMANA,HUMANA CHOICE CARE HMO,1785.20,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $1,785.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,HUMANA,HUMANA CHOICE CARE PPO,3034.84,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,034.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,HUMANA,HUMANA NATIIONAL POS HMO,1785.20,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $1,785.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2606.39,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,606.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,3570.40,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,570.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1785.20,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $1,785.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2999.14,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,999.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2677.80,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,677.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3284.77,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $3,284.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2278.99,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,278.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2570.69,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,570.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2570.69,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,570.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2213.65,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,213.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2570.69,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,570.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2570.69,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,570.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEMENT BONE DIRECTINJECT HA 5CC,C9359,HCPCS,278,RC,10086705,CDM,,,,both,,,3570.4000,2356.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2142.24,,,,,,,1735.2100,3570.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,570.40 in Billed Charges for Rev 278 Proc C9359 = $2,142.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,AETNA,AETNA HSHS,3733.46,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $3,733.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,AETNA,AETNA MEDICARE,120.88,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,AETNA,ALL COMMERCIAL AETNA,5779.35,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $5,779.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,120.88,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,ANTHEM,ANTHEM POS/HMO,3005.26,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $3,005.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,ANTHEM,ANTHEM PPO,3005.26,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $3,005.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5779.35,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $5,779.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,CENPATICO,ALL MEDICAID CENPATICO,5779.35,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $5,779.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4912.45,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,912.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,CIGNA,ALL COMMERCIAL CIGNA,4045.55,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,045.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,COFINITY,COFINITY,5779.35,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $5,779.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5490.38,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $5,490.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,4854.65,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,854.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4103.34,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,103.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4218.93,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,218.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,2808.76,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $2,808.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4912.45,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,912.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HUMANA,HUMANA CHOICE CARE HMO,2889.68,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $2,889.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HUMANA,HUMANA CHOICE CARE PPO,4912.45,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,912.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HUMANA,HUMANA MEDICARE ADVANTAGE,120.88,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,HUMANA,HUMANA NATIIONAL POS HMO,2889.68,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $2,889.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4218.93,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,218.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,5779.35,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $5,779.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,120.88,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,MOLINA HEALTHCARE,MOLINA MEDICARE,120.88,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2889.68,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $2,889.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4854.65,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,854.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,NAPHCARE,ALL COMMERICAL NAPHCARE,271.97,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4334.51,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,334.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5317.00,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $5,317.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2889.68,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $2,889.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2889.68,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $2,889.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,PREVEA HEALTH NETWORK,PREVEA360,2889.68,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $2,889.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2889.68,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $2,889.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3688.96,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $3,688.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,122.09,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4161.13,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,161.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,120.88,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,UNITY HEALTH PLAN,UNITY HOSPICE,120.88,,,,,,,120.8800,5779.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4161.13,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,161.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3583.20,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $3,583.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4161.13,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,161.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4161.13,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $4,161.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 2 X 2,C9363,HCPCS,278,RC,10036835,CDM,,,,both,,,5779.3500,3814.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3467.61,,,,,,,120.8800,5779.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,779.35 in Billed Charges for Rev 278 Proc C9363 = $3,467.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,AETNA,AETNA HSHS,6510.23,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $6,510.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,AETNA,AETNA MEDICARE,120.88,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,AETNA,ALL COMMERCIAL AETNA,10077.75,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $10,077.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,120.88,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,ANTHEM,ANTHEM POS/HMO,5240.43,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,240.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,ANTHEM,ANTHEM PPO,5240.43,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,240.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10077.75,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $10,077.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,CENPATICO,ALL MEDICAID CENPATICO,10077.75,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $10,077.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8566.09,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $8,566.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,CIGNA,ALL COMMERCIAL CIGNA,7054.43,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,054.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,COFINITY,COFINITY,10077.75,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $10,077.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9573.86,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $9,573.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,8465.31,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $8,465.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7155.20,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,155.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7356.76,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,356.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,4897.79,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $4,897.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8566.09,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $8,566.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HUMANA,HUMANA CHOICE CARE HMO,5038.88,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,038.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HUMANA,HUMANA CHOICE CARE PPO,8566.09,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $8,566.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,120.88,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,HUMANA,HUMANA NATIIONAL POS HMO,5038.88,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,038.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7356.76,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,356.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,10077.75,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $10,077.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,120.88,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,120.88,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5038.88,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,038.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8465.31,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $8,465.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,271.97,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7558.31,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,558.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9271.53,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $9,271.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5038.88,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,038.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5038.88,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,038.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,PREVEA HEALTH NETWORK,PREVEA360,5038.88,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,038.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5038.88,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $5,038.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6432.63,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $6,432.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,122.09,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7255.98,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,255.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4696.23,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $4,696.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,4696.23,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $4,696.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,120.88,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,4696.23,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $4,696.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,UNITY HEALTH PLAN,UNITY HOSPICE,120.88,,,,,,,120.8800,10077.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7255.98,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,255.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6248.21,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $6,248.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7255.98,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,255.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7255.98,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $7,255.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TISSUE INTEGRA WOUND MATRIX 4 X 5,C9363,HCPCS,278,RC,10036836,CDM,,,,both,,,10077.7500,6651.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6046.65,,,,,,,120.8800,10077.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $10,077.75 in Billed Charges for Rev 278 Proc C9363 = $6,046.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,AETNA,AETNA HSHS,821.71,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $821.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,AETNA,AETNA MEDICARE,320.84,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,AETNA,ALL COMMERCIAL AETNA,1272.00,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,ANTHEM,ANTEHM MEDICAID,211.52,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00110 Proc G0498 at $125.60 (Base Rate) * 1.6841 (Relative Weight) = $211.52 (Total Line Payment) at 100% = $211.52. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,320.84,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,ANTHEM,ANTHEM POS/HMO,864.96,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $864.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,ANTHEM,ANTHEM PPO,864.96,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $864.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1272.00,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,CENPATICO,ALL MEDICAID CENPATICO,1272.00,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1081.20,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,081.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,CIGNA,ALL COMMERCIAL CIGNA,890.40,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,COFINITY,COFINITY,1272.00,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,211.52,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00110 Proc G0498 at $125.60 (Base Rate) * 1.6841 (Relative Weight) = $211.52 (Total Line Payment) at 100% = $211.52. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,211.52,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00110 Proc G0498 at $125.60 (Base Rate) * 1.6841 (Relative Weight) = $211.52 (Total Line Payment) at 100% = $211.52. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1208.40,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,208.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,1068.48,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,068.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,903.12,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $903.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,928.56,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $928.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,618.19,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $618.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1081.20,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,081.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HUMANA,HUMANA CHOICE CARE HMO,807.72,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $807.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HUMANA,HUMANA CHOICE CARE PPO,1081.20,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,081.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,320.84,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,HUMANA,HUMANA NATIIONAL POS HMO,807.72,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $807.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,928.56,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $928.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1272.00,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,211.52,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00110 Proc G0498 at $125.60 (Base Rate) * 1.6841 (Relative Weight) = $211.52 (Total Line Payment) at 100% = $211.52. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,320.84,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,211.52,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00110 Proc G0498 at $125.60 (Base Rate) * 1.6841 (Relative Weight) = $211.52 (Total Line Payment) at 100% = $211.52. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,224.21,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00110 Proc G0498 at $125.60 (Base Rate) * 1.6841 (Relative Weight) = $211.52 (Total Line Payment) at 100% = $211.52... $211.52 at 106% = $224.21 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,320.84,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,636.00,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $636.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1068.48,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,068.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,721.88,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,954.00,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1170.24,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $1,170.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,763.20,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,763.20,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,PREVEA HEALTH NETWORK,PREVEA360,763.20,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,763.20,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,811.92,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $811.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,324.05,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,915.84,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $915.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,TRIOLOGY,TRILOGY MEDICAID,224.21,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00110 Proc G0498 at $125.60 (Base Rate) * 1.6841 (Relative Weight) = $211.52 (Total Line Payment) at 106% = $224.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,592.75,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $592.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,592.75,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $592.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,320.84,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,592.75,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $592.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,UNITY HEALTH PLAN,UNITY HOSPICE,320.84,,,,,,,211.5200,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,915.84,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $915.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,788.64,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $788.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,915.84,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $915.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,915.84,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $915.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHEMO IV W/PUMP EXTENDED,G0498,HCPCS,280,RC,28000001,CDM,,,,both,,,1272.0000,839.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,763.20,,,,,,,211.5200,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,272.00 in Billed Charges for Rev 280 Proc G0498 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,AETNA,AETNA HSHS,162.15,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $251.00 in Billed Charges for Rev 271 = $162.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,AETNA,ALL COMMERCIAL AETNA,251.00,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $251.00 in Billed Charges for Rev 271 = $251.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,ANTHEM,ANTHEM POS/HMO,170.68,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $251.00 in Billed Charges for Rev 271 = $170.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,ANTHEM,ANTHEM PPO,170.68,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $251.00 in Billed Charges for Rev 271 = $170.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,251.00,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $251.00 in Billed Charges for Rev 271 = $251.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,CENPATICO,ALL MEDICAID CENPATICO,251.00,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $251.00 in Billed Charges for Rev 271 = $251.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,213.35,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $251.00 in Billed Charges for Rev 271 = $213.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,CIGNA,ALL COMMERCIAL CIGNA,175.70,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $251.00 in Billed Charges for Rev 271 = $175.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,COFINITY,COFINITY,251.00,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $251.00 in Billed Charges for Rev 271 = $251.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,238.45,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $251.00 in Billed Charges for Rev 271 = $238.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,210.84,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $251.00 in Billed Charges for Rev 271 = $210.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,178.21,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $251.00 in Billed Charges for Rev 271 = $178.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,183.23,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $251.00 in Billed Charges for Rev 271 = $183.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,121.99,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $251.00 in Billed Charges for Rev 271 = $121.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,213.35,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $251.00 in Billed Charges for Rev 271 = $213.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,HUMANA,HUMANA CHOICE CARE HMO,159.39,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $251.00 in Billed Charges for Rev 271 = $159.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,HUMANA,HUMANA CHOICE CARE PPO,213.35,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $251.00 in Billed Charges for Rev 271 = $213.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,HUMANA,HUMANA NATIIONAL POS HMO,159.39,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $251.00 in Billed Charges for Rev 271 = $159.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,183.23,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $251.00 in Billed Charges for Rev 271 = $183.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,251.00,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $251.00 in Billed Charges for Rev 271 = $251.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,125.50,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $251.00 in Billed Charges for Rev 271 = $125.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,210.84,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $251.00 in Billed Charges for Rev 271 = $210.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,188.25,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $251.00 in Billed Charges for Rev 271 = $188.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,230.92,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $251.00 in Billed Charges for Rev 271 = $230.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,150.60,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $251.00 in Billed Charges for Rev 271 = $150.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,150.60,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $251.00 in Billed Charges for Rev 271 = $150.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,PREVEA HEALTH NETWORK,PREVEA360,150.60,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $251.00 in Billed Charges for Rev 271 = $150.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,150.60,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $251.00 in Billed Charges for Rev 271 = $150.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,160.21,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $251.00 in Billed Charges for Rev 271 = $160.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,180.72,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $251.00 in Billed Charges for Rev 271 = $180.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,138.80,,,,,,,121.9900,251.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $251.00 in Billed Charges for Rev 271 = $138.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,138.80,,,,,,,121.9900,251.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $251.00 in Billed Charges for Rev 271 = $138.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,138.80,,,,,,,121.9900,251.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $251.00 in Billed Charges for Rev 271 = $138.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,180.72,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $251.00 in Billed Charges for Rev 271 = $180.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,155.62,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $251.00 in Billed Charges for Rev 271 = $155.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,180.72,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $251.00 in Billed Charges for Rev 271 = $180.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,180.72,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $251.00 in Billed Charges for Rev 271 = $180.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR BED,271,RC,29200012,CDM,,,,,,both,,,251.0000,165.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,150.60,,,,,,,121.9900,251.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $251.00 in Billed Charges for Rev 271 = $150.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,AETNA,AETNA HSHS,20.67,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $20.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,AETNA,ALL COMMERCIAL AETNA,32.00,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,ANTHEM,ANTEHM MEDICAID,1.23,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36416 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,ANTHEM,ANTHEM POS/HMO,10.00,,,,,,,1.2300,32.0000,other,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36416 Qty 1 * $10.00 = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,ANTHEM,ANTHEM PPO,10.00,,,,,,,1.2300,32.0000,other,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36416 Qty 1 * $10.00 = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,32.00,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,CENPATICO,ALL MEDICAID CENPATICO,32.00,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,27.20,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $27.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,COFINITY,COFINITY,32.00,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1.23,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36416 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1.23,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36416 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,30.40,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $30.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,26.88,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $26.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,22.72,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $22.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,23.36,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $23.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,15.55,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $15.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,27.20,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $27.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,HUMANA,HUMANA CHOICE CARE HMO,14.62,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.62 from Fee Schedule 005543_170 for Rev 300 Proc 36416 * Qty 1 = $14.62 at 100% = $14.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,HUMANA,HUMANA CHOICE CARE PPO,27.20,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $27.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,HUMANA,HUMANA NATIIONAL POS HMO,14.62,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.62 from Fee Schedule 005543_170 for Rev 300 Proc 36416 * Qty 1 = $14.62 at 100% = $14.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,23.36,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $23.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,32.00,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1.23,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36416 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1.23,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36416 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,1.30,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36416 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23... $1.23 at 106% = $1.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.00,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,26.88,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $26.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,24.00,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,29.44,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $29.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,19.20,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,19.20,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,PREVEA HEALTH NETWORK,PREVEA360,19.20,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,19.20,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,20.43,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $20.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,23.04,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $23.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,TRIOLOGY,TRILOGY MEDICAID,1.30,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36416 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 106% = $1.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.16,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.16 from Fee Schedule UHC_98227C for Rev 300 Proc 36416 * Qty 1 = $10.16 at 100% = $10.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,10.16,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.16 from Fee Schedule UHC_98227C for Rev 300 Proc 36416 * Qty 1 = $10.16 at 100% = $10.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,10.16,,,,,,,1.2300,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.16 from Fee Schedule UHC_98227C for Rev 300 Proc 36416 * Qty 1 = $10.16 at 100% = $10.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,23.04,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $23.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,19.84,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $19.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,23.04,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $23.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,23.04,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $23.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAPILLARY COLLECTION,36416,CPT,300,RC,30000009,CDM,,,,both,,,32.0000,21.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,19.20,,,,,,,1.2300,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.00 in Billed Charges for Rev 300 Proc 36416 = $19.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,AETNA,AETNA HSHS,16.15,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $16.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,AETNA,AETNA MEDICARE,9.34,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,AETNA,ALL COMMERCIAL AETNA,25.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,ANTHEM,ANTEHM MEDICAID,1.23,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,9.34,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,ANTHEM,ANTHEM POS/HMO,10.00,,,,,,,1.2300,25.0000,other,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36415 Qty 1 * $10.00 = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,ANTHEM,ANTHEM PPO,10.00,,,,,,,1.2300,25.0000,other,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36415 Qty 1 * $10.00 = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,25.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,CENPATICO,ALL MEDICAID CENPATICO,25.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,21.25,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,COFINITY,COFINITY,25.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1.23,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1.23,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.75,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $23.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,21.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.75,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $17.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.25,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $18.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,12.15,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $12.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,21.25,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HUMANA,HUMANA CHOICE CARE HMO,15.01,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.01 from Fee Schedule 005543_170 for Rev 300 Proc 36415 * Qty 1 = $15.01 at 100% = $15.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HUMANA,HUMANA CHOICE CARE PPO,21.25,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,9.34,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,HUMANA,HUMANA NATIIONAL POS HMO,15.01,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.01 from Fee Schedule 005543_170 for Rev 300 Proc 36415 * Qty 1 = $15.01 at 100% = $15.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.25,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $18.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,25.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1.23,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,9.34,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1.23,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,1.30,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23... $1.23 at 106% = $1.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,9.34,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.50,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,21.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,21.02,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.75,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $18.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,23.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $23.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.14,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.14,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA360,12.14,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.14,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.96,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $15.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,9.43,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,18.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,TRIOLOGY,TRILOGY MEDICAID,1.30,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 106% = $1.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.28,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.28 from Fee Schedule UHC_98227C for Rev 300 Proc 36415 * Qty 1 = $10.28 at 100% = $10.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,10.28,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.28 from Fee Schedule UHC_98227C for Rev 300 Proc 36415 * Qty 1 = $10.28 at 100% = $10.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,9.34,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,10.28,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.28 from Fee Schedule UHC_98227C for Rev 300 Proc 36415 * Qty 1 = $10.28 at 100% = $10.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,UNITY HEALTH PLAN,UNITY HOSPICE,9.34,,,,,,,1.2300,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,18.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.50,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,18.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,18.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VENIPUNCTURE,36415,CPT,300,RC,30000010,CDM,,,,both,,,25.0000,16.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.00,,,,,,,1.2300,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.00 in Billed Charges for Rev 300 Proc 36415 = $15.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA HSHS,126.62,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $126.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA MEDICARE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,AETNA,ALL COMMERCIAL AETNA,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTEHM MEDICAID,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM POS/HMO,133.28,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36592 $196.00 in Billed Charges at 68% = $133.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM PPO,133.28,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36592 $196.00 in Billed Charges at 68% = $133.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,CENPATICO,ALL MEDICAID CENPATICO,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,166.60,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,COFINITY,COFINITY,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,186.20,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $186.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,164.64,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.16,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $139.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.08,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,95.26,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $95.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,166.60,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE HMO,48.38,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $48.38 from Fee Schedule 005543_170 for Rev 300 Proc 36592 * Qty 1 = $48.38 at 100% = $48.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE PPO,166.60,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA NATIIONAL POS HMO,48.38,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $48.38 from Fee Schedule 005543_170 for Rev 300 Proc 36592 * Qty 1 = $48.38 at 100% = $48.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.08,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,36.51,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44... $34.44 at 106% = $36.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,164.64,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,290.78,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,180.32,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $180.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,117.60,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,117.60,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360,117.60,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,117.60,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.11,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $125.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.52,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.12,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,TRILOGY MEDICAID,36.51,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 106% = $36.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,UNITY HEALTH PLAN,UNITY HOSPICE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.12,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,121.52,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $121.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.12,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.12,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLECT BLOOD FROM PICC,36592,CPT,300,RC,30000016,CDM,,,,both,,,196.0000,129.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,117.60,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $196.00 in Billed Charges for Rev 300 Proc 36592 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,AETNA,AETNA HSHS,54.91,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,AETNA,AETNA MEDICARE,5.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,AETNA,ALL COMMERCIAL AETNA,85.00,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,ANTHEM,ANTEHM MEDICAID,5.79,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,ANTHEM,ANTHEM POS/HMO,19.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.60 from Fee Schedule WII28_25 for Rev 300 Proc 89051 Mod TC * Qty 1 = $19.60 at 100% = $19.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,ANTHEM,ANTHEM PPO,19.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.60 from Fee Schedule WII28_25 for Rev 300 Proc 89051 Mod TC * Qty 1 = $19.60 at 100% = $19.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,85.00,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,CENPATICO,ALL MEDICAID CENPATICO,85.00,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,72.25,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $72.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,CIGNA,ALL COMMERCIAL CIGNA,59.50,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $59.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,COFINITY,COFINITY,85.00,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.79,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.79,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,80.75,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,71.40,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,60.35,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $60.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,62.05,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $62.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,41.31,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $41.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,72.25,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $72.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HUMANA,HUMANA CHOICE CARE HMO,9.52,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.52 from Fee Schedule 005543_170 for Rev 300 Proc 89051 * Qty 1 = $9.52 at 100% = $9.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HUMANA,HUMANA CHOICE CARE PPO,72.25,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $72.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,5.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,HUMANA,HUMANA NATIIONAL POS HMO,9.52,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.52 from Fee Schedule 005543_170 for Rev 300 Proc 89051 * Qty 1 = $9.52 at 100% = $9.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,62.05,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $62.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,85.00,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.79,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.79,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,6.14,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79... $5.79 at 106% = $6.14 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,5.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,42.50,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,71.40,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,12.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,63.75,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,78.20,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.28,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.28,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,PREVEA HEALTH NETWORK,PREVEA360,7.28,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.28,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,54.26,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5.66,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,61.20,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,TRIOLOGY,TRILOGY MEDICAID,6.14,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 106% = $6.14. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.72,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.72 from Fee Schedule UHC_98227C for Rev 300 Proc 89051 * Qty 1 = $6.72 at 100% = $6.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,6.72,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.72 from Fee Schedule UHC_98227C for Rev 300 Proc 89051 * Qty 1 = $6.72 at 100% = $6.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,6.72,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.72 from Fee Schedule UHC_98227C for Rev 300 Proc 89051 * Qty 1 = $6.72 at 100% = $6.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,UNITY HEALTH PLAN,UNITY HOSPICE,5.60,,,,,,,5.6000,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,61.20,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,52.70,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $52.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,61.20,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,61.20,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF,89051,CPT,300,RC,30000101,CDM,,,,both,,,85.0000,56.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,51.00,,,,,,,5.6000,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.00 in Billed Charges for Rev 300 Proc 89051 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,AETNA,AETNA HSHS,78.17,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $78.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,AETNA,AETNA MEDICARE,5.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,AETNA,ALL COMMERCIAL AETNA,121.00,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTEHM MEDICAID,5.79,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM POS/HMO,19.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.60 from Fee Schedule WII28_25 for Rev 300 Proc 89051 Mod TC * Qty 1 = $19.60 at 100% = $19.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM PPO,19.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.60 from Fee Schedule WII28_25 for Rev 300 Proc 89051 Mod TC * Qty 1 = $19.60 at 100% = $19.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,121.00,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,CENPATICO,ALL MEDICAID CENPATICO,121.00,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,102.85,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,CIGNA,ALL COMMERCIAL CIGNA,84.70,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $84.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,COFINITY,COFINITY,121.00,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.79,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.79,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,114.95,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $114.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,101.64,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $101.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,85.91,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $85.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,88.33,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $88.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,58.81,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $58.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,102.85,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA CHOICE CARE HMO,9.52,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.52 from Fee Schedule 005543_170 for Rev 300 Proc 89051 * Qty 1 = $9.52 at 100% = $9.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA CHOICE CARE PPO,102.85,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,5.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA NATIIONAL POS HMO,9.52,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.52 from Fee Schedule 005543_170 for Rev 300 Proc 89051 * Qty 1 = $9.52 at 100% = $9.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,88.33,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $88.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,121.00,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.79,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.79,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,6.14,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 100% = $5.79... $5.79 at 106% = $6.14 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,5.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,60.50,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $60.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,101.64,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $101.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,12.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,90.75,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $90.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,111.32,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $111.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.28,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.28,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA360,7.28,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.28,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.23,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $77.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5.66,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.12,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,TRIOLOGY,TRILOGY MEDICAID,6.14,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89051 at $5.79 (Fee Schedule) = $5.79 (Total Line Payment) at 106% = $6.14. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.72,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.72 from Fee Schedule UHC_98227C for Rev 300 Proc 89051 * Qty 1 = $6.72 at 100% = $6.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,6.72,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.72 from Fee Schedule UHC_98227C for Rev 300 Proc 89051 * Qty 1 = $6.72 at 100% = $6.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,6.72,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.72 from Fee Schedule UHC_98227C for Rev 300 Proc 89051 * Qty 1 = $6.72 at 100% = $6.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,UNITY HEALTH PLAN,UNITY HOSPICE,5.60,,,,,,,5.6000,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.12,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.02,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $75.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.12,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.12,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CELL CT BODY FLUID W/DIFF (SYN),89051,CPT,300,RC,30000102,CDM,,,,both,,,121.0000,79.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,72.60,,,,,,,5.6000,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $121.00 in Billed Charges for Rev 300 Proc 89051 = $72.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,AETNA,AETNA HSHS,48.45,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $48.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,AETNA,AETNA MEDICARE,7.33,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,AETNA,ALL COMMERCIAL AETNA,75.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTEHM MEDICAID,7.57,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89060 at $7.57 (Fee Schedule) = $7.57 (Total Line Payment) at 100% = $7.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.33,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM POS/HMO,25.66,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.66 from Fee Schedule WII28_25 for Rev 300 Proc 89060 Mod TC * Qty 1 = $25.66 at 100% = $25.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM PPO,25.66,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.66 from Fee Schedule WII28_25 for Rev 300 Proc 89060 Mod TC * Qty 1 = $25.66 at 100% = $25.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,75.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,CENPATICO,ALL MEDICAID CENPATICO,75.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,63.75,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,CIGNA,ALL COMMERCIAL CIGNA,52.50,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $52.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,COFINITY,COFINITY,75.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,7.57,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89060 at $7.57 (Fee Schedule) = $7.57 (Total Line Payment) at 100% = $7.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,7.57,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89060 at $7.57 (Fee Schedule) = $7.57 (Total Line Payment) at 100% = $7.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,71.25,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,63.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,53.25,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $53.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.75,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,36.45,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $36.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,63.75,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA CHOICE CARE HMO,12.46,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.46 from Fee Schedule 005543_170 for Rev 300 Proc 89060 * Qty 1 = $12.46 at 100% = $12.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA CHOICE CARE PPO,63.75,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,7.33,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA NATIIONAL POS HMO,12.46,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.46 from Fee Schedule 005543_170 for Rev 300 Proc 89060 * Qty 1 = $12.46 at 100% = $12.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.75,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,75.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,7.57,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89060 at $7.57 (Fee Schedule) = $7.57 (Total Line Payment) at 100% = $7.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.33,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,7.57,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89060 at $7.57 (Fee Schedule) = $7.57 (Total Line Payment) at 100% = $7.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,8.02,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89060 at $7.57 (Fee Schedule) = $7.57 (Total Line Payment) at 100% = $7.57... $7.57 at 106% = $8.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,7.33,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.50,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $37.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,63.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,16.49,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,56.25,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $56.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,69.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9.53,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9.53,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA360,9.53,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9.53,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.87,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $47.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.40,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,54.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,TRIOLOGY,TRILOGY MEDICAID,8.02,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89060 at $7.57 (Fee Schedule) = $7.57 (Total Line Payment) at 106% = $8.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.80,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.80 from Fee Schedule UHC_98227C for Rev 300 Proc 89060 * Qty 1 = $8.80 at 100% = $8.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,8.80,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.80 from Fee Schedule UHC_98227C for Rev 300 Proc 89060 * Qty 1 = $8.80 at 100% = $8.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.33,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,8.80,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.80 from Fee Schedule UHC_98227C for Rev 300 Proc 89060 * Qty 1 = $8.80 at 100% = $8.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,UNITY HEALTH PLAN,UNITY HOSPICE,7.33,,,,,,,7.3300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,54.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,46.50,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $46.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,54.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,54.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRYSTAL ID LIGHT MICRO,89060,CPT,300,RC,30000105,CDM,,,,both,,,75.0000,49.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,45.00,,,,,,,7.3300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $75.00 in Billed Charges for Rev 300 Proc 89060 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,AETNA,AETNA HSHS,31.01,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $31.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,AETNA,AETNA MEDICARE,5.88,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,AETNA,ALL COMMERCIAL AETNA,48.00,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $48.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,ANTHEM,ANTEHM MEDICAID,6.08,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89125 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5.88,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,ANTHEM,ANTHEM POS/HMO,20.58,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.58 from Fee Schedule WII28_25 for Rev 300 Proc 89125 Mod TC * Qty 1 = $20.58 at 100% = $20.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,ANTHEM,ANTHEM PPO,20.58,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.58 from Fee Schedule WII28_25 for Rev 300 Proc 89125 Mod TC * Qty 1 = $20.58 at 100% = $20.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,48.00,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $48.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,CENPATICO,ALL MEDICAID CENPATICO,48.00,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $48.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,40.80,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $40.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,CIGNA,ALL COMMERCIAL CIGNA,33.60,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $33.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,COFINITY,COFINITY,48.00,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $48.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.08,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89125 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.08,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89125 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,45.60,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $45.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,40.32,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $40.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.08,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $34.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.04,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $35.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,23.33,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $23.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,40.80,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $40.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HUMANA,HUMANA CHOICE CARE HMO,10.00,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.00 from Fee Schedule 005543_170 for Rev 300 Proc 89125 * Qty 1 = $10.00 at 100% = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HUMANA,HUMANA CHOICE CARE PPO,40.80,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $40.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,5.88,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,HUMANA,HUMANA NATIIONAL POS HMO,10.00,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.00 from Fee Schedule 005543_170 for Rev 300 Proc 89125 * Qty 1 = $10.00 at 100% = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.04,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $35.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,48.00,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $48.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.08,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89125 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5.88,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.08,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89125 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,6.44,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89125 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08... $6.08 at 106% = $6.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,5.88,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.00,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,40.32,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $40.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,13.23,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.00,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,44.16,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $44.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.64,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.64,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,PREVEA HEALTH NETWORK,PREVEA360,7.64,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.64,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,30.64,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $30.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5.94,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,34.56,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $34.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,TRIOLOGY,TRILOGY MEDICAID,6.44,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89125 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 106% = $6.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.06,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.06 from Fee Schedule UHC_98227C for Rev 300 Proc 89125 * Qty 1 = $7.06 at 100% = $7.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,7.06,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.06 from Fee Schedule UHC_98227C for Rev 300 Proc 89125 * Qty 1 = $7.06 at 100% = $7.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5.88,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,7.06,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.06 from Fee Schedule UHC_98227C for Rev 300 Proc 89125 * Qty 1 = $7.06 at 100% = $7.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,UNITY HEALTH PLAN,UNITY HOSPICE,5.88,,,,,,,5.8800,48.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,34.56,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $34.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,29.76,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $29.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,34.56,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $34.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,34.56,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $34.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FAT STAIN,89125,CPT,300,RC,30000106,CDM,,,,both,,,48.0000,31.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,28.80,,,,,,,5.8800,48.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.00 in Billed Charges for Rev 300 Proc 89125 = $28.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,AETNA,AETNA HSHS,224.81,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $224.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,AETNA,AETNA MEDICARE,8.61,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,AETNA,ALL COMMERCIAL AETNA,348.00,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $348.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,ANTHEM,ANTEHM MEDICAID,8.90,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89310 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.61,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,ANTHEM,ANTHEM POS/HMO,30.14,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.14 from Fee Schedule WII28_25 for Rev 300 Proc 89310 Mod TC * Qty 1 = $30.14 at 100% = $30.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,ANTHEM,ANTHEM PPO,30.14,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.14 from Fee Schedule WII28_25 for Rev 300 Proc 89310 Mod TC * Qty 1 = $30.14 at 100% = $30.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,348.00,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $348.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,CENPATICO,ALL MEDICAID CENPATICO,348.00,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $348.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,295.80,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $295.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,CIGNA,ALL COMMERCIAL CIGNA,243.60,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $243.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,COFINITY,COFINITY,348.00,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $348.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.90,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89310 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.90,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89310 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,330.60,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $330.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,292.32,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $292.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,247.08,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $247.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,254.04,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $254.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,169.13,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $169.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,295.80,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $295.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HUMANA,HUMANA CHOICE CARE HMO,14.64,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.64 from Fee Schedule 005543_170 for Rev 300 Proc 89310 * Qty 1 = $14.64 at 100% = $14.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HUMANA,HUMANA CHOICE CARE PPO,295.80,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $295.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,8.61,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,HUMANA,HUMANA NATIIONAL POS HMO,14.64,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.64 from Fee Schedule 005543_170 for Rev 300 Proc 89310 * Qty 1 = $14.64 at 100% = $14.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,254.04,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $254.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,348.00,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $348.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.90,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89310 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.61,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.90,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89310 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,9.43,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89310 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90... $8.90 at 106% = $9.43 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,8.61,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,174.00,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $174.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,292.32,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $292.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,19.37,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,261.00,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $261.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,320.16,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $320.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.19,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.19,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,PREVEA HEALTH NETWORK,PREVEA360,11.19,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.19,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,222.13,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $222.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.70,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,250.56,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $250.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,TRIOLOGY,TRILOGY MEDICAID,9.43,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89310 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 106% = $9.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.33,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.33 from Fee Schedule UHC_98227C for Rev 300 Proc 89310 * Qty 1 = $10.33 at 100% = $10.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,10.33,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.33 from Fee Schedule UHC_98227C for Rev 300 Proc 89310 * Qty 1 = $10.33 at 100% = $10.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.61,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,10.33,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.33 from Fee Schedule UHC_98227C for Rev 300 Proc 89310 * Qty 1 = $10.33 at 100% = $10.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,UNITY HEALTH PLAN,UNITY HOSPICE,8.61,,,,,,,8.6100,348.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,250.56,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $250.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,215.76,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $215.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,250.56,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $250.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,250.56,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $250.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM COUNT,89310,CPT,300,RC,30000111,CDM,,,,both,,,348.0000,229.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,208.80,,,,,,,8.6100,348.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $348.00 in Billed Charges for Rev 300 Proc 89310 = $208.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,AETNA,AETNA HSHS,20.67,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $20.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,AETNA,ALL COMMERCIAL AETNA,32.00,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,ANTHEM,ANTEHM MEDICAID,3.92,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 99001 at $3.92 (Fee Schedule) = $3.92 (Total Line Payment) at 100% = $3.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,ANTHEM,ANTHEM POS/HMO,21.76,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 99001 $32.00 in Billed Charges at 68% = $21.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,ANTHEM,ANTHEM PPO,21.76,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 99001 $32.00 in Billed Charges at 68% = $21.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,32.00,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,CENPATICO,ALL MEDICAID CENPATICO,32.00,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,27.20,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $27.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,CIGNA,ALL COMMERCIAL CIGNA,22.40,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $22.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,COFINITY,COFINITY,32.00,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,3.92,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 99001 at $3.92 (Fee Schedule) = $3.92 (Total Line Payment) at 100% = $3.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,3.92,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 99001 at $3.92 (Fee Schedule) = $3.92 (Total Line Payment) at 100% = $3.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,30.40,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $30.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,26.88,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $26.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,22.72,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $22.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,23.36,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $23.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,15.55,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $15.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,27.20,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $27.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,HUMANA,HUMANA CHOICE CARE HMO,10.08,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.08 from Fee Schedule 005543_170 for Rev 300 Proc 99001 * Qty 1 = $10.08 at 100% = $10.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,HUMANA,HUMANA CHOICE CARE PPO,27.20,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $27.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,HUMANA,HUMANA NATIIONAL POS HMO,10.08,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.08 from Fee Schedule 005543_170 for Rev 300 Proc 99001 * Qty 1 = $10.08 at 100% = $10.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,23.36,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $23.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,32.00,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,3.92,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 99001 at $3.92 (Fee Schedule) = $3.92 (Total Line Payment) at 100% = $3.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,3.92,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 99001 at $3.92 (Fee Schedule) = $3.92 (Total Line Payment) at 100% = $3.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,4.16,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 99001 at $3.92 (Fee Schedule) = $3.92 (Total Line Payment) at 100% = $3.92... $3.92 at 106% = $4.16 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.00,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,26.88,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $26.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,24.00,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,29.44,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $29.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,19.20,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,19.20,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,PREVEA HEALTH NETWORK,PREVEA360,19.20,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,19.20,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,20.43,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $20.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,23.04,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $23.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,TRIOLOGY,TRILOGY MEDICAID,4.16,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 99001 at $3.92 (Fee Schedule) = $3.92 (Total Line Payment) at 106% = $4.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.73,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.73 from Fee Schedule UHC_98227C for Rev 300 Proc 99001 * Qty 1 = $7.73 at 100% = $7.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,7.73,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.73 from Fee Schedule UHC_98227C for Rev 300 Proc 99001 * Qty 1 = $7.73 at 100% = $7.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,7.73,,,,,,,3.9200,32.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.73 from Fee Schedule UHC_98227C for Rev 300 Proc 99001 * Qty 1 = $7.73 at 100% = $7.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,23.04,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $23.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,19.84,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $19.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,23.04,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $23.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,23.04,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $23.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPECIMEN HAND/CONVEY OTHER,99001,CPT,300,RC,30000115,CDM,,,,both,,,32.0000,21.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,19.20,,,,,,,3.9200,32.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.00 in Billed Charges for Rev 300 Proc 99001 = $19.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,AETNA,AETNA HSHS,16.15,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $16.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,AETNA,ALL COMMERCIAL AETNA,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,ANTHEM,ANTHEM POS/HMO,17.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 99080 $25.00 in Billed Charges at 68% = $17.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,ANTHEM,ANTHEM PPO,17.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 99080 $25.00 in Billed Charges at 68% = $17.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,CENPATICO,ALL MEDICAID CENPATICO,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,21.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,CIGNA,ALL COMMERCIAL CIGNA,17.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $17.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,COFINITY,COFINITY,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.75,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $23.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,21.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.75,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $17.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $18.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,12.15,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $12.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,21.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,HUMANA,HUMANA CHOICE CARE PPO,21.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $18.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,21.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.75,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $18.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,23.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $23.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.00,,,,,,,12.1500,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.00,,,,,,,12.1500,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA360,15.00,,,,,,,12.1500,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.00,,,,,,,12.1500,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.96,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $15.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,18.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,18.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,18.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,18.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EMPL DRUG SCREEN COL,99080,CPT,300,RC,30000116,CDM,,,,both,,,25.0000,16.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.00 in Billed Charges for Rev 300 Proc 99080 = $15.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,AETNA,AETNA HSHS,205.43,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $205.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,AETNA,AETNA MEDICARE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,AETNA,ALL COMMERCIAL AETNA,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,ANTHEM,ANTEHM MEDICAID,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,ANTHEM,ANTHEM POS/HMO,59.99,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.99 from Fee Schedule WII28_25 for Rev 300 Proc 80306 Mod TC * Qty 1 = $59.99 at 100% = $59.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,ANTHEM,ANTHEM PPO,59.99,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.99 from Fee Schedule WII28_25 for Rev 300 Proc 80306 Mod TC * Qty 1 = $59.99 at 100% = $59.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,CENPATICO,ALL MEDICAID CENPATICO,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,270.30,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $270.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,CIGNA,ALL COMMERCIAL CIGNA,222.60,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $222.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,COFINITY,COFINITY,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,302.10,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $302.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,267.12,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $267.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,225.78,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $225.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,232.14,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $232.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,154.55,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $154.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,270.30,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $270.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HUMANA,HUMANA CHOICE CARE HMO,29.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.14 from Fee Schedule 005543_170 for Rev 300 Proc 80306 * Qty 1 = $29.14 at 100% = $29.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HUMANA,HUMANA CHOICE CARE PPO,270.30,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $270.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,HUMANA,HUMANA NATIIONAL POS HMO,29.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.14 from Fee Schedule 005543_170 for Rev 300 Proc 80306 * Qty 1 = $29.14 at 100% = $29.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,232.14,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $232.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,18.77,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71... $17.71 at 106% = $18.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,159.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,267.12,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $267.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,38.57,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,238.50,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $238.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,292.56,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $292.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,22.28,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,22.28,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,PREVEA HEALTH NETWORK,PREVEA360,22.28,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,22.28,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,202.98,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $202.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.31,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,228.96,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $228.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,TRIOLOGY,TRILOGY MEDICAID,18.77,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 106% = $18.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.57,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,20.57,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,20.57,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,UNITY HEALTH PLAN,UNITY HOSPICE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,228.96,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $228.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,197.16,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $197.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,228.96,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $228.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,228.96,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $228.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV INSTRMNT,80306,CPT,300,RC,30000120,CDM,,,,both,,,318.0000,209.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,190.80,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $318.00 in Billed Charges for Rev 300 Proc 80306 = $190.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,AETNA,AETNA HSHS,253.23,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $253.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,AETNA,AETNA MEDICARE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,AETNA,ALL COMMERCIAL AETNA,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,ANTHEM,ANTEHM MEDICAID,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,ANTHEM,ANTHEM POS/HMO,217.49,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $217.49 from Fee Schedule WII28_25 for Rev 300 Proc 80307 Mod TC * Qty 1 = $217.49 at 100% = $217.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,ANTHEM,ANTHEM PPO,217.49,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $217.49 from Fee Schedule WII28_25 for Rev 300 Proc 80307 Mod TC * Qty 1 = $217.49 at 100% = $217.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,CENPATICO,ALL MEDICAID CENPATICO,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,333.20,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,CIGNA,ALL COMMERCIAL CIGNA,274.40,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $274.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,COFINITY,COFINITY,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,372.40,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $372.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,329.28,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $329.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,278.32,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $278.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,286.16,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $286.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,190.51,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $190.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,333.20,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HUMANA,HUMANA CHOICE CARE HMO,105.64,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $105.64 from Fee Schedule 005543_170 for Rev 300 Proc 80307 * Qty 1 = $105.64 at 100% = $105.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HUMANA,HUMANA CHOICE CARE PPO,333.20,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,HUMANA,HUMANA NATIIONAL POS HMO,105.64,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $105.64 from Fee Schedule 005543_170 for Rev 300 Proc 80307 * Qty 1 = $105.64 at 100% = $105.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,286.16,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $286.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,67.20,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40... $63.40 at 106% = $67.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,196.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,329.28,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $329.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,139.82,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,294.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $294.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,360.64,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $360.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,80.78,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,80.78,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,PREVEA HEALTH NETWORK,PREVEA360,80.78,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,80.78,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,250.21,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $250.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,62.76,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,282.24,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,TRIOLOGY,TRILOGY MEDICAID,67.20,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 106% = $67.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,74.57,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,74.57,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,74.57,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,UNITY HEALTH PLAN,UNITY HOSPICE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,282.24,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,243.04,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $243.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,282.24,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,282.24,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,300,RC,30000124,CDM,,,,both,,,392.0000,258.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,235.20,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $392.00 in Billed Charges for Rev 300 Proc 80307 = $235.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,AETNA,AETNA HSHS,78.17,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $78.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,AETNA,AETNA MEDICARE,19.57,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,AETNA,ALL COMMERCIAL AETNA,121.00,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTEHM MEDICAID,3.93,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc G0432 at $125.60 (Base Rate) * 0.0313 (Relative Weight) = $3.93 (Total Line Payment) at 100% = $3.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,19.57,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM POS/HMO,68.50,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.50 from Fee Schedule WII28_25 for Rev 300 Proc G0432 Mod TC * Qty 1 = $68.50 at 100% = $68.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM PPO,68.50,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.50 from Fee Schedule WII28_25 for Rev 300 Proc G0432 Mod TC * Qty 1 = $68.50 at 100% = $68.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,121.00,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,CENPATICO,ALL MEDICAID CENPATICO,121.00,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,102.85,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,CIGNA,ALL COMMERCIAL CIGNA,84.70,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $84.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,COFINITY,COFINITY,121.00,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,3.93,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc G0432 at $125.60 (Base Rate) * 0.0313 (Relative Weight) = $3.93 (Total Line Payment) at 100% = $3.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,3.93,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc G0432 at $125.60 (Base Rate) * 0.0313 (Relative Weight) = $3.93 (Total Line Payment) at 100% = $3.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,114.95,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $114.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,101.64,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $101.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,85.91,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $85.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,88.33,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $88.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,58.81,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $58.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,102.85,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA CHOICE CARE HMO,33.27,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $33.27 from Fee Schedule 005543_170 for Rev 300 Proc G0432 * Qty 1 = $33.27 at 100% = $33.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA CHOICE CARE PPO,102.85,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,19.57,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA NATIIONAL POS HMO,33.27,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $33.27 from Fee Schedule 005543_170 for Rev 300 Proc G0432 * Qty 1 = $33.27 at 100% = $33.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,88.33,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $88.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,121.00,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,3.93,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc G0432 at $125.60 (Base Rate) * 0.0313 (Relative Weight) = $3.93 (Total Line Payment) at 100% = $3.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,19.57,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,3.93,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc G0432 at $125.60 (Base Rate) * 0.0313 (Relative Weight) = $3.93 (Total Line Payment) at 100% = $3.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,4.17,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc G0432 at $125.60 (Base Rate) * 0.0313 (Relative Weight) = $3.93 (Total Line Payment) at 100% = $3.93... $3.93 at 106% = $4.17 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,19.57,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,60.50,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $60.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,101.64,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $101.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,44.03,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,90.75,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $90.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,111.32,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $111.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,25.44,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,25.44,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA360,25.44,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,25.44,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.23,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $77.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,19.77,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.12,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,TRIOLOGY,TRILOGY MEDICAID,4.17,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc G0432 at $125.60 (Base Rate) * 0.0313 (Relative Weight) = $3.93 (Total Line Payment) at 106% = $4.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,23.48,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.48 from Fee Schedule UHC_98227C for Rev 300 Proc G0432 * Qty 1 = $23.48 at 100% = $23.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,23.48,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.48 from Fee Schedule UHC_98227C for Rev 300 Proc G0432 * Qty 1 = $23.48 at 100% = $23.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,19.57,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,23.48,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.48 from Fee Schedule UHC_98227C for Rev 300 Proc G0432 * Qty 1 = $23.48 at 100% = $23.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,UNITY HEALTH PLAN,UNITY HOSPICE,19.57,,,,,,,3.9300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.12,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.02,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $75.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.12,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.12,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV I-II SCREEN,G0432,HCPCS,300,RC,30000125,CDM,,,,both,,,121.0000,79.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,72.60,,,,,,,3.9300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $121.00 in Billed Charges for Rev 300 Proc G0432 = $72.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,AETNA,AETNA HSHS,92.93,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $92.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,AETNA,ALL COMMERCIAL AETNA,143.85,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $143.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,ANTHEM,ANTEHM MEDICAID,44.45,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00436 Proc J2790 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,ANTHEM,ANTHEM POS/HMO,97.82,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc J2790 $143.85 in Billed Charges at 68% = $97.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,ANTHEM,ANTHEM PPO,97.82,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc J2790 $143.85 in Billed Charges at 68% = $97.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,143.85,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $143.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,CENPATICO,ALL MEDICAID CENPATICO,143.85,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $143.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,122.27,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $122.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,CIGNA,ALL COMMERCIAL CIGNA,100.70,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,COFINITY,COFINITY,143.85,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $143.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,44.45,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00436 Proc J2790 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,44.45,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00436 Proc J2790 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,136.66,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $136.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,120.83,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $120.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,102.13,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $102.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,105.01,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $105.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,69.91,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $69.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,122.27,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $122.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,HUMANA,HUMANA CHOICE CARE HMO,131.44,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $131.44 from Fee Schedule 005543_170 for Rev 300 Proc J2790 * Qty 1 = $131.44 at 100% = $131.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,HUMANA,HUMANA CHOICE CARE PPO,122.27,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $122.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,HUMANA,HUMANA NATIIONAL POS HMO,131.44,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $131.44 from Fee Schedule 005543_170 for Rev 300 Proc J2790 * Qty 1 = $131.44 at 100% = $131.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,105.01,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $105.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,143.85,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $143.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,44.45,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00436 Proc J2790 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,44.45,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00436 Proc J2790 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,47.12,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00436 Proc J2790 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45... $44.45 at 106% = $47.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,71.93,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $71.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,120.83,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $120.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,107.89,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $107.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,132.34,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $132.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,86.31,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,86.31,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,PREVEA HEALTH NETWORK,PREVEA360,86.31,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,86.31,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,91.82,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $91.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,103.57,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $103.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,TRIOLOGY,TRILOGY MEDICAID,47.12,,,,,,,44.4500,143.8500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00436 Proc J2790 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 106% = $47.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,103.57,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $103.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,89.19,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $89.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,103.57,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $103.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,103.57,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $103.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RH IMMUNE GLOBULIN,J2790,HCPCS,300,RC,30000126,CDM,,,,both,,,143.8500,94.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,86.31,,,,,,,44.4500,143.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $143.85 in Billed Charges for Rev 300 Proc J2790 = $86.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,AETNA,AETNA HSHS,162.79,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $162.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,AETNA,AETNA MEDICARE,24.37,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,AETNA,ALL COMMERCIAL AETNA,252.00,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,ANTHEM,ANTEHM MEDICAID,25.18,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86332 at $25.18 (Fee Schedule) = $25.18 (Total Line Payment) at 100% = $25.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,24.37,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,ANTHEM,ANTHEM POS/HMO,85.30,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $85.30 from Fee Schedule WII28_25 for Rev 300 Proc 86332 Mod TC * Qty 1 = $85.30 at 100% = $85.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,ANTHEM,ANTHEM PPO,85.30,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $85.30 from Fee Schedule WII28_25 for Rev 300 Proc 86332 Mod TC * Qty 1 = $85.30 at 100% = $85.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,252.00,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,CENPATICO,ALL MEDICAID CENPATICO,252.00,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,214.20,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,CIGNA,ALL COMMERCIAL CIGNA,176.40,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,COFINITY,COFINITY,252.00,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,25.18,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86332 at $25.18 (Fee Schedule) = $25.18 (Total Line Payment) at 100% = $25.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,25.18,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86332 at $25.18 (Fee Schedule) = $25.18 (Total Line Payment) at 100% = $25.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,239.40,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $239.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,211.68,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $211.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,178.92,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $178.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,183.96,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $183.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,122.47,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $122.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,214.20,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HUMANA,HUMANA CHOICE CARE HMO,41.43,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.43 from Fee Schedule 005543_170 for Rev 300 Proc 86332 * Qty 1 = $41.43 at 100% = $41.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HUMANA,HUMANA CHOICE CARE PPO,214.20,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,24.37,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,HUMANA,HUMANA NATIIONAL POS HMO,41.43,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.43 from Fee Schedule 005543_170 for Rev 300 Proc 86332 * Qty 1 = $41.43 at 100% = $41.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,183.96,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $183.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,252.00,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,25.18,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86332 at $25.18 (Fee Schedule) = $25.18 (Total Line Payment) at 100% = $25.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,24.37,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,25.18,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86332 at $25.18 (Fee Schedule) = $25.18 (Total Line Payment) at 100% = $25.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,26.69,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86332 at $25.18 (Fee Schedule) = $25.18 (Total Line Payment) at 100% = $25.18... $25.18 at 106% = $26.69 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,24.37,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,126.00,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,211.68,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $211.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,54.83,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,189.00,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,231.84,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $231.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,31.68,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,31.68,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,PREVEA HEALTH NETWORK,PREVEA360,31.68,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,31.68,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,160.85,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $160.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,24.61,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,181.44,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $181.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,TRIOLOGY,TRILOGY MEDICAID,26.69,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86332 at $25.18 (Fee Schedule) = $25.18 (Total Line Payment) at 106% = $26.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,29.24,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.24 from Fee Schedule UHC_98227C for Rev 300 Proc 86332 * Qty 1 = $29.24 at 100% = $29.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,29.24,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.24 from Fee Schedule UHC_98227C for Rev 300 Proc 86332 * Qty 1 = $29.24 at 100% = $29.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,24.37,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,29.24,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.24 from Fee Schedule UHC_98227C for Rev 300 Proc 86332 * Qty 1 = $29.24 at 100% = $29.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,UNITY HEALTH PLAN,UNITY HOSPICE,24.37,,,,,,,24.3700,252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,181.44,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $181.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,156.24,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $156.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,181.44,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $181.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,181.44,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $181.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMMUNE COMPLEX ASSAY,86332,CPT,300,RC,30000201,CDM,,,,both,,,252.0000,166.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,151.20,,,,,,,24.3700,252.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $252.00 in Billed Charges for Rev 300 Proc 86332 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,AETNA,AETNA HSHS,167.31,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $167.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,AETNA,AETNA MEDICARE,8.10,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,AETNA,ALL COMMERCIAL AETNA,259.00,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $259.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,ANTHEM,ANTEHM MEDICAID,8.37,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 84311 at $8.37 (Fee Schedule) = $8.37 (Total Line Payment) at 100% = $8.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.10,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,ANTHEM,ANTHEM POS/HMO,28.35,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.35 from Fee Schedule WII28_25 for Rev 300 Proc 84311 Mod TC * Qty 1 = $28.35 at 100% = $28.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,ANTHEM,ANTHEM PPO,28.35,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.35 from Fee Schedule WII28_25 for Rev 300 Proc 84311 Mod TC * Qty 1 = $28.35 at 100% = $28.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,259.00,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $259.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,CENPATICO,ALL MEDICAID CENPATICO,259.00,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $259.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,220.15,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $220.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,CIGNA,ALL COMMERCIAL CIGNA,181.30,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $181.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,COFINITY,COFINITY,259.00,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $259.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.37,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 84311 at $8.37 (Fee Schedule) = $8.37 (Total Line Payment) at 100% = $8.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.37,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 84311 at $8.37 (Fee Schedule) = $8.37 (Total Line Payment) at 100% = $8.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,246.05,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $246.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,217.56,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $217.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,183.89,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $183.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,189.07,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $189.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,125.87,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $125.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,220.15,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $220.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HUMANA,HUMANA CHOICE CARE HMO,13.77,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.77 from Fee Schedule 005543_170 for Rev 300 Proc 84311 * Qty 1 = $13.77 at 100% = $13.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HUMANA,HUMANA CHOICE CARE PPO,220.15,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $220.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,8.10,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,HUMANA,HUMANA NATIIONAL POS HMO,13.77,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.77 from Fee Schedule 005543_170 for Rev 300 Proc 84311 * Qty 1 = $13.77 at 100% = $13.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,189.07,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $189.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,259.00,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $259.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.37,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 84311 at $8.37 (Fee Schedule) = $8.37 (Total Line Payment) at 100% = $8.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.10,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.37,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 84311 at $8.37 (Fee Schedule) = $8.37 (Total Line Payment) at 100% = $8.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,8.87,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 84311 at $8.37 (Fee Schedule) = $8.37 (Total Line Payment) at 100% = $8.37... $8.37 at 106% = $8.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,8.10,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,129.50,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $129.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,217.56,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $217.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,18.23,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,194.25,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $194.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,238.28,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $238.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.53,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.53,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,PREVEA HEALTH NETWORK,PREVEA360,10.53,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.53,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,165.32,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $165.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.18,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,186.48,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $186.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,TRIOLOGY,TRILOGY MEDICAID,8.87,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 84311 at $8.37 (Fee Schedule) = $8.37 (Total Line Payment) at 106% = $8.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.72,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.72 from Fee Schedule UHC_98227C for Rev 300 Proc 84311 * Qty 1 = $9.72 at 100% = $9.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,9.72,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.72 from Fee Schedule UHC_98227C for Rev 300 Proc 84311 * Qty 1 = $9.72 at 100% = $9.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.10,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,9.72,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.72 from Fee Schedule UHC_98227C for Rev 300 Proc 84311 * Qty 1 = $9.72 at 100% = $9.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,UNITY HEALTH PLAN,UNITY HOSPICE,8.10,,,,,,,8.1000,259.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,186.48,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $186.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,160.58,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $160.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,186.48,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $186.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,186.48,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $186.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PM SCREEN OXIDANT,84311,CPT,300,RC,30000205,CDM,,,,both,,,259.0000,170.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,155.40,,,,,,,8.1000,259.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $259.00 in Billed Charges for Rev 300 Proc 84311 = $155.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,AETNA,AETNA HSHS,405.04,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $405.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,AETNA,AETNA MEDICARE,165.49,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,AETNA,ALL COMMERCIAL AETNA,627.00,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,ANTHEM,ANTEHM MEDICAID,38.82,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00499 Proc 86971 at $125.60 (Base Rate) * 0.3091 (Relative Weight) = $38.82 (Total Line Payment) at 100% = $38.82. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,165.49,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,ANTHEM,ANTHEM POS/HMO,77.59,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $77.59 from Fee Schedule WII28_25 for Rev 300 Proc 86971 Mod TC * Qty 1 = $77.59 at 100% = $77.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,ANTHEM,ANTHEM PPO,77.59,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $77.59 from Fee Schedule WII28_25 for Rev 300 Proc 86971 Mod TC * Qty 1 = $77.59 at 100% = $77.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,627.00,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,CENPATICO,ALL MEDICAID CENPATICO,627.00,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,532.95,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $532.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,CIGNA,ALL COMMERCIAL CIGNA,438.90,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $438.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,COFINITY,COFINITY,627.00,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,38.82,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00499 Proc 86971 at $125.60 (Base Rate) * 0.3091 (Relative Weight) = $38.82 (Total Line Payment) at 100% = $38.82. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,38.82,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00499 Proc 86971 at $125.60 (Base Rate) * 0.3091 (Relative Weight) = $38.82 (Total Line Payment) at 100% = $38.82. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,595.65,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $595.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,526.68,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $526.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,445.17,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $445.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,457.71,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $457.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,304.72,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $304.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,532.95,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $532.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HUMANA,HUMANA CHOICE CARE HMO,36.28,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.28 from Fee Schedule 005543_170 for Rev 300 Proc 86971 * Qty 1 = $36.28 at 100% = $36.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HUMANA,HUMANA CHOICE CARE PPO,532.95,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $532.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,165.49,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,HUMANA,HUMANA NATIIONAL POS HMO,36.28,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.28 from Fee Schedule 005543_170 for Rev 300 Proc 86971 * Qty 1 = $36.28 at 100% = $36.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,457.71,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $457.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,627.00,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,38.82,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00499 Proc 86971 at $125.60 (Base Rate) * 0.3091 (Relative Weight) = $38.82 (Total Line Payment) at 100% = $38.82. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,165.49,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,38.82,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00499 Proc 86971 at $125.60 (Base Rate) * 0.3091 (Relative Weight) = $38.82 (Total Line Payment) at 100% = $38.82. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,41.15,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00499 Proc 86971 at $125.60 (Base Rate) * 0.3091 (Relative Weight) = $38.82 (Total Line Payment) at 100% = $38.82... $38.82 at 106% = $41.15 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,165.49,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,313.50,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $313.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,526.68,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $526.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,372.34,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,470.25,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $470.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,576.84,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $576.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,376.20,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,376.20,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,PREVEA HEALTH NETWORK,PREVEA360,376.20,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,376.20,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,400.21,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $400.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,167.14,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,451.44,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $451.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,TRIOLOGY,TRILOGY MEDICAID,41.15,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00499 Proc 86971 at $125.60 (Base Rate) * 0.3091 (Relative Weight) = $38.82 (Total Line Payment) at 106% = $41.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,388.93,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 300 Proc 86971 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,388.93,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 300 Proc 86971 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,165.49,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,388.93,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 300 Proc 86971 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,UNITY HEALTH PLAN,UNITY HOSPICE,165.49,,,,,,,36.2800,627.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,451.44,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $451.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,388.74,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $388.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,451.44,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $451.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,451.44,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $451.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC PRETREAT ENZYME,86971,CPT,300,RC,30000220,CDM,,,,both,,,627.0000,413.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,376.20,,,,,,,36.2800,627.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $627.00 in Billed Charges for Rev 300 Proc 86971 = $376.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,AETNA,AETNA HSHS,203.49,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $203.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,AETNA,AETNA MEDICARE,12.05,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,AETNA,ALL COMMERCIAL AETNA,315.00,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,ANTHEM,ANTEHM MEDICAID,12.45,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89321 at $12.45 (Fee Schedule) = $12.45 (Total Line Payment) at 100% = $12.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,12.05,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,ANTHEM,ANTHEM POS/HMO,42.18,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.18 from Fee Schedule WII28_25 for Rev 300 Proc 89321 Mod TC * Qty 1 = $42.18 at 100% = $42.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,ANTHEM,ANTHEM PPO,42.18,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.18 from Fee Schedule WII28_25 for Rev 300 Proc 89321 Mod TC * Qty 1 = $42.18 at 100% = $42.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,315.00,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,CENPATICO,ALL MEDICAID CENPATICO,315.00,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,267.75,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,CIGNA,ALL COMMERCIAL CIGNA,220.50,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $220.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,COFINITY,COFINITY,315.00,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.45,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89321 at $12.45 (Fee Schedule) = $12.45 (Total Line Payment) at 100% = $12.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.45,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89321 at $12.45 (Fee Schedule) = $12.45 (Total Line Payment) at 100% = $12.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,299.25,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $299.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,264.60,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $264.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,223.65,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $223.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,229.95,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $229.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,153.09,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $153.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,267.75,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HUMANA,HUMANA CHOICE CARE HMO,20.49,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.49 from Fee Schedule 005543_170 for Rev 300 Proc 89321 * Qty 1 = $20.49 at 100% = $20.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HUMANA,HUMANA CHOICE CARE PPO,267.75,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,12.05,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,HUMANA,HUMANA NATIIONAL POS HMO,20.49,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.49 from Fee Schedule 005543_170 for Rev 300 Proc 89321 * Qty 1 = $20.49 at 100% = $20.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,229.95,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $229.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,315.00,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.45,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89321 at $12.45 (Fee Schedule) = $12.45 (Total Line Payment) at 100% = $12.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.05,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.45,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89321 at $12.45 (Fee Schedule) = $12.45 (Total Line Payment) at 100% = $12.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,13.20,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89321 at $12.45 (Fee Schedule) = $12.45 (Total Line Payment) at 100% = $12.45... $12.45 at 106% = $13.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,12.05,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,157.50,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,264.60,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $264.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,27.11,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,236.25,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $236.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,289.80,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.67,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.67,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,PREVEA HEALTH NETWORK,PREVEA360,15.67,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.67,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,201.06,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $201.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.17,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,226.80,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,TRIOLOGY,TRILOGY MEDICAID,13.20,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89321 at $12.45 (Fee Schedule) = $12.45 (Total Line Payment) at 106% = $13.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.46,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.46 from Fee Schedule UHC_98227C for Rev 300 Proc 89321 * Qty 1 = $14.46 at 100% = $14.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,14.46,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.46 from Fee Schedule UHC_98227C for Rev 300 Proc 89321 * Qty 1 = $14.46 at 100% = $14.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,12.05,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,14.46,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.46 from Fee Schedule UHC_98227C for Rev 300 Proc 89321 * Qty 1 = $14.46 at 100% = $14.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,UNITY HEALTH PLAN,UNITY HOSPICE,12.05,,,,,,,12.0500,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,226.80,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,195.30,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $195.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,226.80,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,226.80,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN PRESENCE/MOTILITY,89321,CPT,300,RC,30000227,CDM,,,,both,,,315.0000,207.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,189.00,,,,,,,12.0500,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $315.00 in Billed Charges for Rev 300 Proc 89321 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,AETNA,AETNA HSHS,304.27,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $304.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,AETNA,AETNA MEDICARE,15.50,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,AETNA,ALL COMMERCIAL AETNA,471.00,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $471.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,ANTHEM,ANTEHM MEDICAID,16.02,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89322 at $16.02 (Fee Schedule) = $16.02 (Total Line Payment) at 100% = $16.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,15.50,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,ANTHEM,ANTHEM POS/HMO,54.25,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $54.25 from Fee Schedule WII28_25 for Rev 300 Proc 89322 Mod TC * Qty 1 = $54.25 at 100% = $54.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,ANTHEM,ANTHEM PPO,54.25,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $54.25 from Fee Schedule WII28_25 for Rev 300 Proc 89322 Mod TC * Qty 1 = $54.25 at 100% = $54.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,471.00,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $471.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,CENPATICO,ALL MEDICAID CENPATICO,471.00,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $471.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,400.35,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $400.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,CIGNA,ALL COMMERCIAL CIGNA,329.70,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $329.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,COFINITY,COFINITY,471.00,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $471.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.02,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89322 at $16.02 (Fee Schedule) = $16.02 (Total Line Payment) at 100% = $16.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.02,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89322 at $16.02 (Fee Schedule) = $16.02 (Total Line Payment) at 100% = $16.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,447.45,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $447.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,395.64,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $395.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,334.41,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $334.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,343.83,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $343.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,228.91,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $228.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,400.35,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $400.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HUMANA,HUMANA CHOICE CARE HMO,26.35,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.35 from Fee Schedule 005543_170 for Rev 300 Proc 89322 * Qty 1 = $26.35 at 100% = $26.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HUMANA,HUMANA CHOICE CARE PPO,400.35,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $400.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,15.50,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,HUMANA,HUMANA NATIIONAL POS HMO,26.35,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.35 from Fee Schedule 005543_170 for Rev 300 Proc 89322 * Qty 1 = $26.35 at 100% = $26.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,343.83,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $343.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,471.00,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $471.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.02,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89322 at $16.02 (Fee Schedule) = $16.02 (Total Line Payment) at 100% = $16.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.50,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.02,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89322 at $16.02 (Fee Schedule) = $16.02 (Total Line Payment) at 100% = $16.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,16.98,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89322 at $16.02 (Fee Schedule) = $16.02 (Total Line Payment) at 100% = $16.02... $16.02 at 106% = $16.98 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,15.50,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,235.50,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $235.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,395.64,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $395.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,34.88,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,353.25,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $353.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,433.32,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $433.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,20.15,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,20.15,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,PREVEA HEALTH NETWORK,PREVEA360,20.15,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,20.15,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,300.64,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $300.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,15.66,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,339.12,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $339.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,TRIOLOGY,TRILOGY MEDICAID,16.98,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89322 at $16.02 (Fee Schedule) = $16.02 (Total Line Payment) at 106% = $16.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,18.60,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule UHC_98227C for Rev 300 Proc 89322 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,18.60,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule UHC_98227C for Rev 300 Proc 89322 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,15.50,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,18.60,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule UHC_98227C for Rev 300 Proc 89322 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,UNITY HEALTH PLAN,UNITY HOSPICE,15.50,,,,,,,15.5000,471.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,339.12,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $339.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,292.02,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $292.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,339.12,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $339.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,339.12,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $339.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA,89322,CPT,300,RC,30000229,CDM,,,,both,,,471.0000,310.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,282.60,,,,,,,15.5000,471.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $471.00 in Billed Charges for Rev 300 Proc 89322 = $282.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,AETNA,AETNA HSHS,93.02,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $144.00 in Billed Charges for Rev 300 = $93.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,AETNA,ALL COMMERCIAL AETNA,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 300 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,ANTHEM,ANTHEM POS/HMO,97.92,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $144.00 in Billed Charges at 68% = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,ANTHEM,ANTHEM PPO,97.92,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $144.00 in Billed Charges at 68% = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 300 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,CENPATICO,ALL MEDICAID CENPATICO,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 300 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,122.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $144.00 in Billed Charges for Rev 300 = $122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,CIGNA,ALL COMMERCIAL CIGNA,100.80,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $144.00 in Billed Charges for Rev 300 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,COFINITY,COFINITY,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 300 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,136.80,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $144.00 in Billed Charges for Rev 300 = $136.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,120.96,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $144.00 in Billed Charges for Rev 300 = $120.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,102.24,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $144.00 in Billed Charges for Rev 300 = $102.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,105.12,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $144.00 in Billed Charges for Rev 300 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,69.98,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $144.00 in Billed Charges for Rev 300 = $69.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,122.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $144.00 in Billed Charges for Rev 300 = $122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,HUMANA,HUMANA CHOICE CARE PPO,122.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $144.00 in Billed Charges for Rev 300 = $122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,105.12,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $144.00 in Billed Charges for Rev 300 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 300 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,72.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $144.00 in Billed Charges for Rev 300 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,120.96,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $144.00 in Billed Charges for Rev 300 = $120.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,108.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $144.00 in Billed Charges for Rev 300 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,132.48,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $144.00 in Billed Charges for Rev 300 = $132.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,86.40,,,,,,,69.9800,144.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,86.40,,,,,,,69.9800,144.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,PREVEA HEALTH NETWORK,PREVEA360,86.40,,,,,,,69.9800,144.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,86.40,,,,,,,69.9800,144.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,91.92,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $144.00 in Billed Charges for Rev 300 = $91.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,103.68,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $144.00 in Billed Charges for Rev 300 = $103.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,72.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $144.00 in Billed Charges at 50% = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,72.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $144.00 in Billed Charges at 50% = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,72.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $144.00 in Billed Charges at 50% = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,103.68,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $144.00 in Billed Charges for Rev 300 = $103.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,89.28,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $144.00 in Billed Charges for Rev 300 = $89.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,103.68,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $144.00 in Billed Charges for Rev 300 = $103.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,103.68,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $144.00 in Billed Charges for Rev 300 = $103.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB HANDLING & TRANSPORT,300,RC,30000261,CDM,,,,,,both,,,144.0000,95.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,86.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $144.00 in Billed Charges for Rev 300 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,AETNA,AETNA HSHS,273.26,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $273.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,AETNA,AETNA MEDICARE,129.23,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,AETNA,ALL COMMERCIAL AETNA,423.00,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,ANTHEM,ANTEHM MEDICAID,34.44,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,129.23,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,ANTHEM,ANTHEM POS/HMO,287.64,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36592 $423.00 in Billed Charges at 68% = $287.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,ANTHEM,ANTHEM PPO,287.64,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36592 $423.00 in Billed Charges at 68% = $287.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,423.00,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,CENPATICO,ALL MEDICAID CENPATICO,423.00,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,359.55,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $359.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,COFINITY,COFINITY,423.00,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,34.44,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,34.44,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,401.85,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $401.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,355.32,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $355.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,300.33,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $300.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,308.79,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $308.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,205.58,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $205.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,359.55,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $359.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HUMANA,HUMANA CHOICE CARE HMO,48.38,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.38 from Fee Schedule 005543_170 for Rev 300 Proc 36592 * Qty 1 = $48.38 at 100% = $48.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HUMANA,HUMANA CHOICE CARE PPO,359.55,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $359.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,129.23,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,HUMANA,HUMANA NATIIONAL POS HMO,48.38,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.38 from Fee Schedule 005543_170 for Rev 300 Proc 36592 * Qty 1 = $48.38 at 100% = $48.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,308.79,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $308.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,423.00,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,34.44,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,129.23,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,34.44,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,36.51,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44... $34.44 at 106% = $36.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,129.23,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,211.50,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $211.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,355.32,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $355.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,290.78,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,317.25,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $317.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,389.16,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $389.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,253.80,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,253.80,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,PREVEA HEALTH NETWORK,PREVEA360,253.80,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,253.80,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,270.00,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.52,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,304.56,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $304.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,TRIOLOGY,TRILOGY MEDICAID,36.51,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 106% = $36.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,129.23,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,UNITY HEALTH PLAN,UNITY HOSPICE,129.23,,,,,,,34.4400,423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,304.56,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $304.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,262.26,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $262.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,304.56,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $304.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,304.56,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $304.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERPH CATH,36592,CPT,300,RC,30002013,CDM,,,,both,,,423.0000,279.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,253.80,,,,,,,34.4400,423.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $423.00 in Billed Charges for Rev 300 Proc 36592 = $253.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,AETNA,AETNA HSHS,459.31,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $459.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,AETNA,AETNA MEDICARE,192.32,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,AETNA,ALL COMMERCIAL AETNA,711.00,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $711.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,ANTHEM,ANTEHM MEDICAID,164.96,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81288 at $164.96 (Fee Schedule) = $164.96 (Total Line Payment) at 100% = $164.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,192.32,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,ANTHEM,ANTHEM POS/HMO,673.12,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $673.12 from Fee Schedule WII28_25 for Rev 300 Proc 81288 Mod TC * Qty 1 = $673.12 at 100% = $673.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,ANTHEM,ANTHEM PPO,673.12,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $673.12 from Fee Schedule WII28_25 for Rev 300 Proc 81288 Mod TC * Qty 1 = $673.12 at 100% = $673.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,711.00,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $711.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,CENPATICO,ALL MEDICAID CENPATICO,711.00,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $711.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,604.35,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $604.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,CIGNA,ALL COMMERCIAL CIGNA,497.70,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $497.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,COFINITY,COFINITY,711.00,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $711.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,164.96,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81288 at $164.96 (Fee Schedule) = $164.96 (Total Line Payment) at 100% = $164.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,164.96,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81288 at $164.96 (Fee Schedule) = $164.96 (Total Line Payment) at 100% = $164.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,675.45,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $675.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,597.24,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $597.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,504.81,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $504.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,519.03,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $519.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,345.55,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $345.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,604.35,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $604.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HUMANA,HUMANA CHOICE CARE HMO,326.94,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $326.94 from Fee Schedule 005543_170 for Rev 300 Proc 81288 * Qty 1 = $326.94 at 100% = $326.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HUMANA,HUMANA CHOICE CARE PPO,604.35,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $604.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,192.32,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,HUMANA,HUMANA NATIIONAL POS HMO,326.94,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $326.94 from Fee Schedule 005543_170 for Rev 300 Proc 81288 * Qty 1 = $326.94 at 100% = $326.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,519.03,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $519.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,711.00,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $711.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,164.96,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81288 at $164.96 (Fee Schedule) = $164.96 (Total Line Payment) at 100% = $164.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,192.32,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,164.96,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81288 at $164.96 (Fee Schedule) = $164.96 (Total Line Payment) at 100% = $164.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,174.86,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81288 at $164.96 (Fee Schedule) = $164.96 (Total Line Payment) at 100% = $164.96... $164.96 at 106% = $174.86 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,192.32,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,355.50,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $355.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,597.24,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $597.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,432.72,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,533.25,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $533.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,654.12,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $654.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,250.02,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,250.02,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,PREVEA HEALTH NETWORK,PREVEA360,250.02,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,250.02,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,453.83,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $453.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,194.24,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,511.92,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $511.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,TRIOLOGY,TRILOGY MEDICAID,174.86,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81288 at $164.96 (Fee Schedule) = $164.96 (Total Line Payment) at 106% = $174.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,230.78,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $230.78 from Fee Schedule UHC_98227C for Rev 300 Proc 81288 * Qty 1 = $230.78 at 100% = $230.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,230.78,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $230.78 from Fee Schedule UHC_98227C for Rev 300 Proc 81288 * Qty 1 = $230.78 at 100% = $230.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,192.32,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,230.78,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $230.78 from Fee Schedule UHC_98227C for Rev 300 Proc 81288 * Qty 1 = $230.78 at 100% = $230.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,UNITY HEALTH PLAN,UNITY HOSPICE,192.32,,,,,,,164.9600,711.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,511.92,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $511.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,440.82,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $440.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,511.92,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $511.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,511.92,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $511.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MLH1 GENE ANALYSIS,81288,CPT,300,RC,30002038,CDM,,,,both,,,711.0000,469.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,426.60,,,,,,,164.9600,711.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $711.00 in Billed Charges for Rev 300 Proc 81288 = $426.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,AETNA,AETNA HSHS,226.75,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $226.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,AETNA,AETNA MEDICARE,17.27,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,AETNA,ALL COMMERCIAL AETNA,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,ANTHEM,ANTEHM MEDICAID,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0280U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,17.27,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,ANTHEM,ANTHEM POS/HMO,60.45,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.45 from Fee Schedule WII28_25 for Rev 300 Proc 0280U Mod TC * Qty 1 = $60.45 at 100% = $60.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,ANTHEM,ANTHEM PPO,60.45,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.45 from Fee Schedule WII28_25 for Rev 300 Proc 0280U Mod TC * Qty 1 = $60.45 at 100% = $60.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,CENPATICO,ALL MEDICAID CENPATICO,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,298.35,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $298.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,CIGNA,ALL COMMERCIAL CIGNA,245.70,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $245.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,COFINITY,COFINITY,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0280U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0280U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,333.45,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $333.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,294.84,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $294.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,249.21,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $249.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,256.23,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $256.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,170.59,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $170.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,298.35,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $298.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HUMANA,HUMANA CHOICE CARE HMO,29.36,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.36 from Fee Schedule 005543_170 for Rev 300 Proc 0280U * Qty 1 = $29.36 at 100% = $29.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HUMANA,HUMANA CHOICE CARE PPO,298.35,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $298.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,17.27,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,HUMANA,HUMANA NATIIONAL POS HMO,29.36,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.36 from Fee Schedule 005543_170 for Rev 300 Proc 0280U * Qty 1 = $29.36 at 100% = $29.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,256.23,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $256.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0280U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.27,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0280U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,1.75,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0280U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65... $1.65 at 106% = $1.75 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,17.27,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,175.50,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $175.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,294.84,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $294.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,38.86,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,263.25,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $263.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,322.92,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $322.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,22.45,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,22.45,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,PREVEA HEALTH NETWORK,PREVEA360,22.45,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,22.45,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,224.04,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $224.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.44,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,252.72,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,TRIOLOGY,TRILOGY MEDICAID,1.74,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0280U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 106% = $1.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.72,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.72 from Fee Schedule UHC_98227C for Rev 300 Proc 0280U * Qty 1 = $20.72 at 100% = $20.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,20.72,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.72 from Fee Schedule UHC_98227C for Rev 300 Proc 0280U * Qty 1 = $20.72 at 100% = $20.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,17.27,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,20.72,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.72 from Fee Schedule UHC_98227C for Rev 300 Proc 0280U * Qty 1 = $20.72 at 100% = $20.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,UNITY HEALTH PLAN,UNITY HOSPICE,17.27,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,252.72,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,217.62,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $217.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,252.72,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,252.72,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN VI BNDG,0280U,CPT,300,RC,30002048,CDM,,,,both,,,351.0000,231.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,210.60,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.00 in Billed Charges for Rev 300 Proc 0280U = $210.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,AETNA,AETNA HSHS,813.96,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $813.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,AETNA,AETNA MEDICARE,720.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,AETNA,ALL COMMERCIAL AETNA,1260.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,260.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,ANTHEM,ANTEHM MEDICAID,243.75,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 0282U at $125.60 (Base Rate) * 1.9407 (Relative Weight) = $243.75 (Total Line Payment) at 100% = $243.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,720.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,ANTHEM,ANTHEM POS/HMO,1260.00,,,,,,,243.7500,1620.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,520.00 from Fee Schedule WII28_25 for Rev 300 Proc 0282U Mod TC * Qty 1 = $2,520.00 at 100% = $2,520.00 (Limited to $1,260.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,ANTHEM,ANTHEM PPO,1260.00,,,,,,,243.7500,1620.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,520.00 from Fee Schedule WII28_25 for Rev 300 Proc 0282U Mod TC * Qty 1 = $2,520.00 at 100% = $2,520.00 (Limited to $1,260.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1260.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,260.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,CENPATICO,ALL MEDICAID CENPATICO,1260.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,260.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1071.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,071.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,CIGNA,ALL COMMERCIAL CIGNA,882.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $882.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,COFINITY,COFINITY,1260.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,260.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,243.75,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 0282U at $125.60 (Base Rate) * 1.9407 (Relative Weight) = $243.75 (Total Line Payment) at 100% = $243.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,243.75,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 0282U at $125.60 (Base Rate) * 1.9407 (Relative Weight) = $243.75 (Total Line Payment) at 100% = $243.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1197.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,1058.40,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,058.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,894.60,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $894.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,919.80,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $919.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,612.36,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $612.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1071.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,071.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HUMANA,HUMANA CHOICE CARE HMO,1224.00,,,,,,,243.7500,1620.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,224.00 from Fee Schedule 005543_170 for Rev 300 Proc 0282U * Qty 1 = $1,224.00 at 100% = $1,224.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HUMANA,HUMANA CHOICE CARE PPO,1071.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,071.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,720.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,HUMANA,HUMANA NATIIONAL POS HMO,1224.00,,,,,,,243.7500,1620.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,224.00 from Fee Schedule 005543_170 for Rev 300 Proc 0282U * Qty 1 = $1,224.00 at 100% = $1,224.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,919.80,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $919.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1260.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,260.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,243.75,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 0282U at $125.60 (Base Rate) * 1.9407 (Relative Weight) = $243.75 (Total Line Payment) at 100% = $243.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,720.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,243.75,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 0282U at $125.60 (Base Rate) * 1.9407 (Relative Weight) = $243.75 (Total Line Payment) at 100% = $243.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,258.38,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 0282U at $125.60 (Base Rate) * 1.9407 (Relative Weight) = $243.75 (Total Line Payment) at 100% = $243.75... $243.75 at 106% = $258.38 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,720.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,630.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1058.40,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,058.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,1620.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,945.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $945.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1159.20,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $1,159.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,936.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,936.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,PREVEA HEALTH NETWORK,PREVEA360,936.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,936.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,804.26,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $804.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,727.20,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,907.20,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $907.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,TRIOLOGY,TRILOGY MEDICAID,258.38,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 0282U at $125.60 (Base Rate) * 1.9407 (Relative Weight) = $243.75 (Total Line Payment) at 106% = $258.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,864.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $864.00 from Fee Schedule UHC_98227C for Rev 300 Proc 0282U * Qty 1 = $864.00 at 100% = $864.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,864.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $864.00 from Fee Schedule UHC_98227C for Rev 300 Proc 0282U * Qty 1 = $864.00 at 100% = $864.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,720.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,864.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $864.00 from Fee Schedule UHC_98227C for Rev 300 Proc 0282U * Qty 1 = $864.00 at 100% = $864.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,UNITY HEALTH PLAN,UNITY HOSPICE,720.00,,,,,,,243.7500,1620.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,907.20,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $907.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,781.20,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $781.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,907.20,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $907.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,907.20,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $907.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC DNA GNTYP 12 BLD GRP GEN,0282U,CPT,300,RC,30002051,CDM,,,,both,,,1260.0000,831.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,756.00,,,,,,,243.7500,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,260.00 in Billed Charges for Rev 300 Proc 0282U = $756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,AETNA,AETNA HSHS,773.91,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $773.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,AETNA,AETNA MEDICARE,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,AETNA,ALL COMMERCIAL AETNA,1198.00,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,ANTHEM,ANTEHM MEDICAID,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81352 at $329.51 (Fee Schedule) = $329.51 (Total Line Payment) at 100% = $329.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,ANTHEM,ANTHEM POS/HMO,1153.29,,,,,,,329.5100,1198.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,153.29 from Fee Schedule WII28_25 for Rev 300 Proc 81352 Mod TC * Qty 1 = $1,153.29 at 100% = $1,153.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,ANTHEM,ANTHEM PPO,1153.29,,,,,,,329.5100,1198.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,153.29 from Fee Schedule WII28_25 for Rev 300 Proc 81352 Mod TC * Qty 1 = $1,153.29 at 100% = $1,153.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1198.00,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,CENPATICO,ALL MEDICAID CENPATICO,1198.00,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1018.30,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,018.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,CIGNA,ALL COMMERCIAL CIGNA,838.60,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $838.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,COFINITY,COFINITY,1198.00,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81352 at $329.51 (Fee Schedule) = $329.51 (Total Line Payment) at 100% = $329.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81352 at $329.51 (Fee Schedule) = $329.51 (Total Line Payment) at 100% = $329.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1138.10,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,138.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,1006.32,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,006.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,850.58,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $850.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,874.54,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $874.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,582.23,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $582.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1018.30,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,018.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HUMANA,HUMANA CHOICE CARE HMO,560.17,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $560.17 from Fee Schedule 005543_170 for Rev 300 Proc 81352 * Qty 1 = $560.17 at 100% = $560.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HUMANA,HUMANA CHOICE CARE PPO,1018.30,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,018.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,HUMANA,HUMANA NATIIONAL POS HMO,560.17,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $560.17 from Fee Schedule 005543_170 for Rev 300 Proc 81352 * Qty 1 = $560.17 at 100% = $560.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,874.54,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $874.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1198.00,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81352 at $329.51 (Fee Schedule) = $329.51 (Total Line Payment) at 100% = $329.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81352 at $329.51 (Fee Schedule) = $329.51 (Total Line Payment) at 100% = $329.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,349.28,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81352 at $329.51 (Fee Schedule) = $329.51 (Total Line Payment) at 100% = $329.51... $329.51 at 106% = $349.28 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,599.00,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $599.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1006.32,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,006.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,741.40,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,898.50,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $898.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1102.16,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $1,102.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,428.36,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,428.36,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,PREVEA HEALTH NETWORK,PREVEA360,428.36,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,428.36,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,764.68,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $764.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,332.81,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,862.56,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $862.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,TRIOLOGY,TRILOGY MEDICAID,349.28,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81352 at $329.51 (Fee Schedule) = $329.51 (Total Line Payment) at 106% = $349.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,395.41,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $395.41 from Fee Schedule UHC_98227C for Rev 300 Proc 81352 * Qty 1 = $395.41 at 100% = $395.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,395.41,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $395.41 from Fee Schedule UHC_98227C for Rev 300 Proc 81352 * Qty 1 = $395.41 at 100% = $395.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,395.41,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $395.41 from Fee Schedule UHC_98227C for Rev 300 Proc 81352 * Qty 1 = $395.41 at 100% = $395.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,UNITY HEALTH PLAN,UNITY HOSPICE,329.51,,,,,,,329.5100,1198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,862.56,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $862.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,742.76,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $742.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,862.56,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $862.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,862.56,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $862.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP53 GENE TRGT SEQUENCE ANALYSIS,81352,CPT,300,RC,30002052,CDM,,,,both,,,1198.0000,790.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,718.80,,,,,,,329.5100,1198.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,198.00 in Billed Charges for Rev 300 Proc 81352 = $718.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,AETNA,AETNA HSHS,121.45,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $121.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,AETNA,ALL COMMERCIAL AETNA,188.00,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80325 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,ANTHEM,ANTHEM POS/HMO,127.84,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 80325 $188.00 in Billed Charges at 68% = $127.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,ANTHEM,ANTHEM PPO,127.84,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 80325 $188.00 in Billed Charges at 68% = $127.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,188.00,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,CENPATICO,ALL MEDICAID CENPATICO,188.00,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,159.80,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $159.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,CIGNA,ALL COMMERCIAL CIGNA,131.60,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $131.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,COFINITY,COFINITY,188.00,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80325 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80325 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,178.60,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $178.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,157.92,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $157.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,133.48,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $133.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,137.24,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $137.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,91.37,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $91.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,159.80,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $159.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,HUMANA,HUMANA CHOICE CARE HMO,22.10,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.10 from Fee Schedule 005543_170 for Rev 300 Proc 80325 * Qty 1 = $22.10 at 100% = $22.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,HUMANA,HUMANA CHOICE CARE PPO,159.80,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $159.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,HUMANA,HUMANA NATIIONAL POS HMO,22.10,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.10 from Fee Schedule 005543_170 for Rev 300 Proc 80325 * Qty 1 = $22.10 at 100% = $22.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,137.24,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $137.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,188.00,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80325 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80325 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80325 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,94.00,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $94.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,157.92,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $157.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,141.00,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,172.96,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $172.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,112.80,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,112.80,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,PREVEA HEALTH NETWORK,PREVEA360,112.80,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,112.80,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,120.00,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,135.36,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $135.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,188.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80325 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,135.36,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $135.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,116.56,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $116.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,135.36,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $135.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,135.36,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $135.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINES 3 OR 4,80325,CPT,300,RC,30002063,CDM,,,,both,,,188.0000,124.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,112.80,,,,,,,5.1700,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.00 in Billed Charges for Rev 300 Proc 80325 = $112.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,AETNA,AETNA HSHS,119.51,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $119.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,AETNA,AETNA MEDICARE,36.62,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,AETNA,ALL COMMERCIAL AETNA,185.00,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $185.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,ANTHEM,ANTEHM MEDICAID,37.84,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81242 at $37.84 (Fee Schedule) = $37.84 (Total Line Payment) at 100% = $37.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,36.62,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,ANTHEM,ANTHEM POS/HMO,128.17,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $128.17 from Fee Schedule WII28_25 for Rev 300 Proc 81242 Mod TC * Qty 1 = $128.17 at 100% = $128.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,ANTHEM,ANTHEM PPO,128.17,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $128.17 from Fee Schedule WII28_25 for Rev 300 Proc 81242 Mod TC * Qty 1 = $128.17 at 100% = $128.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,185.00,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $185.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,CENPATICO,ALL MEDICAID CENPATICO,185.00,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $185.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,157.25,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $157.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,CIGNA,ALL COMMERCIAL CIGNA,129.50,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $129.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,COFINITY,COFINITY,185.00,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $185.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,37.84,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81242 at $37.84 (Fee Schedule) = $37.84 (Total Line Payment) at 100% = $37.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,37.84,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81242 at $37.84 (Fee Schedule) = $37.84 (Total Line Payment) at 100% = $37.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,175.75,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $175.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,155.40,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $155.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,131.35,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $131.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,135.05,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $135.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,89.91,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $89.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,157.25,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $157.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HUMANA,HUMANA CHOICE CARE HMO,62.25,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $62.25 from Fee Schedule 005543_170 for Rev 300 Proc 81242 * Qty 1 = $62.25 at 100% = $62.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HUMANA,HUMANA CHOICE CARE PPO,157.25,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $157.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,36.62,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,HUMANA,HUMANA NATIIONAL POS HMO,62.25,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $62.25 from Fee Schedule 005543_170 for Rev 300 Proc 81242 * Qty 1 = $62.25 at 100% = $62.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,135.05,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $135.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,185.00,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $185.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,37.84,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81242 at $37.84 (Fee Schedule) = $37.84 (Total Line Payment) at 100% = $37.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,36.62,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,37.84,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81242 at $37.84 (Fee Schedule) = $37.84 (Total Line Payment) at 100% = $37.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,40.11,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81242 at $37.84 (Fee Schedule) = $37.84 (Total Line Payment) at 100% = $37.84... $37.84 at 106% = $40.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,36.62,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,92.50,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $92.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,155.40,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $155.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,82.40,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,138.75,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $138.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,170.20,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $170.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,47.61,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,47.61,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,PREVEA HEALTH NETWORK,PREVEA360,47.61,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,47.61,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,118.09,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $118.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,36.99,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,133.20,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $133.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,TRIOLOGY,TRILOGY MEDICAID,40.11,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81242 at $37.84 (Fee Schedule) = $37.84 (Total Line Payment) at 106% = $40.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,43.94,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.94 from Fee Schedule UHC_98227C for Rev 300 Proc 81242 * Qty 1 = $43.94 at 100% = $43.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,43.94,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.94 from Fee Schedule UHC_98227C for Rev 300 Proc 81242 * Qty 1 = $43.94 at 100% = $43.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,36.62,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,43.94,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.94 from Fee Schedule UHC_98227C for Rev 300 Proc 81242 * Qty 1 = $43.94 at 100% = $43.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,UNITY HEALTH PLAN,UNITY HOSPICE,36.62,,,,,,,36.6200,185.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,133.20,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $133.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,114.70,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $114.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,133.20,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $133.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,133.20,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $133.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FANCC GENE ANALYSIS COMMON VARIANT,81242,CPT,300,RC,30002076,CDM,,,,both,,,185.0000,122.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,111.00,,,,,,,36.6200,185.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $185.00 in Billed Charges for Rev 300 Proc 81242 = $111.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,AETNA,AETNA HSHS,755.82,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $755.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,AETNA,AETNA MEDICARE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,AETNA,ALL COMMERCIAL AETNA,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,ANTHEM,ANTEHM MEDICAID,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81413 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,ANTHEM,ANTHEM POS/HMO,1170.00,,,,,,,467.9200,1316.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,047.15 from Fee Schedule WII28_25 for Rev 300 Proc 81413 Mod TC * Qty 1 = $2,047.15 at 100% = $2,047.15 (Limited to $1,170.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,ANTHEM,ANTHEM PPO,1170.00,,,,,,,467.9200,1316.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,047.15 from Fee Schedule WII28_25 for Rev 300 Proc 81413 Mod TC * Qty 1 = $2,047.15 at 100% = $2,047.15 (Limited to $1,170.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,CENPATICO,ALL MEDICAID CENPATICO,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,994.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $994.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,CIGNA,ALL COMMERCIAL CIGNA,819.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,COFINITY,COFINITY,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81413 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81413 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1111.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $1,111.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,982.80,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $982.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,830.70,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $830.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,854.10,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $854.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,568.62,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $568.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,994.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $994.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HUMANA,HUMANA CHOICE CARE HMO,994.33,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $994.33 from Fee Schedule 005543_170 for Rev 300 Proc 81413 * Qty 1 = $994.33 at 100% = $994.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HUMANA,HUMANA CHOICE CARE PPO,994.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $994.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,HUMANA,HUMANA NATIIONAL POS HMO,994.33,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $994.33 from Fee Schedule 005543_170 for Rev 300 Proc 81413 * Qty 1 = $994.33 at 100% = $994.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,854.10,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $854.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81413 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81413 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,496.00,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81413 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92... $467.92 at 106% = $496.00 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,585.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,982.80,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $982.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,1316.03,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,877.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $877.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1076.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $1,076.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,760.37,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,760.37,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,PREVEA HEALTH NETWORK,PREVEA360,760.37,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,760.37,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,746.81,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $746.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,590.75,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,842.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $842.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,TRIOLOGY,TRILOGY MEDICAID,496.00,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81413 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 106% = $496.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,701.88,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 300 Proc 81413 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,701.88,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 300 Proc 81413 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,701.88,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 300 Proc 81413 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,UNITY HEALTH PLAN,UNITY HOSPICE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,842.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $842.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,725.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $725.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,842.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $842.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,842.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $842.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS,81413,CPT,300,RC,30002079,CDM,,,,both,,,1170.0000,772.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,702.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,170.00 in Billed Charges for Rev 300 Proc 81413 = $702.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,AETNA,AETNA HSHS,293.93,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $293.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,AETNA,ALL COMMERCIAL AETNA,455.00,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,ANTHEM,ANTEHM MEDICAID,3.37,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80050 at $125.60 (Base Rate) * 0.0268 (Relative Weight) = $3.37 (Total Line Payment) at 100% = $3.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,ANTHEM,ANTHEM POS/HMO,135.78,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $135.78 from Fee Schedule WII28_25 for Rev 301 Proc 80050 Mod TC * Qty 1 = $135.78 at 100% = $135.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,ANTHEM,ANTHEM PPO,135.78,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $135.78 from Fee Schedule WII28_25 for Rev 301 Proc 80050 Mod TC * Qty 1 = $135.78 at 100% = $135.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,455.00,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,CENPATICO,ALL MEDICAID CENPATICO,455.00,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,386.75,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $386.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,CIGNA,ALL COMMERCIAL CIGNA,318.50,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $318.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,COFINITY,COFINITY,455.00,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,3.37,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80050 at $125.60 (Base Rate) * 0.0268 (Relative Weight) = $3.37 (Total Line Payment) at 100% = $3.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,3.37,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80050 at $125.60 (Base Rate) * 0.0268 (Relative Weight) = $3.37 (Total Line Payment) at 100% = $3.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,432.25,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $432.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,382.20,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $382.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,323.05,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $323.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,332.15,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $332.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,221.13,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $221.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,386.75,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $386.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,HUMANA,HUMANA CHOICE CARE HMO,65.54,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $65.54 from Fee Schedule 005543_170 for Rev 301 Proc 80050 * Qty 1 = $65.54 at 100% = $65.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,HUMANA,HUMANA CHOICE CARE PPO,386.75,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $386.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,HUMANA,HUMANA NATIIONAL POS HMO,65.54,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $65.54 from Fee Schedule 005543_170 for Rev 301 Proc 80050 * Qty 1 = $65.54 at 100% = $65.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,332.15,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $332.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,455.00,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,3.37,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80050 at $125.60 (Base Rate) * 0.0268 (Relative Weight) = $3.37 (Total Line Payment) at 100% = $3.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,3.37,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80050 at $125.60 (Base Rate) * 0.0268 (Relative Weight) = $3.37 (Total Line Payment) at 100% = $3.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,3.57,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80050 at $125.60 (Base Rate) * 0.0268 (Relative Weight) = $3.37 (Total Line Payment) at 100% = $3.37... $3.37 at 106% = $3.57 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,227.50,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $227.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,382.20,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $382.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,341.25,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $341.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,418.60,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $418.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,273.00,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,273.00,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,PREVEA HEALTH NETWORK,PREVEA360,273.00,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,273.00,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,290.43,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $290.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,327.60,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $327.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,TRIOLOGY,TRILOGY MEDICAID,3.57,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80050 at $125.60 (Base Rate) * 0.0268 (Relative Weight) = $3.37 (Total Line Payment) at 106% = $3.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,48.79,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.79 from Fee Schedule UHC_98227C for Rev 301 Proc 80050 * Qty 1 = $48.79 at 100% = $48.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,48.79,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.79 from Fee Schedule UHC_98227C for Rev 301 Proc 80050 * Qty 1 = $48.79 at 100% = $48.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,48.79,,,,,,,3.3700,455.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.79 from Fee Schedule UHC_98227C for Rev 301 Proc 80050 * Qty 1 = $48.79 at 100% = $48.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,327.60,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $327.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,282.10,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $282.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,327.60,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $327.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,327.60,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $327.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL HEALTH PANEL,80050,CPT,301,RC,30100102,CDM,,,,both,,,455.0000,300.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,273.00,,,,,,,3.3700,455.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $455.00 in Billed Charges for Rev 301 Proc 80050 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,AETNA,AETNA HSHS,116.28,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $116.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,AETNA,AETNA MEDICARE,10.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,AETNA,ALL COMMERCIAL AETNA,180.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,ANTHEM,ANTEHM MEDICAID,10.91,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,10.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,ANTHEM,ANTHEM POS/HMO,36.96,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.96 from Fee Schedule WII28_25 for Rev 301 Proc 80053 Mod TC * Qty 1 = $36.96 at 100% = $36.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,ANTHEM,ANTHEM PPO,36.96,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.96 from Fee Schedule WII28_25 for Rev 301 Proc 80053 Mod TC * Qty 1 = $36.96 at 100% = $36.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,180.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,CENPATICO,ALL MEDICAID CENPATICO,180.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,153.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $153.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,CIGNA,ALL COMMERCIAL CIGNA,126.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,COFINITY,COFINITY,180.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.91,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.91,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,171.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $171.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,151.20,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,127.80,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $127.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,131.40,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $131.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,87.48,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $87.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,153.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $153.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HUMANA,HUMANA CHOICE CARE HMO,17.95,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.95 from Fee Schedule 005543_170 for Rev 301 Proc 80053 * Qty 1 = $17.95 at 100% = $17.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HUMANA,HUMANA CHOICE CARE PPO,153.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $153.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,10.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,HUMANA,HUMANA NATIIONAL POS HMO,17.95,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.95 from Fee Schedule 005543_170 for Rev 301 Proc 80053 * Qty 1 = $17.95 at 100% = $17.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,131.40,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $131.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,180.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.91,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.91,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,11.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91... $10.91 at 106% = $11.56 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,10.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,90.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,151.20,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,23.76,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,135.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,165.60,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $165.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.73,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.73,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,PREVEA HEALTH NETWORK,PREVEA360,13.73,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.73,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,114.89,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $114.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,10.67,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,129.60,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $129.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,TRIOLOGY,TRILOGY MEDICAID,11.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 106% = $11.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.67,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.67 from Fee Schedule UHC_98227C for Rev 301 Proc 80053 * Qty 1 = $12.67 at 100% = $12.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,12.67,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.67 from Fee Schedule UHC_98227C for Rev 301 Proc 80053 * Qty 1 = $12.67 at 100% = $12.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,10.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,12.67,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.67 from Fee Schedule UHC_98227C for Rev 301 Proc 80053 * Qty 1 = $12.67 at 100% = $12.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,UNITY HEALTH PLAN,UNITY HOSPICE,10.56,,,,,,,10.5600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,129.60,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $129.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,111.60,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $111.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,129.60,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $129.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,129.60,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $129.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL,80053,CPT,301,RC,30100104,CDM,,,,both,,,180.0000,118.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,108.00,,,,,,,10.5600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $180.00 in Billed Charges for Rev 301 Proc 80053 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,AETNA,AETNA HSHS,15.50,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,AETNA,AETNA MEDICARE,10.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,AETNA,ALL COMMERCIAL AETNA,24.00,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,ANTHEM,ANTEHM MEDICAID,10.91,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,10.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,ANTHEM,ANTHEM POS/HMO,24.00,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.96 from Fee Schedule WII28_25 for Rev 301 Proc 80053 Mod TC * Qty 1 = $36.96 at 100% = $36.96 (Limited to $24.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,ANTHEM,ANTHEM PPO,24.00,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.96 from Fee Schedule WII28_25 for Rev 301 Proc 80053 Mod TC * Qty 1 = $36.96 at 100% = $36.96 (Limited to $24.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.00,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,CENPATICO,ALL MEDICAID CENPATICO,24.00,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.40,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,CIGNA,ALL COMMERCIAL CIGNA,16.80,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $16.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,COFINITY,COFINITY,24.00,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.91,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.91,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,22.80,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,20.16,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $20.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.04,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $17.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.52,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,11.66,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $11.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.40,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HUMANA,HUMANA CHOICE CARE HMO,17.95,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.95 from Fee Schedule 005543_170 for Rev 301 Proc 80053 * Qty 1 = $17.95 at 100% = $17.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HUMANA,HUMANA CHOICE CARE PPO,20.40,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,10.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,HUMANA,HUMANA NATIIONAL POS HMO,17.95,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.95 from Fee Schedule 005543_170 for Rev 301 Proc 80053 * Qty 1 = $17.95 at 100% = $17.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.52,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.00,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.91,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.91,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,11.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 100% = $10.91... $10.91 at 106% = $11.56 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,10.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.00,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.16,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $20.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,23.76,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.00,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.08,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $22.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.73,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.73,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA360,13.73,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.73,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.32,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $15.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,10.67,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.28,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,TRIOLOGY,TRILOGY MEDICAID,11.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80053 at $10.91 (Fee Schedule) = $10.91 (Total Line Payment) at 106% = $11.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.67,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.67 from Fee Schedule UHC_98227C for Rev 301 Proc 80053 * Qty 1 = $12.67 at 100% = $12.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,12.67,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.67 from Fee Schedule UHC_98227C for Rev 301 Proc 80053 * Qty 1 = $12.67 at 100% = $12.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,10.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,12.67,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.67 from Fee Schedule UHC_98227C for Rev 301 Proc 80053 * Qty 1 = $12.67 at 100% = $12.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,UNITY HEALTH PLAN,UNITY HOSPICE,10.56,,,,,,,10.5600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.28,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.88,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $14.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.28,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.28,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMPREHENSIVE METABOL PANEL VET,80053,CPT,301,RC,30100105,CDM,,,,both,,,24.0000,15.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.40,,,,,,,10.5600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.00 in Billed Charges for Rev 301 Proc 80053 = $14.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,AETNA,AETNA HSHS,111.11,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $111.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,AETNA,AETNA MEDICARE,8.68,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,AETNA,ALL COMMERCIAL AETNA,172.00,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $172.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,ANTHEM,ANTEHM MEDICAID,8.97,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80069 at $8.97 (Fee Schedule) = $8.97 (Total Line Payment) at 100% = $8.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.68,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,ANTHEM,ANTHEM POS/HMO,30.38,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.38 from Fee Schedule WII28_25 for Rev 301 Proc 80069 Mod TC * Qty 1 = $30.38 at 100% = $30.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,ANTHEM,ANTHEM PPO,30.38,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.38 from Fee Schedule WII28_25 for Rev 301 Proc 80069 Mod TC * Qty 1 = $30.38 at 100% = $30.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,172.00,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $172.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,CENPATICO,ALL MEDICAID CENPATICO,172.00,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $172.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,146.20,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $146.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,CIGNA,ALL COMMERCIAL CIGNA,120.40,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $120.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,COFINITY,COFINITY,172.00,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $172.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.97,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80069 at $8.97 (Fee Schedule) = $8.97 (Total Line Payment) at 100% = $8.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.97,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80069 at $8.97 (Fee Schedule) = $8.97 (Total Line Payment) at 100% = $8.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,163.40,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $163.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,144.48,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $144.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,122.12,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $122.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,125.56,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $125.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,83.59,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $83.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,146.20,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $146.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HUMANA,HUMANA CHOICE CARE HMO,14.76,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.76 from Fee Schedule 005543_170 for Rev 301 Proc 80069 * Qty 1 = $14.76 at 100% = $14.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HUMANA,HUMANA CHOICE CARE PPO,146.20,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $146.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,8.68,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,HUMANA,HUMANA NATIIONAL POS HMO,14.76,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.76 from Fee Schedule 005543_170 for Rev 301 Proc 80069 * Qty 1 = $14.76 at 100% = $14.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,125.56,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $125.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,172.00,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $172.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.97,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80069 at $8.97 (Fee Schedule) = $8.97 (Total Line Payment) at 100% = $8.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.68,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.97,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80069 at $8.97 (Fee Schedule) = $8.97 (Total Line Payment) at 100% = $8.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,9.51,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80069 at $8.97 (Fee Schedule) = $8.97 (Total Line Payment) at 100% = $8.97... $8.97 at 106% = $9.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,8.68,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,86.00,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $86.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,144.48,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $144.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,19.53,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,129.00,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $129.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,158.24,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $158.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.28,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.28,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,PREVEA HEALTH NETWORK,PREVEA360,11.28,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.28,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,109.79,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $109.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.77,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,123.84,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $123.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,TRIOLOGY,TRILOGY MEDICAID,9.51,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80069 at $8.97 (Fee Schedule) = $8.97 (Total Line Payment) at 106% = $9.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.42,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.42 from Fee Schedule UHC_98227C for Rev 301 Proc 80069 * Qty 1 = $10.42 at 100% = $10.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,10.42,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.42 from Fee Schedule UHC_98227C for Rev 301 Proc 80069 * Qty 1 = $10.42 at 100% = $10.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.68,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,10.42,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.42 from Fee Schedule UHC_98227C for Rev 301 Proc 80069 * Qty 1 = $10.42 at 100% = $10.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,UNITY HEALTH PLAN,UNITY HOSPICE,8.68,,,,,,,8.6800,172.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,123.84,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $123.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,106.64,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $106.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,123.84,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $123.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,123.84,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $123.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RENAL PANEL,80069,CPT,301,RC,30100108,CDM,,,,both,,,172.0000,113.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,103.20,,,,,,,8.6800,172.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $172.00 in Billed Charges for Rev 301 Proc 80069 = $103.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,AETNA,AETNA HSHS,93.67,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $93.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,AETNA,AETNA MEDICARE,15.08,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,AETNA,ALL COMMERCIAL AETNA,145.00,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTEHM MEDICAID,15.58,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80150 at $15.58 (Fee Schedule) = $15.58 (Total Line Payment) at 100% = $15.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,15.08,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM POS/HMO,52.78,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $52.78 from Fee Schedule WII28_25 for Rev 301 Proc 80150 Mod TC * Qty 1 = $52.78 at 100% = $52.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM PPO,52.78,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $52.78 from Fee Schedule WII28_25 for Rev 301 Proc 80150 Mod TC * Qty 1 = $52.78 at 100% = $52.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,145.00,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,CENPATICO,ALL MEDICAID CENPATICO,145.00,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,123.25,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,CIGNA,ALL COMMERCIAL CIGNA,101.50,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $101.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,COFINITY,COFINITY,145.00,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.58,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80150 at $15.58 (Fee Schedule) = $15.58 (Total Line Payment) at 100% = $15.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.58,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80150 at $15.58 (Fee Schedule) = $15.58 (Total Line Payment) at 100% = $15.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,137.75,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $137.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,121.80,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,102.95,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $102.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,105.85,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $105.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,70.47,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $70.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,123.25,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA CHOICE CARE HMO,25.64,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.64 from Fee Schedule 005543_170 for Rev 301 Proc 80150 * Qty 1 = $25.64 at 100% = $25.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA CHOICE CARE PPO,123.25,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,15.08,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA NATIIONAL POS HMO,25.64,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.64 from Fee Schedule 005543_170 for Rev 301 Proc 80150 * Qty 1 = $25.64 at 100% = $25.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,105.85,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $105.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,145.00,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.58,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80150 at $15.58 (Fee Schedule) = $15.58 (Total Line Payment) at 100% = $15.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.08,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.58,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80150 at $15.58 (Fee Schedule) = $15.58 (Total Line Payment) at 100% = $15.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,16.51,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80150 at $15.58 (Fee Schedule) = $15.58 (Total Line Payment) at 100% = $15.58... $15.58 at 106% = $16.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,15.08,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,72.50,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $72.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,121.80,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,33.93,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,108.75,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $108.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,133.40,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $133.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,19.60,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,19.60,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA360,19.60,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,19.60,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,92.55,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $92.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,15.23,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,104.40,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,TRIOLOGY,TRILOGY MEDICAID,16.51,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80150 at $15.58 (Fee Schedule) = $15.58 (Total Line Payment) at 106% = $16.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,18.10,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.10 from Fee Schedule UHC_98227C for Rev 301 Proc 80150 * Qty 1 = $18.10 at 100% = $18.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,18.10,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.10 from Fee Schedule UHC_98227C for Rev 301 Proc 80150 * Qty 1 = $18.10 at 100% = $18.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,15.08,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,18.10,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.10 from Fee Schedule UHC_98227C for Rev 301 Proc 80150 * Qty 1 = $18.10 at 100% = $18.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,UNITY HEALTH PLAN,UNITY HOSPICE,15.08,,,,,,,15.0800,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,104.40,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,89.90,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $89.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,104.40,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,104.40,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMIKACIN,80150,CPT,301,RC,30100111,CDM,,,,both,,,145.0000,95.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.00,,,,,,,15.0800,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.00 in Billed Charges for Rev 301 Proc 80150 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA HSHS,61.37,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,AETNA,ALL COMMERCIAL AETNA,95.00,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM POS/HMO,79.87,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM PPO,79.87,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,95.00,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,CENPATICO,ALL MEDICAID CENPATICO,95.00,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,80.75,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,CIGNA,ALL COMMERCIAL CIGNA,66.50,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $66.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,COFINITY,COFINITY,95.00,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,90.25,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $90.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,79.80,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,67.45,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $67.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,69.35,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,46.17,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $46.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,80.75,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE PPO,80.75,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,69.35,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,95.00,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,47.50,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $47.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,79.80,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,71.25,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,87.40,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $87.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,57.00,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,57.00,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360,57.00,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,57.00,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,60.64,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $60.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,68.40,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,68.40,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.90,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $58.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,68.40,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,68.40,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMITRIPTYLINE,80335,CPT,301,RC,30100112,CDM,,,,both,,,95.0000,62.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,57.00,,,,,,,5.1700,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $95.00 in Billed Charges for Rev 301 Proc 80335 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,AETNA,AETNA HSHS,72.35,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $72.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,AETNA,ALL COMMERCIAL AETNA,112.00,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,ANTHEM,ANTHEM POS/HMO,79.87,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80346 Mod TC * Qty 1 = $79.87 at 100% = $79.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,ANTHEM,ANTHEM PPO,79.87,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80346 Mod TC * Qty 1 = $79.87 at 100% = $79.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,112.00,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,CENPATICO,ALL MEDICAID CENPATICO,112.00,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,95.20,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,CIGNA,ALL COMMERCIAL CIGNA,78.40,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $78.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,COFINITY,COFINITY,112.00,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,106.40,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $106.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,94.08,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $94.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,79.52,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $79.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,81.76,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $81.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,54.43,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $54.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,95.20,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80346 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,HUMANA,HUMANA CHOICE CARE PPO,95.20,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80346 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,81.76,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $81.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,112.00,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,56.00,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $56.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,94.08,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $94.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,84.00,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,103.04,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $103.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,67.20,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,67.20,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,PREVEA HEALTH NETWORK,PREVEA360,67.20,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,67.20,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,71.49,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $71.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,80.64,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,80.64,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,69.44,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $69.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,80.64,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,80.64,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LORAZEPAM,80346,CPT,301,RC,30100113,CDM,,,,both,,,112.0000,73.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,67.20,,,,,,,5.1700,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.00 in Billed Charges for Rev 301 Proc 80346 = $67.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,AETNA,AETNA HSHS,26.49,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $26.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,AETNA,ALL COMMERCIAL AETNA,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,ANTHEM,ANTHEM POS/HMO,41.00,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80346 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $41.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,ANTHEM,ANTHEM PPO,41.00,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80346 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $41.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,CENPATICO,ALL MEDICAID CENPATICO,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,34.85,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,CIGNA,ALL COMMERCIAL CIGNA,28.70,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $28.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,COFINITY,COFINITY,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,38.95,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $38.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,34.44,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $34.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.11,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $29.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,29.93,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,19.93,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $19.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,34.85,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80346 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,HUMANA,HUMANA CHOICE CARE PPO,34.85,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80346 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,29.93,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,20.50,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $20.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,34.44,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $34.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,30.75,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $30.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,37.72,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $37.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,24.60,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,24.60,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,PREVEA HEALTH NETWORK,PREVEA360,24.60,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,24.60,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.17,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $26.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,29.52,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80346 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,29.52,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,25.42,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $25.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,29.52,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,29.52,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZODIAZEPINES1-12,80346,CPT,301,RC,30100114,CDM,,,,both,,,41.0000,27.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,24.60,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.00 in Billed Charges for Rev 301 Proc 80346 = $24.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA MEDICARE,18.05,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTEHM MEDICAID,18.65,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80158 at $18.65 (Fee Schedule) = $18.65 (Total Line Payment) at 100% = $18.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,18.05,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,63.18,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $63.18 from Fee Schedule WII28_25 for Rev 301 Proc 80158 Mod TC * Qty 1 = $63.18 at 100% = $63.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM PPO,63.18,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $63.18 from Fee Schedule WII28_25 for Rev 301 Proc 80158 Mod TC * Qty 1 = $63.18 at 100% = $63.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,18.65,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80158 at $18.65 (Fee Schedule) = $18.65 (Total Line Payment) at 100% = $18.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,18.65,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80158 at $18.65 (Fee Schedule) = $18.65 (Total Line Payment) at 100% = $18.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,30.69,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.69 from Fee Schedule 005543_170 for Rev 301 Proc 80158 * Qty 1 = $30.69 at 100% = $30.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,18.05,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,30.69,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.69 from Fee Schedule 005543_170 for Rev 301 Proc 80158 * Qty 1 = $30.69 at 100% = $30.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,18.65,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80158 at $18.65 (Fee Schedule) = $18.65 (Total Line Payment) at 100% = $18.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,18.05,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,18.65,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80158 at $18.65 (Fee Schedule) = $18.65 (Total Line Payment) at 100% = $18.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,19.77,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80158 at $18.65 (Fee Schedule) = $18.65 (Total Line Payment) at 100% = $18.65... $18.65 at 106% = $19.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,18.05,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,40.61,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,23.47,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,23.47,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,23.47,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,23.47,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,18.23,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,TRILOGY MEDICAID,19.77,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80158 at $18.65 (Fee Schedule) = $18.65 (Total Line Payment) at 106% = $19.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,21.66,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.66 from Fee Schedule UHC_98227C for Rev 301 Proc 80158 * Qty 1 = $21.66 at 100% = $21.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,21.66,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.66 from Fee Schedule UHC_98227C for Rev 301 Proc 80158 * Qty 1 = $21.66 at 100% = $21.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,18.05,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,21.66,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.66 from Fee Schedule UHC_98227C for Rev 301 Proc 80158 * Qty 1 = $21.66 at 100% = $21.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,UNITY HEALTH PLAN,UNITY HOSPICE,18.05,,,,,,,18.0500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYCLOSPORINE,80158,CPT,301,RC,30100118,CDM,,,,both,,,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,18.0500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 301 Proc 80158 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,AETNA,AETNA HSHS,29.07,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $29.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,AETNA,ALL COMMERCIAL AETNA,45.00,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,ANTHEM,ANTHEM POS/HMO,45.00,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $45.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,ANTHEM,ANTHEM PPO,45.00,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $45.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,45.00,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,CENPATICO,ALL MEDICAID CENPATICO,45.00,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,38.25,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $38.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,CIGNA,ALL COMMERCIAL CIGNA,31.50,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $31.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,COFINITY,COFINITY,45.00,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,42.75,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $42.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,37.80,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $37.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,31.95,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $31.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,32.85,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $32.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,21.87,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $21.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,38.25,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $38.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,HUMANA,HUMANA CHOICE CARE PPO,38.25,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $38.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,32.85,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $32.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,45.00,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,22.50,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $22.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,37.80,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $37.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,33.75,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $33.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,41.40,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $41.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,27.00,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,27.00,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,PREVEA HEALTH NETWORK,PREVEA360,27.00,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,27.00,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,28.72,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $28.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,32.40,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $32.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,45.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,32.40,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $32.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,27.90,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,32.40,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $32.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,32.40,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $32.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DESIPRAMINE,80335,CPT,301,RC,30100119,CDM,,,,both,,,45.0000,29.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,27.00,,,,,,,5.1700,45.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $45.00 in Billed Charges for Rev 301 Proc 80335 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,AETNA,AETNA HSHS,111.76,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $111.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,AETNA,AETNA MEDICARE,13.28,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,AETNA,ALL COMMERCIAL AETNA,173.00,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,ANTHEM,ANTEHM MEDICAID,13.72,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80162 at $13.72 (Fee Schedule) = $13.72 (Total Line Payment) at 100% = $13.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.28,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,ANTHEM,ANTHEM POS/HMO,46.48,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.48 from Fee Schedule WII28_25 for Rev 301 Proc 80162 Mod TC * Qty 1 = $46.48 at 100% = $46.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,ANTHEM,ANTHEM PPO,46.48,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.48 from Fee Schedule WII28_25 for Rev 301 Proc 80162 Mod TC * Qty 1 = $46.48 at 100% = $46.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,173.00,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,CENPATICO,ALL MEDICAID CENPATICO,173.00,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,147.05,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $147.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,CIGNA,ALL COMMERCIAL CIGNA,121.10,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $121.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,COFINITY,COFINITY,173.00,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.72,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80162 at $13.72 (Fee Schedule) = $13.72 (Total Line Payment) at 100% = $13.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.72,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80162 at $13.72 (Fee Schedule) = $13.72 (Total Line Payment) at 100% = $13.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,164.35,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $164.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,145.32,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $145.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,122.83,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $122.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,126.29,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $126.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,84.08,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $84.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,147.05,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $147.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HUMANA,HUMANA CHOICE CARE HMO,22.58,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.58 from Fee Schedule 005543_170 for Rev 301 Proc 80162 * Qty 1 = $22.58 at 100% = $22.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HUMANA,HUMANA CHOICE CARE PPO,147.05,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $147.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,13.28,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,HUMANA,HUMANA NATIIONAL POS HMO,22.58,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.58 from Fee Schedule 005543_170 for Rev 301 Proc 80162 * Qty 1 = $22.58 at 100% = $22.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,126.29,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $126.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,173.00,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.72,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80162 at $13.72 (Fee Schedule) = $13.72 (Total Line Payment) at 100% = $13.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.28,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.72,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80162 at $13.72 (Fee Schedule) = $13.72 (Total Line Payment) at 100% = $13.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,14.54,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80162 at $13.72 (Fee Schedule) = $13.72 (Total Line Payment) at 100% = $13.72... $13.72 at 106% = $14.54 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,13.28,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,86.50,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $86.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,145.32,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $145.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,29.88,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,129.75,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $129.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,159.16,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $159.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.26,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.26,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,PREVEA HEALTH NETWORK,PREVEA360,17.26,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.26,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,110.43,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $110.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.41,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,124.56,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $124.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,TRIOLOGY,TRILOGY MEDICAID,14.54,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80162 at $13.72 (Fee Schedule) = $13.72 (Total Line Payment) at 106% = $14.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.94,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.94 from Fee Schedule UHC_98227C for Rev 301 Proc 80162 * Qty 1 = $15.94 at 100% = $15.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,15.94,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.94 from Fee Schedule UHC_98227C for Rev 301 Proc 80162 * Qty 1 = $15.94 at 100% = $15.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.28,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,15.94,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.94 from Fee Schedule UHC_98227C for Rev 301 Proc 80162 * Qty 1 = $15.94 at 100% = $15.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,UNITY HEALTH PLAN,UNITY HOSPICE,13.28,,,,,,,13.2800,173.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,124.56,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $124.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,107.26,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $107.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,124.56,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $124.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,124.56,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $124.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIGOXIN LEVELS,80162,CPT,301,RC,30100120,CDM,,,,both,,,173.0000,114.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,103.80,,,,,,,13.2800,173.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $173.00 in Billed Charges for Rev 301 Proc 80162 = $103.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,AETNA,AETNA HSHS,93.67,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $93.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,AETNA,AETNA MEDICARE,16.34,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,AETNA,ALL COMMERCIAL AETNA,145.00,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTEHM MEDICAID,16.88,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80168 at $16.88 (Fee Schedule) = $16.88 (Total Line Payment) at 100% = $16.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.34,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM POS/HMO,57.19,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.19 from Fee Schedule WII28_25 for Rev 301 Proc 80168 Mod TC * Qty 1 = $57.19 at 100% = $57.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM PPO,57.19,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.19 from Fee Schedule WII28_25 for Rev 301 Proc 80168 Mod TC * Qty 1 = $57.19 at 100% = $57.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,145.00,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,CENPATICO,ALL MEDICAID CENPATICO,145.00,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,123.25,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,CIGNA,ALL COMMERCIAL CIGNA,101.50,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $101.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,COFINITY,COFINITY,145.00,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.88,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80168 at $16.88 (Fee Schedule) = $16.88 (Total Line Payment) at 100% = $16.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.88,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80168 at $16.88 (Fee Schedule) = $16.88 (Total Line Payment) at 100% = $16.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,137.75,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $137.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,121.80,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,102.95,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $102.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,105.85,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $105.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,70.47,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $70.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,123.25,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA CHOICE CARE HMO,27.78,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.78 from Fee Schedule 005543_170 for Rev 301 Proc 80168 * Qty 1 = $27.78 at 100% = $27.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA CHOICE CARE PPO,123.25,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,16.34,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA NATIIONAL POS HMO,27.78,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.78 from Fee Schedule 005543_170 for Rev 301 Proc 80168 * Qty 1 = $27.78 at 100% = $27.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,105.85,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $105.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,145.00,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.88,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80168 at $16.88 (Fee Schedule) = $16.88 (Total Line Payment) at 100% = $16.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.34,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.88,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80168 at $16.88 (Fee Schedule) = $16.88 (Total Line Payment) at 100% = $16.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,17.89,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80168 at $16.88 (Fee Schedule) = $16.88 (Total Line Payment) at 100% = $16.88... $16.88 at 106% = $17.89 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,16.34,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,72.50,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $72.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,121.80,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,36.77,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,108.75,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $108.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,133.40,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $133.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.24,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.24,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA360,21.24,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.24,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,92.55,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $92.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.50,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,104.40,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,TRIOLOGY,TRILOGY MEDICAID,17.89,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80168 at $16.88 (Fee Schedule) = $16.88 (Total Line Payment) at 106% = $17.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.61,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.61 from Fee Schedule UHC_98227C for Rev 301 Proc 80168 * Qty 1 = $19.61 at 100% = $19.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,19.61,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.61 from Fee Schedule UHC_98227C for Rev 301 Proc 80168 * Qty 1 = $19.61 at 100% = $19.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.34,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,19.61,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.61 from Fee Schedule UHC_98227C for Rev 301 Proc 80168 * Qty 1 = $19.61 at 100% = $19.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,UNITY HEALTH PLAN,UNITY HOSPICE,16.34,,,,,,,16.3400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,104.40,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,89.90,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $89.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,104.40,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,104.40,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASSAY OF ETHOSUXIMIDE  (ZARONTIN),80168,CPT,301,RC,30100123,CDM,,,,both,,,145.0000,95.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.00,,,,,,,16.3400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.00 in Billed Charges for Rev 301 Proc 80168 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,AETNA,AETNA HSHS,152.46,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $152.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,AETNA,AETNA MEDICARE,14.69,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,AETNA,ALL COMMERCIAL AETNA,236.00,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,ANTHEM,ANTEHM MEDICAID,15.18,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80176 at $15.18 (Fee Schedule) = $15.18 (Total Line Payment) at 100% = $15.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.69,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,ANTHEM,ANTHEM POS/HMO,51.42,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.42 from Fee Schedule WII28_25 for Rev 301 Proc 80176 Mod TC * Qty 1 = $51.42 at 100% = $51.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,ANTHEM,ANTHEM PPO,51.42,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.42 from Fee Schedule WII28_25 for Rev 301 Proc 80176 Mod TC * Qty 1 = $51.42 at 100% = $51.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,236.00,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,CENPATICO,ALL MEDICAID CENPATICO,236.00,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,200.60,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $200.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,CIGNA,ALL COMMERCIAL CIGNA,165.20,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $165.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,COFINITY,COFINITY,236.00,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.18,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80176 at $15.18 (Fee Schedule) = $15.18 (Total Line Payment) at 100% = $15.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.18,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80176 at $15.18 (Fee Schedule) = $15.18 (Total Line Payment) at 100% = $15.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,224.20,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $224.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,198.24,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $198.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,167.56,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $167.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,172.28,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $172.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,114.70,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $114.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,200.60,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $200.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HUMANA,HUMANA CHOICE CARE HMO,24.97,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.97 from Fee Schedule 005543_170 for Rev 301 Proc 80176 * Qty 1 = $24.97 at 100% = $24.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HUMANA,HUMANA CHOICE CARE PPO,200.60,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $200.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,14.69,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,HUMANA,HUMANA NATIIONAL POS HMO,24.97,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.97 from Fee Schedule 005543_170 for Rev 301 Proc 80176 * Qty 1 = $24.97 at 100% = $24.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,172.28,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $172.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,236.00,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.18,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80176 at $15.18 (Fee Schedule) = $15.18 (Total Line Payment) at 100% = $15.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.69,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.18,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80176 at $15.18 (Fee Schedule) = $15.18 (Total Line Payment) at 100% = $15.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,16.09,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80176 at $15.18 (Fee Schedule) = $15.18 (Total Line Payment) at 100% = $15.18... $15.18 at 106% = $16.09 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,14.69,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,118.00,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,198.24,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $198.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,33.05,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,177.00,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,217.12,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $217.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,19.10,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,19.10,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,PREVEA HEALTH NETWORK,PREVEA360,19.10,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,19.10,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,150.64,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $150.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.84,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,169.92,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $169.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,TRIOLOGY,TRILOGY MEDICAID,16.09,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80176 at $15.18 (Fee Schedule) = $15.18 (Total Line Payment) at 106% = $16.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.63,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.63 from Fee Schedule UHC_98227C for Rev 301 Proc 80176 * Qty 1 = $17.63 at 100% = $17.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,17.63,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.63 from Fee Schedule UHC_98227C for Rev 301 Proc 80176 * Qty 1 = $17.63 at 100% = $17.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.69,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,17.63,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.63 from Fee Schedule UHC_98227C for Rev 301 Proc 80176 * Qty 1 = $17.63 at 100% = $17.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,UNITY HEALTH PLAN,UNITY HOSPICE,14.69,,,,,,,14.6900,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,169.92,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $169.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,146.32,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $146.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,169.92,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $169.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,169.92,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $169.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIDOCAINE,80176,CPT,301,RC,30100126,CDM,,,,both,,,236.0000,155.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,141.60,,,,,,,14.6900,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $236.00 in Billed Charges for Rev 301 Proc 80176 = $141.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA HSHS,58.14,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $58.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,AETNA,ALL COMMERCIAL AETNA,90.00,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM POS/HMO,79.87,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM PPO,79.87,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,90.00,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,CENPATICO,ALL MEDICAID CENPATICO,90.00,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,76.50,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,CIGNA,ALL COMMERCIAL CIGNA,63.00,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,COFINITY,COFINITY,90.00,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,85.50,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,75.60,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.90,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $63.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,65.70,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,43.74,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $43.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,76.50,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE PPO,76.50,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,65.70,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,90.00,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.00,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,75.60,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,67.50,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,82.80,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,54.00,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,54.00,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360,54.00,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,54.00,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,57.45,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $57.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,64.80,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,64.80,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.80,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,64.80,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,64.80,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NORTRIPTYLINE,80335,CPT,301,RC,30100128,CDM,,,,both,,,90.0000,59.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,54.00,,,,,,,5.1700,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $90.00 in Billed Charges for Rev 301 Proc 80335 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA HSHS,76.23,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $76.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA MEDICARE,15.30,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,AETNA,ALL COMMERCIAL AETNA,118.00,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTEHM MEDICAID,15.81,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80184 at $15.81 (Fee Schedule) = $15.81 (Total Line Payment) at 100% = $15.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,15.30,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM POS/HMO,53.55,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $53.55 from Fee Schedule WII28_25 for Rev 301 Proc 80184 Mod TC * Qty 1 = $53.55 at 100% = $53.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM PPO,53.55,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $53.55 from Fee Schedule WII28_25 for Rev 301 Proc 80184 Mod TC * Qty 1 = $53.55 at 100% = $53.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.00,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,CENPATICO,ALL MEDICAID CENPATICO,118.00,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.30,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,CIGNA,ALL COMMERCIAL CIGNA,82.60,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,COFINITY,COFINITY,118.00,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.81,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80184 at $15.81 (Fee Schedule) = $15.81 (Total Line Payment) at 100% = $15.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.81,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80184 at $15.81 (Fee Schedule) = $15.81 (Total Line Payment) at 100% = $15.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.10,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $112.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.12,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.78,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $83.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.14,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.35,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $57.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.30,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE HMO,26.01,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.01 from Fee Schedule 005543_170 for Rev 301 Proc 80184 * Qty 1 = $26.01 at 100% = $26.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE PPO,100.30,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,15.30,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA NATIIONAL POS HMO,26.01,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.01 from Fee Schedule 005543_170 for Rev 301 Proc 80184 * Qty 1 = $26.01 at 100% = $26.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.14,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.00,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.81,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80184 at $15.81 (Fee Schedule) = $15.81 (Total Line Payment) at 100% = $15.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.30,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.81,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80184 at $15.81 (Fee Schedule) = $15.81 (Total Line Payment) at 100% = $15.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,16.76,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80184 at $15.81 (Fee Schedule) = $15.81 (Total Line Payment) at 100% = $15.81... $15.81 at 106% = $16.76 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,15.30,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.00,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $59.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.12,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,34.43,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.50,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,108.56,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $108.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,19.89,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,19.89,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360,19.89,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,19.89,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.32,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $75.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,15.45,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.96,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,TRILOGY MEDICAID,16.76,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80184 at $15.81 (Fee Schedule) = $15.81 (Total Line Payment) at 106% = $16.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,18.36,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.36 from Fee Schedule UHC_98227C for Rev 301 Proc 80184 * Qty 1 = $18.36 at 100% = $18.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,18.36,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.36 from Fee Schedule UHC_98227C for Rev 301 Proc 80184 * Qty 1 = $18.36 at 100% = $18.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,15.30,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,18.36,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.36 from Fee Schedule UHC_98227C for Rev 301 Proc 80184 * Qty 1 = $18.36 at 100% = $18.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,UNITY HEALTH PLAN,UNITY HOSPICE,15.30,,,,,,,15.3000,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.96,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.16,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $73.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.96,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.96,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOBARBITAL,80184,CPT,301,RC,30100129,CDM,,,,both,,,118.0000,77.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.80,,,,,,,15.3000,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.00 in Billed Charges for Rev 301 Proc 80184 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA HSHS,76.23,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $76.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA MEDICARE,13.25,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,AETNA,ALL COMMERCIAL AETNA,118.00,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTEHM MEDICAID,13.69,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80185 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.25,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM POS/HMO,46.38,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80185 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM PPO,46.38,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80185 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.00,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,CENPATICO,ALL MEDICAID CENPATICO,118.00,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.30,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,CIGNA,ALL COMMERCIAL CIGNA,82.60,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,COFINITY,COFINITY,118.00,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.69,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80185 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.69,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80185 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.10,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $112.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.12,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.78,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $83.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.14,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.35,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $57.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.30,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE HMO,22.53,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80185 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE PPO,100.30,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,13.25,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA NATIIONAL POS HMO,22.53,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80185 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.14,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.00,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.69,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80185 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.25,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.69,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80185 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,14.51,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80185 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69... $13.69 at 106% = $14.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,13.25,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.00,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $59.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.12,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,29.81,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.50,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,108.56,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $108.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.23,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.23,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360,17.23,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.23,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.32,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $75.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.38,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.96,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,TRILOGY MEDICAID,14.51,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80185 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 106% = $14.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.90,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80185 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,15.90,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80185 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.25,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,15.90,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80185 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,UNITY HEALTH PLAN,UNITY HOSPICE,13.25,,,,,,,13.2500,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.96,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.16,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $73.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.96,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.96,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN TOTAL,80185,CPT,301,RC,30100130,CDM,,,,both,,,118.0000,77.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.80,,,,,,,13.2500,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.00 in Billed Charges for Rev 301 Proc 80185 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA HSHS,76.23,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $76.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA MEDICARE,16.59,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,AETNA,ALL COMMERCIAL AETNA,118.00,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTEHM MEDICAID,17.14,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80188 at $17.14 (Fee Schedule) = $17.14 (Total Line Payment) at 100% = $17.14. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.59,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM POS/HMO,58.07,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.07 from Fee Schedule WII28_25 for Rev 301 Proc 80188 Mod TC * Qty 1 = $58.07 at 100% = $58.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM PPO,58.07,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.07 from Fee Schedule WII28_25 for Rev 301 Proc 80188 Mod TC * Qty 1 = $58.07 at 100% = $58.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.00,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,CENPATICO,ALL MEDICAID CENPATICO,118.00,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.30,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,CIGNA,ALL COMMERCIAL CIGNA,82.60,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,COFINITY,COFINITY,118.00,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.14,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80188 at $17.14 (Fee Schedule) = $17.14 (Total Line Payment) at 100% = $17.14. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.14,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80188 at $17.14 (Fee Schedule) = $17.14 (Total Line Payment) at 100% = $17.14. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.10,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $112.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.12,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.78,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $83.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.14,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.35,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $57.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.30,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE HMO,28.20,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.20 from Fee Schedule 005543_170 for Rev 301 Proc 80188 * Qty 1 = $28.20 at 100% = $28.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE PPO,100.30,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,16.59,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA NATIIONAL POS HMO,28.20,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.20 from Fee Schedule 005543_170 for Rev 301 Proc 80188 * Qty 1 = $28.20 at 100% = $28.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.14,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.00,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.14,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80188 at $17.14 (Fee Schedule) = $17.14 (Total Line Payment) at 100% = $17.14. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.59,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.14,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80188 at $17.14 (Fee Schedule) = $17.14 (Total Line Payment) at 100% = $17.14. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,18.17,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80188 at $17.14 (Fee Schedule) = $17.14 (Total Line Payment) at 100% = $17.14... $17.14 at 106% = $18.17 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,16.59,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.00,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $59.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.12,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,37.33,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.50,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,108.56,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $108.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.57,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.57,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360,21.57,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.57,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.32,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $75.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.76,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.96,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,TRILOGY MEDICAID,18.17,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80188 at $17.14 (Fee Schedule) = $17.14 (Total Line Payment) at 106% = $18.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.91,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.91 from Fee Schedule UHC_98227C for Rev 301 Proc 80188 * Qty 1 = $19.91 at 100% = $19.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,19.91,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.91 from Fee Schedule UHC_98227C for Rev 301 Proc 80188 * Qty 1 = $19.91 at 100% = $19.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.59,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,19.91,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.91 from Fee Schedule UHC_98227C for Rev 301 Proc 80188 * Qty 1 = $19.91 at 100% = $19.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,UNITY HEALTH PLAN,UNITY HOSPICE,16.59,,,,,,,16.5900,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.96,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.16,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $73.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.96,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.96,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRIMIDONE,80188,CPT,301,RC,30100132,CDM,,,,both,,,118.0000,77.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.80,,,,,,,16.5900,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.00 in Billed Charges for Rev 301 Proc 80188 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,AETNA,AETNA HSHS,90.44,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $90.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,AETNA,AETNA MEDICARE,16.75,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,AETNA,ALL COMMERCIAL AETNA,140.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $140.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,ANTHEM,ANTEHM MEDICAID,17.31,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80192 at $17.31 (Fee Schedule) = $17.31 (Total Line Payment) at 100% = $17.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.75,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,ANTHEM,ANTHEM POS/HMO,58.63,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.63 from Fee Schedule WII28_25 for Rev 301 Proc 80192 Mod TC * Qty 1 = $58.63 at 100% = $58.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,ANTHEM,ANTHEM PPO,58.63,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.63 from Fee Schedule WII28_25 for Rev 301 Proc 80192 Mod TC * Qty 1 = $58.63 at 100% = $58.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,140.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $140.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,CENPATICO,ALL MEDICAID CENPATICO,140.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $140.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,119.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $119.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,CIGNA,ALL COMMERCIAL CIGNA,98.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,COFINITY,COFINITY,140.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $140.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.31,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80192 at $17.31 (Fee Schedule) = $17.31 (Total Line Payment) at 100% = $17.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.31,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80192 at $17.31 (Fee Schedule) = $17.31 (Total Line Payment) at 100% = $17.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,133.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $133.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,117.60,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,99.40,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $99.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,102.20,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,68.04,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $68.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,119.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $119.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HUMANA,HUMANA CHOICE CARE HMO,28.48,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.48 from Fee Schedule 005543_170 for Rev 301 Proc 80192 * Qty 1 = $28.48 at 100% = $28.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HUMANA,HUMANA CHOICE CARE PPO,119.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $119.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,16.75,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,HUMANA,HUMANA NATIIONAL POS HMO,28.48,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.48 from Fee Schedule 005543_170 for Rev 301 Proc 80192 * Qty 1 = $28.48 at 100% = $28.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,102.20,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,140.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $140.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.31,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80192 at $17.31 (Fee Schedule) = $17.31 (Total Line Payment) at 100% = $17.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.75,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.31,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80192 at $17.31 (Fee Schedule) = $17.31 (Total Line Payment) at 100% = $17.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,18.35,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80192 at $17.31 (Fee Schedule) = $17.31 (Total Line Payment) at 100% = $17.31... $17.31 at 106% = $18.35 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,16.75,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,70.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,117.60,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,37.69,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,105.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,128.80,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $128.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.78,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.78,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,PREVEA HEALTH NETWORK,PREVEA360,21.78,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.78,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,89.36,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $89.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.92,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,100.80,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,TRIOLOGY,TRILOGY MEDICAID,18.35,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80192 at $17.31 (Fee Schedule) = $17.31 (Total Line Payment) at 106% = $18.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.10,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.10 from Fee Schedule UHC_98227C for Rev 301 Proc 80192 * Qty 1 = $20.10 at 100% = $20.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,20.10,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.10 from Fee Schedule UHC_98227C for Rev 301 Proc 80192 * Qty 1 = $20.10 at 100% = $20.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.75,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,20.10,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.10 from Fee Schedule UHC_98227C for Rev 301 Proc 80192 * Qty 1 = $20.10 at 100% = $20.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,UNITY HEALTH PLAN,UNITY HOSPICE,16.75,,,,,,,16.7500,140.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,100.80,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,86.80,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $86.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,100.80,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,100.80,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROCAINEAMIDE,80192,CPT,301,RC,30100133,CDM,,,,both,,,140.0000,92.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,84.00,,,,,,,16.7500,140.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $140.00 in Billed Charges for Rev 301 Proc 80192 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,AETNA,AETNA HSHS,69.77,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $69.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,AETNA,AETNA MEDICARE,13.73,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,AETNA,ALL COMMERCIAL AETNA,108.00,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,ANTHEM,ANTEHM MEDICAID,14.19,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80195 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.73,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,ANTHEM,ANTHEM POS/HMO,48.06,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.06 from Fee Schedule WII28_25 for Rev 301 Proc 80195 Mod TC * Qty 1 = $48.06 at 100% = $48.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,ANTHEM,ANTHEM PPO,48.06,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.06 from Fee Schedule WII28_25 for Rev 301 Proc 80195 Mod TC * Qty 1 = $48.06 at 100% = $48.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,108.00,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,CENPATICO,ALL MEDICAID CENPATICO,108.00,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,91.80,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $91.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,CIGNA,ALL COMMERCIAL CIGNA,75.60,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,COFINITY,COFINITY,108.00,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.19,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80195 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.19,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80195 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,102.60,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $102.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,90.72,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $90.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,76.68,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $76.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,78.84,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $78.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,52.49,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $52.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,91.80,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $91.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HUMANA,HUMANA CHOICE CARE HMO,23.34,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.34 from Fee Schedule 005543_170 for Rev 301 Proc 80195 * Qty 1 = $23.34 at 100% = $23.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HUMANA,HUMANA CHOICE CARE PPO,91.80,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $91.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,13.73,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,HUMANA,HUMANA NATIIONAL POS HMO,23.34,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.34 from Fee Schedule 005543_170 for Rev 301 Proc 80195 * Qty 1 = $23.34 at 100% = $23.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,78.84,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $78.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,108.00,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.19,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80195 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.73,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.19,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80195 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,15.04,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80195 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19... $14.19 at 106% = $15.04 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,13.73,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,54.00,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,90.72,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $90.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,30.89,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,81.00,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $81.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,99.36,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $99.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.85,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.85,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,PREVEA HEALTH NETWORK,PREVEA360,17.85,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.85,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,68.94,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $68.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.87,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,77.76,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $77.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,TRIOLOGY,TRILOGY MEDICAID,15.04,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80195 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 106% = $15.04. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.48,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80195 * Qty 1 = $16.48 at 100% = $16.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,16.48,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80195 * Qty 1 = $16.48 at 100% = $16.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.73,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,16.48,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80195 * Qty 1 = $16.48 at 100% = $16.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,UNITY HEALTH PLAN,UNITY HOSPICE,13.73,,,,,,,13.7300,108.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,77.76,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $77.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,66.96,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,77.76,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $77.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,77.76,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $77.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPAMYCIN (SIROLIMUS),80195,CPT,301,RC,30100135,CDM,,,,both,,,108.0000,71.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,64.80,,,,,,,13.7300,108.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $108.00 in Billed Charges for Rev 301 Proc 80195 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA HSHS,76.23,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $76.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA MEDICARE,13.73,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,AETNA,ALL COMMERCIAL AETNA,118.00,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTEHM MEDICAID,14.19,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80197 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.73,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM POS/HMO,48.06,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.06 from Fee Schedule WII28_25 for Rev 301 Proc 80197 Mod TC * Qty 1 = $48.06 at 100% = $48.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM PPO,48.06,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.06 from Fee Schedule WII28_25 for Rev 301 Proc 80197 Mod TC * Qty 1 = $48.06 at 100% = $48.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.00,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,CENPATICO,ALL MEDICAID CENPATICO,118.00,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.30,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,CIGNA,ALL COMMERCIAL CIGNA,82.60,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,COFINITY,COFINITY,118.00,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.19,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80197 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.19,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80197 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.10,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $112.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.12,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.78,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $83.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.14,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.35,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $57.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.30,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE HMO,23.34,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.34 from Fee Schedule 005543_170 for Rev 301 Proc 80197 * Qty 1 = $23.34 at 100% = $23.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE PPO,100.30,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,13.73,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA NATIIONAL POS HMO,23.34,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.34 from Fee Schedule 005543_170 for Rev 301 Proc 80197 * Qty 1 = $23.34 at 100% = $23.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.14,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.00,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.19,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80197 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.73,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.19,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80197 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,15.04,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80197 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 100% = $14.19... $14.19 at 106% = $15.04 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,13.73,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.00,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $59.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.12,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,30.89,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.50,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,108.56,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $108.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.85,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.85,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360,17.85,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.85,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.32,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $75.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.87,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.96,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,TRILOGY MEDICAID,15.04,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80197 at $14.19 (Fee Schedule) = $14.19 (Total Line Payment) at 106% = $15.04. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.48,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80197 * Qty 1 = $16.48 at 100% = $16.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,16.48,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80197 * Qty 1 = $16.48 at 100% = $16.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.73,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,16.48,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80197 * Qty 1 = $16.48 at 100% = $16.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,UNITY HEALTH PLAN,UNITY HOSPICE,13.73,,,,,,,13.7300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.96,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.16,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $73.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.96,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.96,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TACROLIMUS,80197,CPT,301,RC,30100137,CDM,,,,both,,,118.0000,77.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.80,,,,,,,13.7300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.00 in Billed Charges for Rev 301 Proc 80197 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,AETNA,AETNA HSHS,67.83,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $67.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,AETNA,AETNA MEDICARE,14.14,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,AETNA,ALL COMMERCIAL AETNA,105.00,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,ANTHEM,ANTEHM MEDICAID,14.61,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80198 at $14.61 (Fee Schedule) = $14.61 (Total Line Payment) at 100% = $14.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.14,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,ANTHEM,ANTHEM POS/HMO,49.49,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $49.49 from Fee Schedule WII28_25 for Rev 301 Proc 80198 Mod TC * Qty 1 = $49.49 at 100% = $49.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,ANTHEM,ANTHEM PPO,49.49,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $49.49 from Fee Schedule WII28_25 for Rev 301 Proc 80198 Mod TC * Qty 1 = $49.49 at 100% = $49.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,105.00,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,CENPATICO,ALL MEDICAID CENPATICO,105.00,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,89.25,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $89.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,CIGNA,ALL COMMERCIAL CIGNA,73.50,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $73.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,COFINITY,COFINITY,105.00,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.61,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80198 at $14.61 (Fee Schedule) = $14.61 (Total Line Payment) at 100% = $14.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.61,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80198 at $14.61 (Fee Schedule) = $14.61 (Total Line Payment) at 100% = $14.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,99.75,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $99.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,88.20,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $88.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,74.55,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $74.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,76.65,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $76.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,51.03,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $51.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,89.25,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $89.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HUMANA,HUMANA CHOICE CARE HMO,24.04,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.04 from Fee Schedule 005543_170 for Rev 301 Proc 80198 * Qty 1 = $24.04 at 100% = $24.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HUMANA,HUMANA CHOICE CARE PPO,89.25,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $89.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,14.14,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,HUMANA,HUMANA NATIIONAL POS HMO,24.04,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.04 from Fee Schedule 005543_170 for Rev 301 Proc 80198 * Qty 1 = $24.04 at 100% = $24.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,76.65,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $76.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,105.00,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.61,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80198 at $14.61 (Fee Schedule) = $14.61 (Total Line Payment) at 100% = $14.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.14,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.61,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80198 at $14.61 (Fee Schedule) = $14.61 (Total Line Payment) at 100% = $14.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,15.49,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80198 at $14.61 (Fee Schedule) = $14.61 (Total Line Payment) at 100% = $14.61... $14.61 at 106% = $15.49 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,14.14,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,52.50,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $52.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,88.20,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $88.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,31.82,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,78.75,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $78.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,96.60,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $96.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.38,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.38,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,PREVEA HEALTH NETWORK,PREVEA360,18.38,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.38,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.02,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $67.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.28,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,75.60,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,TRIOLOGY,TRILOGY MEDICAID,15.49,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80198 at $14.61 (Fee Schedule) = $14.61 (Total Line Payment) at 106% = $15.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.97,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.97 from Fee Schedule UHC_98227C for Rev 301 Proc 80198 * Qty 1 = $16.97 at 100% = $16.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,16.97,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.97 from Fee Schedule UHC_98227C for Rev 301 Proc 80198 * Qty 1 = $16.97 at 100% = $16.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.14,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,16.97,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.97 from Fee Schedule UHC_98227C for Rev 301 Proc 80198 * Qty 1 = $16.97 at 100% = $16.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,UNITY HEALTH PLAN,UNITY HOSPICE,14.14,,,,,,,14.1400,105.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,75.60,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.10,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $65.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,75.60,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,75.60,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THEOPHYLLINE,80198,CPT,301,RC,30100138,CDM,,,,both,,,105.0000,69.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.00,,,,,,,14.1400,105.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $105.00 in Billed Charges for Rev 301 Proc 80198 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA HSHS,76.23,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $76.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA MEDICARE,16.13,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,AETNA,ALL COMMERCIAL AETNA,118.00,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTEHM MEDICAID,16.67,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80200 at $16.67 (Fee Schedule) = $16.67 (Total Line Payment) at 100% = $16.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.13,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM POS/HMO,56.46,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $56.46 from Fee Schedule WII28_25 for Rev 301 Proc 80200 Mod TC * Qty 1 = $56.46 at 100% = $56.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM PPO,56.46,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $56.46 from Fee Schedule WII28_25 for Rev 301 Proc 80200 Mod TC * Qty 1 = $56.46 at 100% = $56.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.00,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,CENPATICO,ALL MEDICAID CENPATICO,118.00,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.30,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,CIGNA,ALL COMMERCIAL CIGNA,82.60,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,COFINITY,COFINITY,118.00,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.67,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80200 at $16.67 (Fee Schedule) = $16.67 (Total Line Payment) at 100% = $16.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.67,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80200 at $16.67 (Fee Schedule) = $16.67 (Total Line Payment) at 100% = $16.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.10,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $112.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.12,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.78,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $83.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.14,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.35,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $57.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.30,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE HMO,27.42,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.42 from Fee Schedule 005543_170 for Rev 301 Proc 80200 * Qty 1 = $27.42 at 100% = $27.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE PPO,100.30,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,16.13,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA NATIIONAL POS HMO,27.42,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.42 from Fee Schedule 005543_170 for Rev 301 Proc 80200 * Qty 1 = $27.42 at 100% = $27.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.14,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.00,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.67,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80200 at $16.67 (Fee Schedule) = $16.67 (Total Line Payment) at 100% = $16.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.13,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.67,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80200 at $16.67 (Fee Schedule) = $16.67 (Total Line Payment) at 100% = $16.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,17.67,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80200 at $16.67 (Fee Schedule) = $16.67 (Total Line Payment) at 100% = $16.67... $16.67 at 106% = $17.67 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,16.13,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.00,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $59.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.12,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,36.29,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.50,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,108.56,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $108.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,20.97,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,20.97,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360,20.97,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,20.97,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.32,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $75.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.29,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.96,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,TRILOGY MEDICAID,17.67,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80200 at $16.67 (Fee Schedule) = $16.67 (Total Line Payment) at 106% = $17.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.36,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.36 from Fee Schedule UHC_98227C for Rev 301 Proc 80200 * Qty 1 = $19.36 at 100% = $19.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,19.36,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.36 from Fee Schedule UHC_98227C for Rev 301 Proc 80200 * Qty 1 = $19.36 at 100% = $19.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.13,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,19.36,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.36 from Fee Schedule UHC_98227C for Rev 301 Proc 80200 * Qty 1 = $19.36 at 100% = $19.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,UNITY HEALTH PLAN,UNITY HOSPICE,16.13,,,,,,,16.1300,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.96,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.16,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $73.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.96,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.96,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOBRAMYCIN,80200,CPT,301,RC,30100139,CDM,,,,both,,,118.0000,77.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.80,,,,,,,16.1300,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.00 in Billed Charges for Rev 301 Proc 80200 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,AETNA,AETNA HSHS,127.26,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $127.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,AETNA,AETNA MEDICARE,18.64,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,AETNA,ALL COMMERCIAL AETNA,197.00,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,ANTHEM,ANTEHM MEDICAID,19.26,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80299 at $19.26 (Fee Schedule) = $19.26 (Total Line Payment) at 100% = $19.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,18.64,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,ANTHEM,ANTHEM POS/HMO,65.24,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $65.24 from Fee Schedule WII28_25 for Rev 301 Proc 80299 Mod TC * Qty 1 = $65.24 at 100% = $65.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,ANTHEM,ANTHEM PPO,65.24,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $65.24 from Fee Schedule WII28_25 for Rev 301 Proc 80299 Mod TC * Qty 1 = $65.24 at 100% = $65.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,197.00,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,CENPATICO,ALL MEDICAID CENPATICO,197.00,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,167.45,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $167.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,CIGNA,ALL COMMERCIAL CIGNA,137.90,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $137.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,COFINITY,COFINITY,197.00,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,19.26,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80299 at $19.26 (Fee Schedule) = $19.26 (Total Line Payment) at 100% = $19.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,19.26,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80299 at $19.26 (Fee Schedule) = $19.26 (Total Line Payment) at 100% = $19.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,187.15,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $187.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,165.48,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $165.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.87,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $139.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.81,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $143.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,95.74,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $95.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,167.45,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $167.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HUMANA,HUMANA CHOICE CARE HMO,31.69,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $31.69 from Fee Schedule 005543_170 for Rev 301 Proc 80299 * Qty 1 = $31.69 at 100% = $31.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HUMANA,HUMANA CHOICE CARE PPO,167.45,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $167.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,18.64,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,HUMANA,HUMANA NATIIONAL POS HMO,31.69,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $31.69 from Fee Schedule 005543_170 for Rev 301 Proc 80299 * Qty 1 = $31.69 at 100% = $31.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.81,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $143.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,197.00,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,19.26,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80299 at $19.26 (Fee Schedule) = $19.26 (Total Line Payment) at 100% = $19.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,18.64,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,19.26,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80299 at $19.26 (Fee Schedule) = $19.26 (Total Line Payment) at 100% = $19.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,20.42,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80299 at $19.26 (Fee Schedule) = $19.26 (Total Line Payment) at 100% = $19.26... $19.26 at 106% = $20.42 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,18.64,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.50,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $98.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,165.48,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $165.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,41.94,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.75,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $147.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,181.24,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $181.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,24.23,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,24.23,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,PREVEA HEALTH NETWORK,PREVEA360,24.23,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,24.23,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.75,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $125.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,18.83,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.84,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $141.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,TRIOLOGY,TRILOGY MEDICAID,20.42,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80299 at $19.26 (Fee Schedule) = $19.26 (Total Line Payment) at 106% = $20.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,22.37,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.37 from Fee Schedule UHC_98227C for Rev 301 Proc 80299 * Qty 1 = $22.37 at 100% = $22.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,22.37,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.37 from Fee Schedule UHC_98227C for Rev 301 Proc 80299 * Qty 1 = $22.37 at 100% = $22.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,18.64,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,22.37,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.37 from Fee Schedule UHC_98227C for Rev 301 Proc 80299 * Qty 1 = $22.37 at 100% = $22.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,UNITY HEALTH PLAN,UNITY HOSPICE,18.64,,,,,,,18.6400,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.84,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $141.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,122.14,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $122.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.84,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $141.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.84,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $141.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,30100142,CDM,,,,both,,,197.0000,130.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,118.20,,,,,,,18.6400,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $197.00 in Billed Charges for Rev 301 Proc 80299 = $118.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,AETNA,AETNA HSHS,34.24,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $34.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,AETNA,AETNA MEDICARE,27.11,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,AETNA,ALL COMMERCIAL AETNA,53.00,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,ANTHEM,ANTEHM MEDICAID,21.69,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80187 at $21.69 (Fee Schedule) = $21.69 (Total Line Payment) at 100% = $21.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,27.11,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,ANTHEM,ANTHEM POS/HMO,53.00,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $94.89 from Fee Schedule WII28_25 for Rev 301 Proc 80187 Mod TC * Qty 1 = $94.89 at 100% = $94.89 (Limited to $53.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,ANTHEM,ANTHEM PPO,53.00,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $94.89 from Fee Schedule WII28_25 for Rev 301 Proc 80187 Mod TC * Qty 1 = $94.89 at 100% = $94.89 (Limited to $53.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,53.00,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,CENPATICO,ALL MEDICAID CENPATICO,53.00,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,45.05,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $45.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,CIGNA,ALL COMMERCIAL CIGNA,37.10,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $37.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,COFINITY,COFINITY,53.00,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,21.69,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80187 at $21.69 (Fee Schedule) = $21.69 (Total Line Payment) at 100% = $21.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,21.69,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80187 at $21.69 (Fee Schedule) = $21.69 (Total Line Payment) at 100% = $21.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,50.35,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $50.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,44.52,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $44.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,37.63,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $37.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,38.69,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $38.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,25.76,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $25.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,45.05,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $45.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HUMANA,HUMANA CHOICE CARE HMO,46.09,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.09 from Fee Schedule 005543_170 for Rev 301 Proc 80187 * Qty 1 = $46.09 at 100% = $46.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HUMANA,HUMANA CHOICE CARE PPO,45.05,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $45.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HUMANA,HUMANA MEDICARE ADVANTAGE,27.11,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,HUMANA,HUMANA NATIIONAL POS HMO,46.09,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.09 from Fee Schedule 005543_170 for Rev 301 Proc 80187 * Qty 1 = $46.09 at 100% = $46.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,38.69,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $38.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,53.00,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,21.69,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80187 at $21.69 (Fee Schedule) = $21.69 (Total Line Payment) at 100% = $21.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,27.11,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,21.69,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80187 at $21.69 (Fee Schedule) = $21.69 (Total Line Payment) at 100% = $21.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,MOLINA HEALTHCARE,MOLINA MEDICAID,22.99,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80187 at $21.69 (Fee Schedule) = $21.69 (Total Line Payment) at 100% = $21.69... $21.69 at 106% = $22.99 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,MOLINA HEALTHCARE,MOLINA MEDICARE,27.11,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.50,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $26.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,44.52,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $44.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,NAPHCARE,ALL COMMERICAL NAPHCARE,61.00,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,39.75,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $39.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,48.76,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $48.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,35.24,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,35.24,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,PREVEA HEALTH NETWORK,PREVEA360,35.24,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,35.24,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,33.83,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $33.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,27.38,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,38.16,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,TRIOLOGY,TRILOGY MEDICAID,22.99,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80187 at $21.69 (Fee Schedule) = $21.69 (Total Line Payment) at 106% = $22.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32.53,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.53 from Fee Schedule UHC_98227C for Rev 301 Proc 80187 * Qty 1 = $32.53 at 100% = $32.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,UNITED HEALTHCARE,UHC ONEIDA NATION,32.53,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.53 from Fee Schedule UHC_98227C for Rev 301 Proc 80187 * Qty 1 = $32.53 at 100% = $32.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,27.11,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,UNITED HEALTHCARE,UNITED HEALTHCARE,32.53,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.53 from Fee Schedule UHC_98227C for Rev 301 Proc 80187 * Qty 1 = $32.53 at 100% = $32.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,UNITY HEALTH PLAN,UNITY HOSPICE,27.11,,,,,,,21.6900,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,38.16,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.86,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $32.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,38.16,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,38.16,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLECAINAIDE,80187,CPT,301,RC,30100145,CDM,,,,both,,,53.0000,34.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.80,,,,,,,21.6900,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $53.00 in Billed Charges for Rev 301 Proc 80187 = $31.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,AETNA,AETNA HSHS,62.02,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $62.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,AETNA,AETNA MEDICARE,13.25,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,AETNA,ALL COMMERCIAL AETNA,96.00,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,ANTHEM,ANTEHM MEDICAID,13.69,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80175 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.25,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,ANTHEM,ANTHEM POS/HMO,46.38,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80175 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,ANTHEM,ANTHEM PPO,46.38,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80175 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,96.00,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,CENPATICO,ALL MEDICAID CENPATICO,96.00,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,81.60,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,CIGNA,ALL COMMERCIAL CIGNA,67.20,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $67.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,COFINITY,COFINITY,96.00,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.69,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80175 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.69,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80175 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,91.20,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $91.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,80.64,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,68.16,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $68.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,70.08,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $70.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,46.66,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $46.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,81.60,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HUMANA,HUMANA CHOICE CARE HMO,22.53,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80175 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HUMANA,HUMANA CHOICE CARE PPO,81.60,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,13.25,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,HUMANA,HUMANA NATIIONAL POS HMO,22.53,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80175 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,70.08,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $70.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,96.00,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.69,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80175 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.25,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.69,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80175 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,14.51,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80175 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69... $13.69 at 106% = $14.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,13.25,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,48.00,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $48.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,80.64,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,29.81,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,72.00,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,88.32,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $88.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.23,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.23,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,PREVEA HEALTH NETWORK,PREVEA360,17.23,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.23,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,61.28,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $61.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.38,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,69.12,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $69.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,TRIOLOGY,TRILOGY MEDICAID,14.51,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80175 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 106% = $14.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.90,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80175 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,15.90,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80175 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.25,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,15.90,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80175 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,UNITY HEALTH PLAN,UNITY HOSPICE,13.25,,,,,,,13.2500,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,69.12,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $69.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,59.52,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $59.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,69.12,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $69.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,69.12,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $69.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAMOTRIGINE,80175,CPT,301,RC,30100147,CDM,,,,both,,,96.0000,63.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,57.60,,,,,,,13.2500,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $96.00 in Billed Charges for Rev 301 Proc 80175 = $57.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,AETNA,AETNA HSHS,916.22,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $916.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,AETNA,ALL COMMERCIAL AETNA,1418.29,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,418.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,ANTHEM,ANTHEM POS/HMO,737.51,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $737.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,ANTHEM,ANTHEM PPO,737.51,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $737.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1418.29,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,418.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,CENPATICO,ALL MEDICAID CENPATICO,1418.29,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,418.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1205.55,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,205.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,CIGNA,ALL COMMERCIAL CIGNA,992.80,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $992.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,COFINITY,COFINITY,1418.29,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,418.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1347.38,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,347.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,1191.36,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,191.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1006.99,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,006.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1035.35,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,035.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,689.29,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $689.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1205.55,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,205.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,HUMANA,HUMANA CHOICE CARE PPO,1205.55,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,205.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1035.35,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,035.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1418.29,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,418.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,709.15,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $709.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1191.36,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,191.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1063.72,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,063.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1304.83,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,304.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,905.29,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $905.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1021.17,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,021.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1021.17,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,021.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,879.34,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $879.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1021.17,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,021.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1021.17,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $1,021.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VASC 50CM 6MM CENTERFLEX STRT CARBOFLO PTFE HEMODIA,C1768,HCPCS,278,RC,10003852,CDM,,,,both,,,1418.2900,936.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,850.97,,,,,,,689.2900,1418.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,418.29 in Billed Charges for Rev 278 Proc C1768 = $850.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,AETNA,AETNA HSHS,956.34,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $956.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,AETNA,ALL COMMERCIAL AETNA,1480.41,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,480.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,ANTHEM,ANTHEM POS/HMO,769.81,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $769.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,ANTHEM,ANTHEM PPO,769.81,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $769.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1480.41,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,480.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,CENPATICO,ALL MEDICAID CENPATICO,1480.41,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,480.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1258.35,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,258.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,CIGNA,ALL COMMERCIAL CIGNA,1036.29,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,036.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,COFINITY,COFINITY,1480.41,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,480.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1406.39,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,406.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,1243.54,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,243.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1051.09,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,051.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1080.70,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,080.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,719.48,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $719.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1258.35,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,258.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,HUMANA,HUMANA CHOICE CARE PPO,1258.35,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,258.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1080.70,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,080.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1480.41,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,480.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,740.21,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $740.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1243.54,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,243.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1110.31,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,110.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1361.98,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,361.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,944.95,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $944.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1065.90,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,065.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1065.90,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,065.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,917.85,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $917.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1065.90,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,065.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1065.90,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $1,065.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT VENAFLO STRAIGHT 6MMX50CM,C1768,HCPCS,278,RC,10015984,CDM,,,,both,,,1480.4100,977.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,888.25,,,,,,,719.4800,1480.4100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,480.41 in Billed Charges for Rev 278 Proc C1768 = $888.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,AETNA,AETNA HSHS,3284.91,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,284.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,AETNA,ALL COMMERCIAL AETNA,5085.00,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $5,085.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,ANTHEM,ANTHEM POS/HMO,2644.20,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,644.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,ANTHEM,ANTHEM PPO,2644.20,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,644.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5085.00,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $5,085.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,CENPATICO,ALL MEDICAID CENPATICO,5085.00,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $5,085.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4322.25,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $4,322.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,CIGNA,ALL COMMERCIAL CIGNA,3559.50,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,559.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,COFINITY,COFINITY,5085.00,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $5,085.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4830.75,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $4,830.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,4271.40,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $4,271.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3610.35,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,610.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3712.05,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,712.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,2471.31,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,471.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4322.25,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $4,322.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,HUMANA,HUMANA CHOICE CARE HMO,2542.50,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,542.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,HUMANA,HUMANA CHOICE CARE PPO,4322.25,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $4,322.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,HUMANA,HUMANA NATIIONAL POS HMO,2542.50,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,542.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3712.05,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,712.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,5085.00,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $5,085.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2542.50,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,542.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4271.40,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $4,271.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3813.75,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,813.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4678.20,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $4,678.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2542.50,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,542.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2542.50,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,542.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,PREVEA HEALTH NETWORK,PREVEA360,2542.50,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,542.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2542.50,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $2,542.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3245.76,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,245.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3661.20,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3661.20,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3152.70,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,152.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3661.20,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3661.20,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
KIT MALE SLING,C1771,HCPCS,278,RC,10035409,CDM,,,,both,,,5085.0000,3356.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3051.00,,,,,,,2471.3100,5085.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,085.00 in Billed Charges for Rev 278 Proc C1771 = $3,051.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,AETNA,AETNA HSHS,1916.31,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,916.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,AETNA,ALL COMMERCIAL AETNA,2966.43,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,966.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,ANTHEM,ANTHEM POS/HMO,1542.54,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,542.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,ANTHEM,ANTHEM PPO,1542.54,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,542.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2966.43,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,966.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,CENPATICO,ALL MEDICAID CENPATICO,2966.43,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,966.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2521.47,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,521.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,CIGNA,ALL COMMERCIAL CIGNA,2076.50,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,076.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,COFINITY,COFINITY,2966.43,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,966.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2818.11,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,818.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,2491.80,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,491.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2106.17,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,106.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2165.49,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,165.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,1441.69,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,441.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2521.47,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,521.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,HUMANA,HUMANA CHOICE CARE HMO,1483.22,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,483.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,HUMANA,HUMANA CHOICE CARE PPO,2521.47,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,521.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,HUMANA,HUMANA NATIIONAL POS HMO,1483.22,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,483.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2165.49,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,165.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2966.43,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,966.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1483.22,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,483.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2491.80,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,491.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2224.82,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,224.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2729.12,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,729.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1893.47,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,893.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2135.83,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,135.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2135.83,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,135.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1839.19,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,839.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2135.83,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,135.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2135.83,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $2,135.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING LYNX MIDURETHRAL,C1771,HCPCS,278,RC,10028131,CDM,,,,both,,,2966.4300,1957.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1779.86,,,,,,,1441.6900,2966.4300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,966.43 in Billed Charges for Rev 278 Proc C1771 = $1,779.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,AETNA,AETNA HSHS,1054.14,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,054.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,AETNA,ALL COMMERCIAL AETNA,1631.80,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,631.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,ANTHEM,ANTHEM POS/HMO,848.54,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $848.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,ANTHEM,ANTHEM PPO,848.54,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $848.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1631.80,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,631.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,CENPATICO,ALL MEDICAID CENPATICO,1631.80,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,631.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1387.03,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,387.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,CIGNA,ALL COMMERCIAL CIGNA,1142.26,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,142.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,COFINITY,COFINITY,1631.80,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,631.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1550.21,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,550.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,1370.71,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,370.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1158.58,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,158.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1191.21,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,191.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,793.05,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $793.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1387.03,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,387.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,HUMANA,HUMANA CHOICE CARE PPO,1387.03,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,387.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1191.21,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,191.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1631.80,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,631.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,815.90,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $815.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1370.71,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,370.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1223.85,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,223.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1501.26,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,501.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1041.58,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,041.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1174.90,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,174.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1174.90,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,174.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1011.72,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,011.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1174.90,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,174.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1174.90,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $1,174.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,10058476,CDM,,,,both,,,1631.8000,1076.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,979.08,,,,,,,793.0500,1631.8000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,631.80 in Billed Charges for Rev 278 Proc C1771 = $979.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,AETNA,AETNA HSHS,2146.26,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,146.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,AETNA,ALL COMMERCIAL AETNA,3322.38,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $3,322.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,ANTHEM,ANTHEM POS/HMO,1727.64,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $1,727.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,ANTHEM,ANTHEM PPO,1727.64,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $1,727.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3322.38,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $3,322.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,CENPATICO,ALL MEDICAID CENPATICO,3322.38,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $3,322.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2824.02,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,824.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,CIGNA,ALL COMMERCIAL CIGNA,2325.67,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,325.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,COFINITY,COFINITY,3322.38,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $3,322.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3156.26,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $3,156.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,2790.80,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,790.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2358.89,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,358.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2425.34,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,425.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,1614.68,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $1,614.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2824.02,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,824.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,HUMANA,HUMANA CHOICE CARE HMO,1661.19,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $1,661.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,HUMANA,HUMANA CHOICE CARE PPO,2824.02,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,824.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,HUMANA,HUMANA NATIIONAL POS HMO,1661.19,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $1,661.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2425.34,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,425.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,3322.38,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $3,322.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1661.19,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $1,661.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2790.80,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,790.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2491.79,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,491.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3056.59,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $3,056.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2120.68,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,120.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2392.11,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,392.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2392.11,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,392.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2059.88,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,059.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2392.11,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,392.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2392.11,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $2,392.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SLING OBTRYX II HALO TRANSOBTURATOR SLING SYSTEM,C1771,HCPCS,278,RC,10068305,CDM,,,,both,,,3322.3800,2192.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1993.43,,,,,,,1614.6800,3322.3800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,322.38 in Billed Charges for Rev 278 Proc C1771 = $1,993.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,AETNA,AETNA HSHS,425.56,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $425.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,AETNA,ALL COMMERCIAL AETNA,658.76,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $658.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,658.76,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $658.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,CENPATICO,ALL MEDICAID CENPATICO,658.76,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $658.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,559.95,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $559.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,CIGNA,ALL COMMERCIAL CIGNA,461.13,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $461.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,COFINITY,COFINITY,658.76,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $658.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,625.82,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $625.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,553.36,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $553.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,467.72,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $467.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,480.89,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $480.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,320.16,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $320.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,559.95,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $559.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,HUMANA,HUMANA CHOICE CARE PPO,559.95,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $559.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,480.89,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $480.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,658.76,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $658.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,329.38,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $329.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,553.36,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $553.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,494.07,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $494.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,606.06,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $606.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,420.49,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $420.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,474.31,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $474.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,474.31,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $474.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,408.43,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $408.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,474.31,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $474.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,474.31,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $474.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q I FLOW FEMORAL PAIN (CB005),C1772,HCPCS,278,RC,10053354,CDM,,,,both,,,658.7600,434.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,395.26,,,,,,,320.1600,658.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $658.76 in Billed Charges for Rev 278 Proc C1772 = $395.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,AETNA,AETNA HSHS,120.22,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $120.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,AETNA,ALL COMMERCIAL AETNA,186.10,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $186.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,186.10,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $186.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,CENPATICO,ALL MEDICAID CENPATICO,186.10,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $186.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,158.19,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $158.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,CIGNA,ALL COMMERCIAL CIGNA,130.27,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $130.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,COFINITY,COFINITY,186.10,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $186.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,176.80,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $176.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,156.32,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $156.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,132.13,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $132.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,135.85,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $135.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,90.44,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $90.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,158.19,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $158.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,HUMANA,HUMANA CHOICE CARE PPO,158.19,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $158.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,135.85,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $135.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,186.10,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $186.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,93.05,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $93.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,156.32,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $156.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,139.58,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $139.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,171.21,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $171.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,118.79,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $118.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,133.99,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $133.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,133.99,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $133.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,115.38,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $115.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,133.99,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $133.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,133.99,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $133.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN (PM012),C1772,HCPCS,278,RC,10056929,CDM,,,,both,,,186.1000,122.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,111.66,,,,,,,90.4400,186.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $186.10 in Billed Charges for Rev 278 Proc C1772 = $111.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,AETNA,AETNA HSHS,247.39,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $247.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,AETNA,ALL COMMERCIAL AETNA,382.95,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $382.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,382.95,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $382.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,CENPATICO,ALL MEDICAID CENPATICO,382.95,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $382.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,325.51,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $325.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,CIGNA,ALL COMMERCIAL CIGNA,268.07,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $268.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,COFINITY,COFINITY,382.95,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $382.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,363.80,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $363.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,321.68,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $321.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,271.89,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $271.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,279.55,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $279.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,186.11,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $186.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,325.51,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $325.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,HUMANA,HUMANA CHOICE CARE PPO,325.51,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $325.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,279.55,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $279.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,382.95,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $382.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,191.48,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $191.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,321.68,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $321.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,287.21,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $287.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,352.31,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $352.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,244.44,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $244.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,275.72,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $275.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,275.72,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $275.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,237.43,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $237.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,275.72,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $275.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,275.72,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $275.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PUMP ON Q PAIN 2 SITE (PM025),C1772,HCPCS,278,RC,10052710,CDM,,,,both,,,382.9500,252.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,229.77,,,,,,,186.1100,382.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $382.95 in Billed Charges for Rev 278 Proc C1772 = $229.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,AETNA,AETNA HSHS,993.23,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $993.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,AETNA,ALL COMMERCIAL AETNA,1537.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,537.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,ANTHEM,ANTHEM POS/HMO,799.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $799.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,ANTHEM,ANTHEM PPO,799.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $799.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1537.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,537.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,CENPATICO,ALL MEDICAID CENPATICO,1537.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,537.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1306.88,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,306.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,CIGNA,ALL COMMERCIAL CIGNA,1076.25,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,076.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,COFINITY,COFINITY,1537.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,537.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1460.63,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,460.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,1291.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,291.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1091.63,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,091.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1122.38,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,122.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,747.23,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $747.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1306.88,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,306.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,HUMANA,HUMANA CHOICE CARE PPO,1306.88,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,306.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1122.38,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,122.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1537.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,537.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,768.75,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $768.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1291.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,291.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1153.13,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,153.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1414.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,414.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,981.39,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $981.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1107.00,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,107.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1107.00,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,107.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,953.25,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $953.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1107.00,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,107.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1107.00,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $1,107.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,10023762,CDM,,,,both,,,1537.5000,1014.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,922.50,,,,,,,747.2300,1537.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,537.50 in Billed Charges for Rev 278 Proc C1776 = $922.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,AETNA,AETNA HSHS,282.84,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $282.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,AETNA,ALL COMMERCIAL AETNA,437.83,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $437.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,437.83,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $437.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,CENPATICO,ALL MEDICAID CENPATICO,437.83,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $437.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,372.16,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $372.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,CIGNA,ALL COMMERCIAL CIGNA,306.48,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $306.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,COFINITY,COFINITY,437.83,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $437.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,415.94,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $415.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,367.78,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $367.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,310.86,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $310.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,319.62,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $319.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,212.79,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $212.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,372.16,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $372.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,HUMANA,HUMANA CHOICE CARE PPO,372.16,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $372.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,319.62,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $319.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,437.83,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $437.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,218.92,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $218.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,367.78,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $367.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,328.37,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $328.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,402.80,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $402.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,279.47,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $279.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,315.24,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $315.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,315.24,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $315.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,271.45,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $271.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,315.24,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $315.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,315.24,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $315.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PARIETEX POLYESTER 6X6 TET1515,C1781,HCPCS,278,RC,10032315,CDM,,,,both,,,437.8300,288.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,262.70,,,,,,,212.7900,437.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $437.83 in Billed Charges for Rev 278 Proc C1781 = $262.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,AETNA,AETNA HSHS,330.56,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $330.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,AETNA,ALL COMMERCIAL AETNA,511.70,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $511.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,511.70,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $511.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,CENPATICO,ALL MEDICAID CENPATICO,511.70,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $511.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,434.95,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $434.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,CIGNA,ALL COMMERCIAL CIGNA,358.19,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $358.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,COFINITY,COFINITY,511.70,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $511.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,486.12,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $486.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,429.83,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $429.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,363.31,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $363.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,373.54,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $373.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,248.69,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $248.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,434.95,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $434.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,HUMANA,HUMANA CHOICE CARE PPO,434.95,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $434.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,373.54,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $373.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,511.70,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $511.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,255.85,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $255.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,429.83,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $429.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,383.78,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $383.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,470.76,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $470.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,326.62,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $326.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,368.42,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $368.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,368.42,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $368.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,317.25,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $317.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,368.42,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $368.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,368.42,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $368.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PATCH HERNIA BARK KUGEL 8X8,C1781,HCPCS,278,RC,10054154,CDM,,,,both,,,511.7000,337.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,307.02,,,,,,,248.6900,511.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $511.70 in Billed Charges for Rev 278 Proc C1781 = $307.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,AETNA,AETNA HSHS,5870.98,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $5,870.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,AETNA,ALL COMMERCIAL AETNA,9088.20,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $9,088.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,ANTHEM,ANTHEM POS/HMO,4725.86,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,725.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,ANTHEM,ANTHEM PPO,4725.86,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,725.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9088.20,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $9,088.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,CENPATICO,ALL MEDICAID CENPATICO,9088.20,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $9,088.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7724.97,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $7,724.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,CIGNA,ALL COMMERCIAL CIGNA,6361.74,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,361.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,COFINITY,COFINITY,9088.20,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $9,088.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8633.79,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $8,633.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,7634.09,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $7,634.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6452.62,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,452.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6634.39,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,634.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,4416.87,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,416.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7724.97,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $7,724.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,HUMANA,HUMANA CHOICE CARE HMO,4544.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,544.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,HUMANA,HUMANA CHOICE CARE PPO,7724.97,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $7,724.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,HUMANA,HUMANA NATIIONAL POS HMO,4544.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,544.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6634.39,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,634.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,9088.20,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $9,088.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4544.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,544.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7634.09,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $7,634.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6816.15,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,816.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8361.14,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $8,361.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4544.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,544.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4544.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,544.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,PREVEA HEALTH NETWORK,PREVEA360,4544.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,544.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4544.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,544.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5801.00,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $5,801.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6543.50,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,543.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4235.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,235.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,UNITED HEALTHCARE,UHC ONEIDA NATION,4235.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,235.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,UNITED HEALTHCARE,UNITED HEALTHCARE,4235.10,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $4,235.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6543.50,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,543.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5634.68,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $5,634.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6543.50,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,543.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6543.50,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $6,543.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PHASIX BARD 6IN X 4IN,C1781,HCPCS,278,RC,10093965,CDM,,,,both,,,9088.2000,5998.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5452.92,,,,,,,4235.1000,9088.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,088.20 in Billed Charges for Rev 278 Proc C1781 = $5,452.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,AETNA,AETNA HSHS,495.42,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $495.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,AETNA,ALL COMMERCIAL AETNA,766.91,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $766.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,766.91,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $766.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,CENPATICO,ALL MEDICAID CENPATICO,766.91,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $766.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,651.87,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $651.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,CIGNA,ALL COMMERCIAL CIGNA,536.84,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $536.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,COFINITY,COFINITY,766.91,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $766.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,728.56,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $728.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,644.20,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $644.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,544.51,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $544.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,559.84,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $559.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,372.72,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $372.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,651.87,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $651.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,HUMANA,HUMANA CHOICE CARE PPO,651.87,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $651.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,559.84,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $559.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,766.91,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $766.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,383.46,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $383.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,644.20,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $644.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,575.18,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $575.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,705.56,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $705.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,489.52,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $489.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,552.18,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $552.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,552.18,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $552.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,475.48,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $475.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,552.18,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $552.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,552.18,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $552.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 15CM X 10CM LAP,C1781,HCPCS,278,RC,10069030,CDM,,,,both,,,766.9100,506.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,460.15,,,,,,,372.7200,766.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $766.91 in Billed Charges for Rev 278 Proc C1781 = $460.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,AETNA,AETNA HSHS,554.85,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $554.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,AETNA,ALL COMMERCIAL AETNA,858.90,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $858.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,858.90,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $858.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,CENPATICO,ALL MEDICAID CENPATICO,858.90,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $858.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,730.07,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $730.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,CIGNA,ALL COMMERCIAL CIGNA,601.23,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $601.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,COFINITY,COFINITY,858.90,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $858.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,815.96,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $815.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,721.48,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $721.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,609.82,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $609.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,627.00,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,417.43,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $417.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,730.07,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $730.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,HUMANA,HUMANA CHOICE CARE PPO,730.07,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $730.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,627.00,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,858.90,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $858.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,429.45,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $429.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,721.48,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $721.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,644.18,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $644.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,790.19,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $790.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,548.24,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $548.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,618.41,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $618.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,618.41,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $618.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,532.52,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $532.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,618.41,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $618.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,618.41,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $618.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH PROGRIP SELF FIXATING 16CM X 12CM LAPAROSCOPIC INGUINAL,C1781,HCPCS,278,RC,10076288,CDM,,,,both,,,858.9000,566.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,515.34,,,,,,,417.4300,858.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $858.90 in Billed Charges for Rev 278 Proc C1781 = $515.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,AETNA,AETNA HSHS,13907.09,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $13,907.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,AETNA,ALL COMMERCIAL AETNA,21528.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $21,528.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,ANTHEM,ANTHEM POS/HMO,11194.56,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $11,194.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,ANTHEM,ANTHEM PPO,11194.56,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $11,194.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,21528.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $21,528.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,CENPATICO,ALL MEDICAID CENPATICO,21528.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $21,528.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18298.80,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $18,298.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,CIGNA,ALL COMMERCIAL CIGNA,15069.60,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $15,069.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,COFINITY,COFINITY,21528.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $21,528.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,20451.60,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $20,451.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,18083.52,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $18,083.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15284.88,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $15,284.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15715.44,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $15,715.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,10462.61,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,462.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18298.80,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $18,298.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,HUMANA,HUMANA CHOICE CARE HMO,10764.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,764.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,HUMANA,HUMANA CHOICE CARE PPO,18298.80,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $18,298.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,HUMANA,HUMANA NATIIONAL POS HMO,10764.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,764.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15715.44,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $15,715.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,21528.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $21,528.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10764.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,764.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18083.52,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $18,083.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16146.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $16,146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,19805.76,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $19,805.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10764.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,764.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10764.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,764.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,PREVEA HEALTH NETWORK,PREVEA360,10764.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,764.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10764.00,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,764.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13741.32,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $13,741.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15500.16,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $15,500.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10032.05,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,032.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,10032.05,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,032.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,10032.05,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $10,032.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15500.16,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $15,500.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13347.36,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $13,347.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15500.16,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $15,500.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15500.16,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $15,500.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH STRATTICE LIFECELL 20 X 25,C1781,HCPCS,278,RC,10044745,CDM,,,,both,,,21528.0000,14208.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12916.80,,,,,,,10032.0500,21528.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $21,528.00 in Billed Charges for Rev 278 Proc C1781 = $12,916.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,AETNA,AETNA HSHS,1477.87,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,477.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,AETNA,ALL COMMERCIAL AETNA,2287.73,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $2,287.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,ANTHEM,ANTHEM POS/HMO,1189.62,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,189.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,ANTHEM,ANTHEM PPO,1189.62,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,189.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2287.73,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $2,287.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,CENPATICO,ALL MEDICAID CENPATICO,2287.73,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $2,287.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1944.57,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,944.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,CIGNA,ALL COMMERCIAL CIGNA,1601.41,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,601.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,COFINITY,COFINITY,2287.73,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $2,287.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2173.34,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $2,173.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,1921.69,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,921.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1624.29,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,624.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1670.04,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,670.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,1111.84,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,111.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1944.57,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,944.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,HUMANA,HUMANA CHOICE CARE PPO,1944.57,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,944.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1670.04,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,670.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2287.73,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $2,287.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1143.87,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,143.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1921.69,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,921.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1715.80,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,715.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2104.71,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $2,104.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1460.26,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,460.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1647.17,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,647.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1647.17,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,647.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1418.39,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,418.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1647.17,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,647.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1647.17,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,647.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX 30X20CM,C1781,HCPCS,278,RC,10066955,CDM,,,,both,,,2287.7300,1509.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1372.64,,,,,,,1111.8400,2287.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,287.73 in Billed Charges for Rev 278 Proc C1781 = $1,372.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,AETNA,AETNA HSHS,501.70,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $501.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,AETNA,ALL COMMERCIAL AETNA,776.62,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $776.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,776.62,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $776.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,CENPATICO,ALL MEDICAID CENPATICO,776.62,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $776.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,660.13,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $660.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,CIGNA,ALL COMMERCIAL CIGNA,543.63,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $543.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,COFINITY,COFINITY,776.62,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $776.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,737.79,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $737.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,652.36,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $652.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,551.40,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $551.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,566.93,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $566.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,377.44,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $377.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,660.13,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $660.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,HUMANA,HUMANA CHOICE CARE PPO,660.13,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $660.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,566.93,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $566.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,776.62,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $776.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,388.31,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $388.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,652.36,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $652.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,582.47,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $582.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,714.49,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $714.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,495.72,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $495.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,559.17,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $559.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,559.17,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $559.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,481.50,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $481.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,559.17,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $559.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,559.17,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $559.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH SYMBOTEX COMPOSITE 12CM,C1781,HCPCS,278,RC,10066950,CDM,,,,both,,,776.6200,512.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,465.97,,,,,,,377.4400,776.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $776.62 in Billed Charges for Rev 278 Proc C1781 = $465.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,AETNA,AETNA HSHS,904.50,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $904.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,AETNA,ALL COMMERCIAL AETNA,1400.15,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,400.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,ANTHEM,ANTHEM POS/HMO,728.08,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $728.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,ANTHEM,ANTHEM PPO,728.08,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $728.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1400.15,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,400.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,CENPATICO,ALL MEDICAID CENPATICO,1400.15,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,400.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1190.13,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,190.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,CIGNA,ALL COMMERCIAL CIGNA,980.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $980.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,COFINITY,COFINITY,1400.15,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,400.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1330.14,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,330.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,1176.13,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,176.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,994.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $994.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1022.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,022.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,680.47,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $680.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1190.13,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,190.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,HUMANA,HUMANA CHOICE CARE PPO,1190.13,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,190.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1022.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,022.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1400.15,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,400.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,700.08,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $700.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1176.13,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,176.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1050.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,050.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1288.14,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,288.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,893.72,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $893.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1008.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,008.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1008.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,008.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,868.09,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $868.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1008.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,008.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1008.11,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $1,008.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALEX ST MEDIUM WITH STRAP 5950008,C1781,HCPCS,278,RC,10051860,CDM,,,,both,,,1400.1500,924.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,840.09,,,,,,,680.4700,1400.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,400.15 in Billed Charges for Rev 278 Proc C1781 = $840.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,AETNA,AETNA HSHS,1404.51,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,404.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,AETNA,ALL COMMERCIAL AETNA,2174.17,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $2,174.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,ANTHEM,ANTHEM POS/HMO,1130.57,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,130.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,ANTHEM,ANTHEM PPO,1130.57,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,130.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2174.17,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $2,174.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,CENPATICO,ALL MEDICAID CENPATICO,2174.17,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $2,174.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1848.04,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,848.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,CIGNA,ALL COMMERCIAL CIGNA,1521.92,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,521.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,COFINITY,COFINITY,2174.17,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $2,174.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2065.46,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $2,065.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,HEALTH CARE ALLIANCE,THE ALLIANCE,1826.30,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,826.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1543.66,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,543.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1587.14,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,587.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,HSHS EMPLOYEES,HSHS EMPLOYEES,1056.65,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,056.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1848.04,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,848.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,HUMANA,HUMANA CHOICE CARE PPO,1848.04,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,848.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1587.14,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,587.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,LIVE360,LIVE360 HSHS HEALTHY PLAN,2174.17,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $2,174.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1087.09,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,087.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1826.30,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,826.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1630.63,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,630.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2000.24,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $2,000.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1387.77,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,387.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1565.40,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,565.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1565.40,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,565.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1347.99,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,347.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1565.40,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,565.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1565.40,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,565.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 6 X 8 5954680,C1781,HCPCS,278,RC,10049712,CDM,,,,both,,,2174.1700,1434.9500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1304.50,,,,,,,1056.6500,2174.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,174.17 in Billed Charges for Rev 278 Proc C1781 = $1,304.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,AETNA,AETNA HSHS,2103.15,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,103.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,AETNA,ALL COMMERCIAL AETNA,3255.65,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $3,255.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,ANTHEM,ANTHEM POS/HMO,1692.94,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $1,692.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,ANTHEM,ANTHEM PPO,1692.94,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $1,692.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3255.65,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $3,255.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,CENPATICO,ALL MEDICAID CENPATICO,3255.65,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $3,255.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2767.30,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,767.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,CIGNA,ALL COMMERCIAL CIGNA,2278.96,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,278.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,COFINITY,COFINITY,3255.65,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $3,255.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3092.87,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $3,092.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,2734.75,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,734.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2311.51,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,311.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2376.62,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,376.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,1582.25,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $1,582.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2767.30,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,767.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,HUMANA,HUMANA CHOICE CARE HMO,1627.83,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $1,627.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,HUMANA,HUMANA CHOICE CARE PPO,2767.30,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,767.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,HUMANA,HUMANA NATIIONAL POS HMO,1627.83,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $1,627.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2376.62,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,376.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,3255.65,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $3,255.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1627.83,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $1,627.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2734.75,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,734.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2441.74,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,441.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2995.20,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,995.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2078.08,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,078.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2344.07,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,344.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2344.07,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,344.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2018.50,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,018.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2344.07,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,344.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2344.07,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $2,344.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT 8 X 10 5954810,C1781,HCPCS,278,RC,10049398,CDM,,,,both,,,3255.6500,2148.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1953.39,,,,,,,1582.2500,3255.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,255.65 in Billed Charges for Rev 278 Proc C1781 = $1,953.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,AETNA,AETNA HSHS,1346.95,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,346.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,AETNA,ALL COMMERCIAL AETNA,2085.06,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $2,085.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,ANTHEM,ANTHEM POS/HMO,1084.23,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,084.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,ANTHEM,ANTHEM PPO,1084.23,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,084.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2085.06,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $2,085.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,CENPATICO,ALL MEDICAID CENPATICO,2085.06,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $2,085.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1772.30,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,772.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,CIGNA,ALL COMMERCIAL CIGNA,1459.54,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,459.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,COFINITY,COFINITY,2085.06,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $2,085.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1980.81,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,980.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,1751.45,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,751.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1480.39,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,480.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1522.09,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,522.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,1013.34,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,013.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1772.30,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,772.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,HUMANA,HUMANA CHOICE CARE PPO,1772.30,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,772.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1522.09,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,522.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2085.06,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $2,085.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1042.53,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,042.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1751.45,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,751.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1563.80,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,563.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1918.26,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,918.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1330.89,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,330.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1501.24,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,501.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1501.24,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,501.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1292.74,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,292.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1501.24,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,501.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1501.24,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,501.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO CIRCLE 4.5,C1781,HCPCS,278,RC,10072764,CDM,,,,both,,,2085.0600,1376.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1251.04,,,,,,,1013.3400,2085.0600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,085.06 in Billed Charges for Rev 278 Proc C1781 = $1,251.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,AETNA,AETNA HSHS,2237.67,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,237.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,AETNA,ALL COMMERCIAL AETNA,3463.89,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $3,463.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,ANTHEM,ANTHEM POS/HMO,1801.22,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $1,801.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,ANTHEM,ANTHEM PPO,1801.22,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $1,801.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3463.89,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $3,463.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,CENPATICO,ALL MEDICAID CENPATICO,3463.89,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $3,463.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2944.31,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,944.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,CIGNA,ALL COMMERCIAL CIGNA,2424.72,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,424.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,COFINITY,COFINITY,3463.89,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $3,463.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3290.70,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $3,290.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,2909.67,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,909.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2459.36,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,459.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2528.64,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,528.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,1683.45,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $1,683.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2944.31,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,944.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,HUMANA,HUMANA CHOICE CARE HMO,1731.95,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $1,731.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,HUMANA,HUMANA CHOICE CARE PPO,2944.31,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,944.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,HUMANA,HUMANA NATIIONAL POS HMO,1731.95,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $1,731.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2528.64,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,528.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,3463.89,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $3,463.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1731.95,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $1,731.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2909.67,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,909.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2597.92,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,597.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3186.78,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $3,186.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2211.00,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,211.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2494.00,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,494.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2494.00,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,494.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2147.61,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,147.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2494.00,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,494.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2494.00,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,494.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 6 X 8 5955680,C1781,HCPCS,278,RC,10052749,CDM,,,,both,,,3463.8900,2286.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2078.33,,,,,,,1683.4500,3463.8900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,463.89 in Billed Charges for Rev 278 Proc C1781 = $2,078.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,AETNA,AETNA HSHS,2552.11,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,552.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,AETNA,ALL COMMERCIAL AETNA,3950.64,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,950.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,ANTHEM,ANTHEM POS/HMO,2054.33,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,054.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,ANTHEM,ANTHEM PPO,2054.33,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,054.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3950.64,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,950.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,CENPATICO,ALL MEDICAID CENPATICO,3950.64,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,950.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3358.04,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,358.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,CIGNA,ALL COMMERCIAL CIGNA,2765.45,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,765.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,COFINITY,COFINITY,3950.64,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,950.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3753.11,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,753.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,3318.54,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,318.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2804.95,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,804.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2883.97,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,883.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,1920.01,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $1,920.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3358.04,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,358.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,HUMANA,HUMANA CHOICE CARE HMO,1975.32,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $1,975.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,HUMANA,HUMANA CHOICE CARE PPO,3358.04,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,358.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,HUMANA,HUMANA NATIIONAL POS HMO,1975.32,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $1,975.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2883.97,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,883.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,3950.64,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,950.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1975.32,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $1,975.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3318.54,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,318.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2962.98,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,962.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3634.59,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $3,634.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2521.69,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,521.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2844.46,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,844.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2844.46,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,844.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2449.40,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2844.46,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,844.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2844.46,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,844.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VENTRALIGHT ST ECHO OVAL 9X7IN,C1781,HCPCS,278,RC,10052750,CDM,,,,both,,,3950.6400,2607.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2370.38,,,,,,,1920.0100,3950.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,950.64 in Billed Charges for Rev 278 Proc C1781 = $2,370.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,AETNA,AETNA HSHS,1115.46,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,115.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,AETNA,ALL COMMERCIAL AETNA,1726.72,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,726.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,ANTHEM,ANTHEM POS/HMO,897.89,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $897.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,ANTHEM,ANTHEM PPO,897.89,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $897.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1726.72,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,726.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,CENPATICO,ALL MEDICAID CENPATICO,1726.72,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,726.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1467.71,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,467.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,CIGNA,ALL COMMERCIAL CIGNA,1208.70,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,208.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,COFINITY,COFINITY,1726.72,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,726.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1640.38,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,640.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,1450.44,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,450.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1225.97,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,225.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1260.51,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,260.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,839.19,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $839.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1467.71,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,467.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,HUMANA,HUMANA CHOICE CARE PPO,1467.71,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,467.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1260.51,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,260.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1726.72,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,726.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,863.36,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $863.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1450.44,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,450.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1295.04,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,295.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1588.58,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,588.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1102.17,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,102.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1243.24,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,243.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1243.24,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,243.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1070.57,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,070.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1243.24,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,243.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1243.24,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,243.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MESH VICRYL 12 X 12 VKM-L,C1781,HCPCS,278,RC,10018063,CDM,,,,both,,,1726.7200,1139.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1036.03,,,,,,,839.1900,1726.7200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,726.72 in Billed Charges for Rev 278 Proc C1781 = $1,036.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,AETNA,AETNA HSHS,498.62,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $498.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,AETNA,ALL COMMERCIAL AETNA,771.85,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $771.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,771.85,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $771.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,CENPATICO,ALL MEDICAID CENPATICO,771.85,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $771.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,656.07,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $656.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,CIGNA,ALL COMMERCIAL CIGNA,540.30,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $540.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,COFINITY,COFINITY,771.85,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $771.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,733.26,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $733.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,648.35,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $648.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,548.01,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $548.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,563.45,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $563.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,375.12,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $375.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,656.07,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $656.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,HUMANA,HUMANA CHOICE CARE PPO,656.07,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $656.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,563.45,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $563.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,771.85,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $771.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,385.93,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $385.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,648.35,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $648.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,578.89,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $578.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,710.10,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $710.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,492.67,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $492.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,555.73,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $555.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,555.73,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $555.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,478.55,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $478.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,555.73,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $555.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,555.73,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $555.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORE SOFT TISSUE 5 X 10CM X 1MM W.L. GORE,C1781,HCPCS,278,RC,10003950,CDM,,,,both,,,771.8500,509.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,463.11,,,,,,,375.1200,771.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $771.85 in Billed Charges for Rev 278 Proc C1781 = $463.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,AETNA,AETNA HSHS,866.09,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $866.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,AETNA,ALL COMMERCIAL AETNA,1340.70,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,340.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,ANTHEM,ANTHEM POS/HMO,697.16,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $697.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,ANTHEM,ANTHEM PPO,697.16,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $697.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1340.70,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,340.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,CENPATICO,ALL MEDICAID CENPATICO,1340.70,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,340.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1139.60,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,139.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,CIGNA,ALL COMMERCIAL CIGNA,938.49,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $938.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,COFINITY,COFINITY,1340.70,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,340.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1273.67,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,273.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,1126.19,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,126.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,951.90,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $951.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,978.71,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $978.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,651.58,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $651.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1139.60,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,139.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,HUMANA,HUMANA CHOICE CARE PPO,1139.60,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,139.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,978.71,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $978.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1340.70,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,340.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,670.35,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $670.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1126.19,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,126.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1005.53,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,005.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1233.44,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $1,233.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,855.77,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $855.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,965.30,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $965.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,965.30,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $965.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,831.23,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $831.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,965.30,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $965.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,965.30,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $965.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH GORTEX PERICARDIAL MEMBRANE 8X16X.01,C1781,HCPCS,278,RC,10076463,CDM,,,,both,,,1340.7000,884.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,804.42,,,,,,,651.5800,1340.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,340.70 in Billed Charges for Rev 278 Proc C1781 = $804.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,AETNA,AETNA HSHS,426.11,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $426.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,AETNA,ALL COMMERCIAL AETNA,659.62,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $659.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,659.62,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $659.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,CENPATICO,ALL MEDICAID CENPATICO,659.62,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $659.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,560.68,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $560.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,CIGNA,ALL COMMERCIAL CIGNA,461.73,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $461.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,COFINITY,COFINITY,659.62,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $659.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,626.64,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $626.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,554.08,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $554.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,468.33,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $468.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,481.52,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $481.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,320.58,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $320.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,560.68,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $560.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,HUMANA,HUMANA CHOICE CARE PPO,560.68,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $560.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,481.52,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $481.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,659.62,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $659.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,329.81,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $329.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,554.08,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $554.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,494.72,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $494.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,606.85,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $606.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,421.04,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $421.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,474.93,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $474.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,474.93,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $474.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,408.96,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $408.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,474.93,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $474.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,474.93,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $474.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PATCH PARIETEX VENTRAL 4.6CM,C1781,HCPCS,278,RC,10060718,CDM,,,,both,,,659.6200,435.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,395.77,,,,,,,320.5800,659.6200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $659.62 in Billed Charges for Rev 278 Proc C1781 = $395.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,AETNA,AETNA HSHS,268.90,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $268.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,AETNA,ALL COMMERCIAL AETNA,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,CENPATICO,ALL MEDICAID CENPATICO,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,353.81,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $353.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,CIGNA,ALL COMMERCIAL CIGNA,291.38,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $291.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,COFINITY,COFINITY,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,395.44,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $395.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,349.65,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $349.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,295.54,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $295.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,303.86,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $303.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,202.30,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $202.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,353.81,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $353.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,HUMANA,HUMANA CHOICE CARE PPO,353.81,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $353.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,303.86,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $303.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,416.25,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $416.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,208.13,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $208.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,349.65,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $349.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,312.19,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $312.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,382.95,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $382.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,265.69,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $265.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,299.70,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $299.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,299.70,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $299.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,258.08,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $258.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,299.70,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $299.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,299.70,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $299.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLUG LARGE MESH PERFIX 1.6 X 1.90,C1781,HCPCS,278,RC,10031849,CDM,,,,both,,,416.2500,274.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,249.75,,,,,,,202.3000,416.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $416.25 in Billed Charges for Rev 278 Proc C1781 = $249.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,AETNA,AETNA HSHS,413.89,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $413.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,AETNA,ALL COMMERCIAL AETNA,640.70,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $640.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,640.70,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $640.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,CENPATICO,ALL MEDICAID CENPATICO,640.70,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $640.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,544.60,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $544.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,CIGNA,ALL COMMERCIAL CIGNA,448.49,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $448.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,COFINITY,COFINITY,640.70,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $640.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,608.67,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $608.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,538.19,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $538.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,454.90,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $454.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,467.71,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $467.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,311.38,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $311.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,544.60,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $544.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,HUMANA,HUMANA CHOICE CARE PPO,544.60,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $544.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,467.71,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $467.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,640.70,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $640.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,320.35,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $320.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,538.19,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $538.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,480.53,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $480.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,589.44,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $589.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,408.96,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $408.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,461.30,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $461.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,461.30,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $461.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,397.23,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $397.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,461.30,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $461.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,461.30,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $461.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH CIRCULAR,C1781,HCPCS,278,RC,10071122,CDM,,,,both,,,640.7000,422.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,384.42,,,,,,,311.3800,640.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $640.70 in Billed Charges for Rev 278 Proc C1781 = $384.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,AETNA,AETNA HSHS,230.13,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $230.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,AETNA,ALL COMMERCIAL AETNA,356.24,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $356.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,356.24,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $356.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,CENPATICO,ALL MEDICAID CENPATICO,356.24,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $356.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,302.80,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $302.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,CIGNA,ALL COMMERCIAL CIGNA,249.37,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $249.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,COFINITY,COFINITY,356.24,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $356.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,338.43,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $338.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,299.24,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $299.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,252.93,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $252.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,260.06,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $260.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,173.13,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $173.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,302.80,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $302.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,HUMANA,HUMANA CHOICE CARE PPO,302.80,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $302.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,260.06,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $260.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,356.24,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $356.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,178.12,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $178.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,299.24,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $299.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,267.18,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $267.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,327.74,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $327.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,227.39,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $227.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,256.49,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $256.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,256.49,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $256.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,220.87,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $220.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,256.49,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $256.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,256.49,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $256.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL GIA 45,C1781,HCPCS,278,RC,10074225,CDM,,,,both,,,356.2400,235.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,213.74,,,,,,,173.1300,356.2400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $356.24 in Billed Charges for Rev 278 Proc C1781 = $213.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,AETNA,AETNA HSHS,286.34,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $286.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,AETNA,ALL COMMERCIAL AETNA,443.25,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $443.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,443.25,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $443.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,CENPATICO,ALL MEDICAID CENPATICO,443.25,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $443.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,376.76,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $376.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,CIGNA,ALL COMMERCIAL CIGNA,310.28,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $310.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,COFINITY,COFINITY,443.25,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $443.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,421.09,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $421.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,372.33,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $372.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,314.71,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $314.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,323.57,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $323.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,215.42,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $215.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,376.76,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $376.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,HUMANA,HUMANA CHOICE CARE PPO,376.76,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $376.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,323.57,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $323.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,443.25,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $443.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,221.63,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $221.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,372.33,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $372.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,332.44,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $332.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,407.79,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $407.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,282.93,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $282.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,319.14,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $319.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,319.14,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $319.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,274.82,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $274.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,319.14,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $319.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,319.14,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $319.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STRIP SEAMGUARD MESH UNIVERSAL STRAIGHT 45,C1781,HCPCS,278,RC,10010526,CDM,,,,both,,,443.2500,292.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,265.95,,,,,,,215.4200,443.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $443.25 in Billed Charges for Rev 278 Proc C1781 = $265.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,AETNA,AETNA HSHS,1841.10,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,841.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,AETNA,ALL COMMERCIAL AETNA,2850.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,ANTHEM,ANTHEM POS/HMO,1482.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,482.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,ANTHEM,ANTHEM PPO,1482.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,482.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2850.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,CENPATICO,ALL MEDICAID CENPATICO,2850.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2422.50,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,422.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,CIGNA,ALL COMMERCIAL CIGNA,1995.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,COFINITY,COFINITY,2850.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2707.50,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,707.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,2394.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2023.50,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,023.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2080.50,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,080.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,1385.10,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,385.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2422.50,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,422.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,HUMANA,HUMANA CHOICE CARE HMO,1425.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,425.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,HUMANA,HUMANA CHOICE CARE PPO,2422.50,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,422.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,HUMANA,HUMANA NATIIONAL POS HMO,1425.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,425.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2080.50,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,080.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2850.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1425.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,425.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2394.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2137.50,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,137.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2622.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,622.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1819.16,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,819.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2052.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,052.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2052.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,052.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1767.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,767.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2052.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,052.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2052.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $2,052.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DRAIN GLCM THK.9MM BLUNT TAPER AHMED FLEX PLATE SIL 16X13MM,C1783,HCPCS,278,RC,10014310,CDM,,,,both,,,2850.0000,1881.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1710.00,,,,,,,1385.1000,2850.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,850.00 in Billed Charges for Rev 278 Proc C1783 = $1,710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,AETNA,AETNA HSHS,1320.79,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,320.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,AETNA,ALL COMMERCIAL AETNA,2044.57,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $2,044.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,ANTHEM,ANTHEM POS/HMO,1063.18,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,063.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,ANTHEM,ANTHEM PPO,1063.18,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,063.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2044.57,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $2,044.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,CENPATICO,ALL MEDICAID CENPATICO,2044.57,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $2,044.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1737.88,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,737.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,CIGNA,ALL COMMERCIAL CIGNA,1431.20,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,431.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,COFINITY,COFINITY,2044.57,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $2,044.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1942.34,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,942.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,1717.44,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,717.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1451.64,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,451.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1492.54,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,492.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,993.66,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $993.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1737.88,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,737.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,HUMANA,HUMANA CHOICE CARE PPO,1737.88,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,737.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1492.54,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,492.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2044.57,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $2,044.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1022.29,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,022.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1717.44,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,717.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1533.43,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,533.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1881.00,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,881.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1305.05,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,305.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1472.09,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,472.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1472.09,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,472.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1267.63,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,267.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1472.09,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,472.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1472.09,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,472.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA P-50 PRELOAD,C1783,HCPCS,278,RC,10043231,CDM,,,,both,,,2044.5700,1349.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1226.74,,,,,,,993.6600,2044.5700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,044.57 in Billed Charges for Rev 278 Proc C1783 = $1,226.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,AETNA,AETNA HSHS,1317.68,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,317.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,AETNA,ALL COMMERCIAL AETNA,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,ANTHEM,ANTHEM POS/HMO,1060.67,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,060.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,ANTHEM,ANTHEM PPO,1060.67,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,060.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,CENPATICO,ALL MEDICAID CENPATICO,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1733.79,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,733.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,CIGNA,ALL COMMERCIAL CIGNA,1427.83,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,427.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,COFINITY,COFINITY,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1937.76,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,937.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,1713.39,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,713.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1448.22,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,448.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1489.02,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,489.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,991.32,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $991.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1733.79,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,733.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,HUMANA,HUMANA CHOICE CARE PPO,1733.79,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,733.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1489.02,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,489.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2039.75,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $2,039.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1019.88,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,019.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1713.39,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,713.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1529.81,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,529.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1876.57,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,876.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1301.97,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,301.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1468.62,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,468.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1468.62,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,468.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1264.65,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,264.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1468.62,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,468.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1468.62,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,468.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SHUNT EXPRESS GLAUCOMA S-50 PRELOAD,C1783,HCPCS,278,RC,10043028,CDM,,,,both,,,2039.7500,1346.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1223.85,,,,,,,991.3200,2039.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,039.75 in Billed Charges for Rev 278 Proc C1783 = $1,223.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,AETNA,AETNA HSHS,2698.34,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,698.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,AETNA,ALL COMMERCIAL AETNA,4177.00,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $4,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,ANTHEM,ANTHEM POS/HMO,2172.04,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,172.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,ANTHEM,ANTHEM PPO,2172.04,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,172.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4177.00,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $4,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,CENPATICO,ALL MEDICAID CENPATICO,4177.00,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $4,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3550.45,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,550.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,CIGNA,ALL COMMERCIAL CIGNA,2923.90,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,923.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,COFINITY,COFINITY,4177.00,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $4,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3968.15,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,968.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,3508.68,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,508.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2965.67,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,965.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3049.21,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,049.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,2030.02,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,030.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3550.45,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,550.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,HUMANA,HUMANA CHOICE CARE HMO,2088.50,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,088.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,HUMANA,HUMANA CHOICE CARE PPO,3550.45,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,550.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,HUMANA,HUMANA NATIIONAL POS HMO,2088.50,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,088.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3049.21,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,049.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,4177.00,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $4,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2088.50,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,088.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3508.68,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,508.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3132.75,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,132.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3842.84,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,842.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2666.18,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,666.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3007.44,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,007.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3007.44,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,007.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2589.74,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,589.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3007.44,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,007.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3007.44,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $3,007.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE",C1783,HCPCS,278,RC,27871783,CDM,,,,both,,,4177.0000,2756.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2506.20,,,,,,,2030.0200,4177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,177.00 in Billed Charges for Rev 278 Proc C1783 = $2,506.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,AETNA,AETNA HSHS,338.89,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $338.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,AETNA,ALL COMMERCIAL AETNA,524.60,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $524.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,524.60,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $524.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,CENPATICO,ALL MEDICAID CENPATICO,524.60,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $524.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,445.91,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $445.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,CIGNA,ALL COMMERCIAL CIGNA,367.22,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $367.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,COFINITY,COFINITY,524.60,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $524.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,498.37,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $498.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,440.66,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $440.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,372.47,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $372.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,382.96,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $382.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,254.96,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $254.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,445.91,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $445.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,HUMANA,HUMANA CHOICE CARE PPO,445.91,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $445.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,382.96,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $382.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,524.60,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $524.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,262.30,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $262.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,440.66,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $440.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,393.45,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $393.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,482.63,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $482.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,334.85,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $334.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,377.71,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $377.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,377.71,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $377.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,325.25,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $325.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,377.71,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $377.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,377.71,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $377.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORT POWER BARD ACCESS 8FR,C1788,HCPCS,278,RC,10037118,CDM,,,,both,,,524.6000,346.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,314.76,,,,,,,254.9600,524.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $524.60 in Billed Charges for Rev 278 Proc C1788 = $314.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,AETNA,AETNA HSHS,5814.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $5,814.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,AETNA,ALL COMMERCIAL AETNA,9000.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $9,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,ANTHEM,ANTHEM POS/HMO,4680.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,ANTHEM,ANTHEM PPO,4680.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9000.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $9,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,CENPATICO,ALL MEDICAID CENPATICO,9000.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $9,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7650.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $7,650.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,CIGNA,ALL COMMERCIAL CIGNA,6300.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,COFINITY,COFINITY,9000.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $9,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8550.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $8,550.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,7560.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $7,560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6390.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,390.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6570.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,570.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,4374.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,374.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7650.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $7,650.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,HUMANA,HUMANA CHOICE CARE HMO,4500.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,HUMANA,HUMANA CHOICE CARE PPO,7650.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $7,650.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,HUMANA,HUMANA NATIIONAL POS HMO,4500.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6570.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,570.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,9000.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $9,000.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4500.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7560.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $7,560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6750.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8280.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $8,280.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4500.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4500.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,PREVEA HEALTH NETWORK,PREVEA360,4500.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4500.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5744.70,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $5,744.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6480.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4194.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,4194.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,4194.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $4,194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6480.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5580.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $5,580.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6480.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6480.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $6,480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STIMULATOR EBI FUSION SPINAL SPF-XL IIB 2/DM,C1820,HCPCS,278,RC,10027800,CDM,,,,both,,,9000.0000,5940.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5400.00,,,,,,,4194.0000,9000.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,000.00 in Billed Charges for Rev 278 Proc C1820 = $5,400.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,AETNA,AETNA HSHS,787.96,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $787.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,AETNA,ALL COMMERCIAL AETNA,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,ANTHEM,ANTHEM POS/HMO,634.27,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $634.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,ANTHEM,ANTHEM PPO,634.27,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $634.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,CENPATICO,ALL MEDICAID CENPATICO,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1036.79,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,036.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,CIGNA,ALL COMMERCIAL CIGNA,853.83,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $853.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,COFINITY,COFINITY,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1158.76,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,1024.59,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,024.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,866.02,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $866.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,890.42,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $890.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,592.80,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $592.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1036.79,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,036.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,HUMANA,HUMANA CHOICE CARE PPO,1036.79,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,036.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,890.42,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $890.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1219.75,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,219.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,609.88,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $609.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1024.59,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,024.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,914.81,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $914.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1122.17,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $1,122.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,778.57,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $778.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,878.22,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $878.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,878.22,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $878.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,756.25,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $756.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,878.22,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $878.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,878.22,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $878.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,10088000,CDM,,,,both,,,1219.7500,805.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,731.85,,,,,,,592.8000,1219.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,219.75 in Billed Charges for Rev 278 Proc C1874 = $731.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,AETNA,AETNA HSHS,2610.49,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,610.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,AETNA,ALL COMMERCIAL AETNA,4041.00,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $4,041.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,ANTHEM,ANTHEM POS/HMO,2101.32,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,101.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,ANTHEM,ANTHEM PPO,2101.32,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,101.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4041.00,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $4,041.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,CENPATICO,ALL MEDICAID CENPATICO,4041.00,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $4,041.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3434.85,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $3,434.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,CIGNA,ALL COMMERCIAL CIGNA,2828.70,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,828.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,COFINITY,COFINITY,4041.00,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $4,041.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3838.95,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $3,838.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,3394.44,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $3,394.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2869.11,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,869.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2949.93,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,949.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,1963.93,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $1,963.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3434.85,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $3,434.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,HUMANA,HUMANA CHOICE CARE HMO,2020.50,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,020.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,HUMANA,HUMANA CHOICE CARE PPO,3434.85,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $3,434.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,HUMANA,HUMANA NATIIONAL POS HMO,2020.50,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,020.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2949.93,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,949.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,4041.00,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $4,041.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2020.50,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,020.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3394.44,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $3,394.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3030.75,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $3,030.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3717.72,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $3,717.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2579.37,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,579.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2909.52,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,909.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2909.52,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,909.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2505.42,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,505.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2909.52,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,909.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2909.52,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,909.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT TRACHBRONC 7MM 80CM 40MM .035IN GRFT FLN NTNL,C1874,HCPCS,278,RC,10050798,CDM,,,,both,,,4041.0000,2667.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2424.60,,,,,,,1963.9300,4041.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,041.00 in Billed Charges for Rev 278 Proc C1874 = $2,424.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,AETNA,AETNA HSHS,1116.06,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,116.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,AETNA,ALL COMMERCIAL AETNA,1727.64,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,727.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,ANTHEM,ANTHEM POS/HMO,898.37,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $898.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,ANTHEM,ANTHEM PPO,898.37,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $898.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1727.64,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,727.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,CENPATICO,ALL MEDICAID CENPATICO,1727.64,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,727.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1468.49,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,468.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,CIGNA,ALL COMMERCIAL CIGNA,1209.35,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,209.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,COFINITY,COFINITY,1727.64,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,727.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1641.26,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,641.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,1451.22,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,451.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1226.62,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,226.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1261.18,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,261.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,839.63,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $839.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1468.49,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,468.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,HUMANA,HUMANA CHOICE CARE PPO,1468.49,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,468.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1261.18,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,261.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1727.64,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,727.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,863.82,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $863.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1451.22,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,451.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1295.73,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,295.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1589.43,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,589.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1102.75,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,102.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1243.90,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,243.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1243.90,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,243.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1071.14,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,071.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1243.90,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,243.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1243.90,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,243.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10034858,CDM,,,,both,,,1727.6400,1140.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1036.58,,,,,,,839.6300,1727.6400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,727.64 in Billed Charges for Rev 278 Proc C1876 = $1,036.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,AETNA,AETNA HSHS,1149.33,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,149.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,AETNA,ALL COMMERCIAL AETNA,1779.15,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,779.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,ANTHEM,ANTHEM POS/HMO,925.16,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $925.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,ANTHEM,ANTHEM PPO,925.16,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $925.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1779.15,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,779.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,CENPATICO,ALL MEDICAID CENPATICO,1779.15,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,779.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1512.28,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,512.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,CIGNA,ALL COMMERCIAL CIGNA,1245.41,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,245.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,COFINITY,COFINITY,1779.15,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,779.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1690.19,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,690.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,1494.49,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,494.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1263.20,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,263.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1298.78,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,298.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,864.67,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $864.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1512.28,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,512.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,HUMANA,HUMANA CHOICE CARE PPO,1512.28,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,512.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1298.78,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,298.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1779.15,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,779.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,889.58,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $889.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1494.49,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,494.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1334.36,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,334.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1636.82,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,636.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1135.63,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,135.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1280.99,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,280.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1280.99,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,280.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1103.07,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,103.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1280.99,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,280.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1280.99,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,280.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,10002997,CDM,,,,both,,,1779.1500,1174.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1067.49,,,,,,,864.6700,1779.1500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,779.15 in Billed Charges for Rev 278 Proc C1876 = $1,067.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,AETNA,AETNA HSHS,1423.78,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,423.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,AETNA,ALL COMMERCIAL AETNA,2204.00,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $2,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,ANTHEM,ANTHEM POS/HMO,1146.08,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,146.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,ANTHEM,ANTHEM PPO,1146.08,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,146.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2204.00,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $2,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,CENPATICO,ALL MEDICAID CENPATICO,2204.00,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $2,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1873.40,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,873.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,CIGNA,ALL COMMERCIAL CIGNA,1542.80,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,542.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,COFINITY,COFINITY,2204.00,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $2,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2093.80,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $2,093.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,1851.36,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,851.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1564.84,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,564.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1608.92,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,608.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,1071.14,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,071.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1873.40,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,873.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,HUMANA,HUMANA CHOICE CARE PPO,1873.40,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,873.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1608.92,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,608.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2204.00,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $2,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1102.00,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1851.36,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,851.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1653.00,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,653.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2027.68,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $2,027.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1406.81,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,406.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1586.88,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,586.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1586.88,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,586.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1366.48,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,366.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1586.88,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,586.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1586.88,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,586.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT STENT WALL 8 X 40,C1876,HCPCS,278,RC,10005027,CDM,,,,both,,,2204.0000,1454.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1322.40,,,,,,,1071.1400,2204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,204.00 in Billed Charges for Rev 278 Proc C1876 = $1,322.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,AETNA,AETNA HSHS,1145.52,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,145.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,AETNA,ALL COMMERCIAL AETNA,1773.25,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,773.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,ANTHEM,ANTHEM POS/HMO,922.09,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $922.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,ANTHEM,ANTHEM PPO,922.09,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $922.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1773.25,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,773.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,CENPATICO,ALL MEDICAID CENPATICO,1773.25,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,773.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1507.26,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,507.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,CIGNA,ALL COMMERCIAL CIGNA,1241.28,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,241.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,COFINITY,COFINITY,1773.25,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,773.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1684.59,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,684.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,1489.53,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,489.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1259.01,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,259.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1294.47,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,294.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,861.80,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $861.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1507.26,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,507.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,HUMANA,HUMANA CHOICE CARE PPO,1507.26,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,507.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1294.47,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,294.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1773.25,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,773.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,886.63,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $886.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1489.53,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,489.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1329.94,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,329.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1631.39,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,631.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1131.87,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,131.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1276.74,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,276.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1276.74,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,276.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1099.42,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,099.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1276.74,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,276.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1276.74,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,276.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
STENT BILI 8MM 20MM 130CM BALON EXPND DEL SYS BRDG ASR,C1876,HCPCS,278,RC,10006186,CDM,,,,both,,,1773.2500,1170.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1063.95,,,,,,,861.8000,1773.2500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,773.25 in Billed Charges for Rev 278 Proc C1876 = $1,063.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,AETNA,AETNA HSHS,261.63,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $261.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,AETNA,ALL COMMERCIAL AETNA,405.00,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $405.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,405.00,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $405.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,CENPATICO,ALL MEDICAID CENPATICO,405.00,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $405.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,344.25,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $344.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,CIGNA,ALL COMMERCIAL CIGNA,283.50,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $283.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,COFINITY,COFINITY,405.00,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $405.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,384.75,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $384.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,340.20,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $340.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,287.55,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $287.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,295.65,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $295.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,196.83,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $196.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,344.25,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $344.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,HUMANA,HUMANA CHOICE CARE PPO,344.25,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $344.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,295.65,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $295.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,405.00,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $405.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,202.50,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $202.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,340.20,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $340.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,303.75,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $303.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,372.60,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $372.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,258.51,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $258.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,291.60,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $291.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,291.60,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $291.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,251.10,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $251.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,291.60,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $291.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,291.60,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $291.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BASKET STON RETRVL 3FR ULTRA-CTCH RND NTNL NO TIP 4WR 1 HAND,C1889,HCPCS,278,RC,10092360,CDM,,,,both,,,405.0000,267.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,243.00,,,,,,,196.8300,405.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $405.00 in Billed Charges for Rev 278 Proc C1889 = $243.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,AETNA,AETNA HSHS,7639.60,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $7,639.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,AETNA,ALL COMMERCIAL AETNA,11826.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $11,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,ANTHEM,ANTHEM POS/HMO,6149.52,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $6,149.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,ANTHEM,ANTHEM PPO,6149.52,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $6,149.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11826.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $11,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,CENPATICO,ALL MEDICAID CENPATICO,11826.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $11,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10052.10,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $10,052.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,CIGNA,ALL COMMERCIAL CIGNA,8278.20,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,278.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,COFINITY,COFINITY,11826.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $11,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11234.70,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $11,234.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,9933.84,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $9,933.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8396.46,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,396.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8632.98,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,632.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,5747.44,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,747.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10052.10,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $10,052.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,HUMANA,HUMANA CHOICE CARE HMO,5913.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,913.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,HUMANA,HUMANA CHOICE CARE PPO,10052.10,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $10,052.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,HUMANA,HUMANA NATIIONAL POS HMO,5913.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,913.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8632.98,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,632.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,11826.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $11,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5913.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,913.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9933.84,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $9,933.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8869.50,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,869.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10879.92,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $10,879.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5913.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,913.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5913.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,913.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,PREVEA HEALTH NETWORK,PREVEA360,5913.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,913.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5913.00,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,913.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7548.54,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $7,548.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8514.72,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,514.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5510.92,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,510.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,5510.92,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,510.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,5510.92,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 46.6% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $5,510.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8514.72,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,514.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7332.12,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $7,332.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8514.72,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,514.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8514.72,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $8,514.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GRAFT BONE INFUSE MEDTRONIC LARGE KIT,C1889,HCPCS,278,RC,10005436,CDM,,,,both,,,11826.0000,7805.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7095.60,,,,,,,5510.9200,11826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $11,826.00 in Billed Charges for Rev 278 Proc C1889 = $7,095.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,AETNA,AETNA HSHS,1288.77,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,288.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,AETNA,ALL COMMERCIAL AETNA,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,ANTHEM,ANTHEM POS/HMO,1037.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,037.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,ANTHEM,ANTHEM PPO,1037.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,037.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,CENPATICO,ALL MEDICAID CENPATICO,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1695.75,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,695.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,CIGNA,ALL COMMERCIAL CIGNA,1396.50,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,396.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,COFINITY,COFINITY,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1895.25,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,895.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,1675.80,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,675.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1416.45,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,416.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1456.35,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,456.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,969.57,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $969.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1695.75,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,695.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,HUMANA,HUMANA CHOICE CARE PPO,1695.75,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,695.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1456.35,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,456.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1995.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,995.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,997.50,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1675.80,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,675.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1496.25,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,496.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1835.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,835.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1273.41,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,273.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1436.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1436.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1236.90,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,236.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1436.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1436.40,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT UROLIFT 2 CARTRIDGE,C1889,HCPCS,278,RC,10090036,CDM,,,,both,,,1995.0000,1316.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1197.00,,,,,,,969.5700,1995.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,995.00 in Billed Charges for Rev 278 Proc C1889 = $1,197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,AETNA,AETNA HSHS,267.01,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $267.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,AETNA,ALL COMMERCIAL AETNA,413.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $413.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,413.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $413.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,CENPATICO,ALL MEDICAID CENPATICO,413.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $413.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,351.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $351.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,CIGNA,ALL COMMERCIAL CIGNA,289.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $289.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,COFINITY,COFINITY,413.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $413.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,392.66,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $392.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,347.20,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $347.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,293.46,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $293.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,301.73,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $301.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,200.88,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $200.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,351.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $351.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,HUMANA,HUMANA CHOICE CARE PPO,351.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $351.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,301.73,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $301.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,413.33,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $413.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,206.67,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $206.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,347.20,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $347.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,310.00,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,380.26,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $380.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,263.83,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $263.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,297.60,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,297.60,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,256.26,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $256.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,297.60,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,297.60,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10010171,CDM,,,,both,,,413.3300,272.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,248.00,,,,,,,200.8800,413.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $413.33 in Billed Charges for Rev 278 Proc C2617 = $248.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,AETNA,AETNA HSHS,213.88,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $213.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,AETNA,ALL COMMERCIAL AETNA,331.09,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,331.09,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,CENPATICO,ALL MEDICAID CENPATICO,331.09,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,281.43,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $281.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,CIGNA,ALL COMMERCIAL CIGNA,231.76,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $231.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,COFINITY,COFINITY,331.09,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,314.54,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $314.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,278.12,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $278.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,235.07,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $235.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,241.70,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $241.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,160.91,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $160.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,281.43,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $281.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,HUMANA,HUMANA CHOICE CARE PPO,281.43,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $281.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,241.70,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $241.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,331.09,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,165.55,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $165.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,278.12,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $278.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,248.32,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $248.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,304.60,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $304.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,211.33,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $211.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,238.38,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $238.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,238.38,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $238.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,205.28,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $205.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,238.38,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $238.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,238.38,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $238.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,70408239,CDM,,,,both,,,331.0900,218.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,198.65,,,,,,,160.9100,331.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $331.09 in Billed Charges for Rev 278 Proc C2617 = $198.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,AETNA,AETNA HSHS,208.58,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $208.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,AETNA,ALL COMMERCIAL AETNA,322.88,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $322.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,322.88,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $322.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,CENPATICO,ALL MEDICAID CENPATICO,322.88,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $322.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,274.45,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $274.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,CIGNA,ALL COMMERCIAL CIGNA,226.02,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $226.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,COFINITY,COFINITY,322.88,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $322.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,306.74,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $306.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,271.22,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $271.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,229.24,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $229.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,235.70,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $235.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,156.92,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $156.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,274.45,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $274.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,HUMANA,HUMANA CHOICE CARE PPO,274.45,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $274.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,235.70,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $235.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,322.88,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $322.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,161.44,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $161.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,271.22,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $271.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,242.16,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $242.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,297.05,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $297.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,206.09,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $206.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,232.47,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $232.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,232.47,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $232.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,200.19,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $200.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,232.47,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $232.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,232.47,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $232.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STENT POLARIS ULTRA 7FRX24CM,C2617,HCPCS,278,RC,70401972,CDM,,,,both,,,322.8800,213.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,193.73,,,,,,,156.9200,322.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $322.88 in Billed Charges for Rev 278 Proc C2617 = $193.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA HSHS,75.58,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $75.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA MEDICARE,13.25,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,AETNA,ALL COMMERCIAL AETNA,117.00,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTEHM MEDICAID,13.69,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80177 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.25,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM POS/HMO,46.38,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80177 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM PPO,46.38,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80177 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,117.00,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,CENPATICO,ALL MEDICAID CENPATICO,117.00,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,99.45,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,CIGNA,ALL COMMERCIAL CIGNA,81.90,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $81.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,COFINITY,COFINITY,117.00,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.69,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80177 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.69,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80177 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,111.15,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $111.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,98.28,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.07,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $83.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,85.41,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,56.86,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $56.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,99.45,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE HMO,22.53,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80177 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE PPO,99.45,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,13.25,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA NATIIONAL POS HMO,22.53,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80177 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,85.41,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,117.00,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.69,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80177 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.25,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.69,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80177 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,14.51,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80177 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69... $13.69 at 106% = $14.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,13.25,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,58.50,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,98.28,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,29.81,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,87.75,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $87.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,107.64,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $107.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.23,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.23,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360,17.23,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.23,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,74.68,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $74.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.38,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.24,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,TRILOGY MEDICAID,14.51,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80177 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 106% = $14.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.90,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80177 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,15.90,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80177 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.25,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,15.90,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80177 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,UNITY HEALTH PLAN,UNITY HOSPICE,13.25,,,,,,,13.2500,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.24,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,72.54,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $72.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.24,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.24,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC  DRUG SCRN QUAN LEVETIRACETAM (KEPPRA),80177,CPT,301,RC,30100149,CDM,,,,both,,,117.0000,77.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.20,,,,,,,13.2500,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $117.00 in Billed Charges for Rev 301 Proc 80177 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,AETNA,AETNA HSHS,82.04,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $82.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,AETNA,AETNA MEDICARE,27.11,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,AETNA,ALL COMMERCIAL AETNA,127.00,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTEHM MEDICAID,19.70,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80199 at $19.70 (Fee Schedule) = $19.70 (Total Line Payment) at 100% = $19.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,27.11,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTHEM POS/HMO,94.89,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $94.89 from Fee Schedule WII28_25 for Rev 301 Proc 80199 Mod TC * Qty 1 = $94.89 at 100% = $94.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTHEM PPO,94.89,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $94.89 from Fee Schedule WII28_25 for Rev 301 Proc 80199 Mod TC * Qty 1 = $94.89 at 100% = $94.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,127.00,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,CENPATICO,ALL MEDICAID CENPATICO,127.00,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,107.95,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,CIGNA,ALL COMMERCIAL CIGNA,88.90,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $88.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,COFINITY,COFINITY,127.00,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,19.70,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80199 at $19.70 (Fee Schedule) = $19.70 (Total Line Payment) at 100% = $19.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,19.70,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80199 at $19.70 (Fee Schedule) = $19.70 (Total Line Payment) at 100% = $19.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,120.65,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $120.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,106.68,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $106.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,90.17,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $90.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,92.71,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $92.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,61.72,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $61.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,107.95,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA CHOICE CARE HMO,46.09,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.09 from Fee Schedule 005543_170 for Rev 301 Proc 80199 * Qty 1 = $46.09 at 100% = $46.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA CHOICE CARE PPO,107.95,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,27.11,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA NATIIONAL POS HMO,46.09,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.09 from Fee Schedule 005543_170 for Rev 301 Proc 80199 * Qty 1 = $46.09 at 100% = $46.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,92.71,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $92.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,127.00,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,19.70,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80199 at $19.70 (Fee Schedule) = $19.70 (Total Line Payment) at 100% = $19.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,27.11,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,19.70,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80199 at $19.70 (Fee Schedule) = $19.70 (Total Line Payment) at 100% = $19.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,20.88,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80199 at $19.70 (Fee Schedule) = $19.70 (Total Line Payment) at 100% = $19.70... $19.70 at 106% = $20.88 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,27.11,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,63.50,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $63.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,106.68,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $106.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,61.00,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,95.25,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $95.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,116.84,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $116.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,35.24,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,35.24,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA360,35.24,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,35.24,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,81.06,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $81.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,27.38,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,91.44,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,TRIOLOGY,TRILOGY MEDICAID,20.88,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80199 at $19.70 (Fee Schedule) = $19.70 (Total Line Payment) at 106% = $20.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32.53,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.53 from Fee Schedule UHC_98227C for Rev 301 Proc 80199 * Qty 1 = $32.53 at 100% = $32.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,32.53,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.53 from Fee Schedule UHC_98227C for Rev 301 Proc 80199 * Qty 1 = $32.53 at 100% = $32.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,27.11,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,32.53,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.53 from Fee Schedule UHC_98227C for Rev 301 Proc 80199 * Qty 1 = $32.53 at 100% = $32.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,UNITY HEALTH PLAN,UNITY HOSPICE,27.11,,,,,,,19.7000,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,91.44,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,78.74,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $78.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,91.44,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,91.44,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TIAGABINE,80199,CPT,301,RC,30100151,CDM,,,,both,,,127.0000,83.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,76.20,,,,,,,19.7000,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $127.00 in Billed Charges for Rev 301 Proc 80199 = $76.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,AETNA,AETNA HSHS,572.36,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $572.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,AETNA,ALL COMMERCIAL AETNA,886.00,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $886.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,ANTHEM,ANTEHM MEDICAID,1.11,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81099 at $125.60 (Base Rate) * 0.0088 (Relative Weight) = $1.11 (Total Line Payment) at 100% = $1.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,ANTHEM,ANTHEM POS/HMO,602.48,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 301 Proc 81099 $886.00 in Billed Charges at 68% = $602.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,ANTHEM,ANTHEM PPO,602.48,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 301 Proc 81099 $886.00 in Billed Charges at 68% = $602.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,886.00,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $886.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,CENPATICO,ALL MEDICAID CENPATICO,886.00,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $886.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,753.10,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $753.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,CIGNA,ALL COMMERCIAL CIGNA,620.20,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $620.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,COFINITY,COFINITY,886.00,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $886.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1.11,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81099 at $125.60 (Base Rate) * 0.0088 (Relative Weight) = $1.11 (Total Line Payment) at 100% = $1.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1.11,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81099 at $125.60 (Base Rate) * 0.0088 (Relative Weight) = $1.11 (Total Line Payment) at 100% = $1.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,841.70,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $841.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,744.24,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $744.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,629.06,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $629.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,646.78,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $646.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,430.60,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $430.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,753.10,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $753.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,HUMANA,HUMANA CHOICE CARE PPO,753.10,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $753.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,646.78,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $646.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,886.00,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $886.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1.11,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81099 at $125.60 (Base Rate) * 0.0088 (Relative Weight) = $1.11 (Total Line Payment) at 100% = $1.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1.11,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81099 at $125.60 (Base Rate) * 0.0088 (Relative Weight) = $1.11 (Total Line Payment) at 100% = $1.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,1.18,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81099 at $125.60 (Base Rate) * 0.0088 (Relative Weight) = $1.11 (Total Line Payment) at 100% = $1.11... $1.11 at 106% = $1.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,620.20,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $620.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,443.00,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,744.24,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $744.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,531.60,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $531.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,664.50,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $664.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,815.12,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $815.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,531.60,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,531.60,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,PREVEA HEALTH NETWORK,PREVEA360,531.60,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,531.60,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,565.53,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $565.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,637.92,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $637.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,TRIOLOGY,TRILOGY MEDICAID,1.17,,,,,,,1.1100,886.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81099 at $125.60 (Base Rate) * 0.0088 (Relative Weight) = $1.11 (Total Line Payment) at 106% = $1.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,637.92,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $637.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,549.32,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $549.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,637.92,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $637.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,637.92,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $637.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INBORN ERR METABOLISM,81099,CPT,301,RC,30100155,CDM,,,,both,,,886.0000,584.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,531.60,,,,,,,1.1100,886.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $886.00 in Billed Charges for Rev 301 Proc 81099 = $531.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,AETNA,AETNA HSHS,157.62,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $157.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,AETNA,AETNA MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,AETNA,ALL COMMERCIAL AETNA,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,ANTHEM,ANTEHM MEDICAID,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,ANTHEM,ANTHEM POS/HMO,244.00,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $400.51 from Fee Schedule WII28_25 for Rev 301 Proc G0480 Mod TC * Qty 1 = $400.51 at 100% = $400.51 (Limited to $244.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,ANTHEM,ANTHEM PPO,244.00,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $400.51 from Fee Schedule WII28_25 for Rev 301 Proc G0480 Mod TC * Qty 1 = $400.51 at 100% = $400.51 (Limited to $244.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,CENPATICO,ALL MEDICAID CENPATICO,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,207.40,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $207.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,CIGNA,ALL COMMERCIAL CIGNA,170.80,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $170.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,COFINITY,COFINITY,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,231.80,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $231.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,204.96,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $204.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,173.24,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $173.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,178.12,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $178.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,118.58,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $118.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,207.40,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $207.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HUMANA,HUMANA CHOICE CARE HMO,194.53,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $194.53 from Fee Schedule 005543_170 for Rev 301 Proc G0480 * Qty 1 = $194.53 at 100% = $194.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HUMANA,HUMANA CHOICE CARE PPO,207.40,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $207.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HUMANA,HUMANA MEDICARE ADVANTAGE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,HUMANA,HUMANA NATIIONAL POS HMO,194.53,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $194.53 from Fee Schedule 005543_170 for Rev 301 Proc G0480 * Qty 1 = $194.53 at 100% = $194.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,178.12,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $178.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,MOLINA HEALTHCARE,MOLINA MEDICAID,67.79,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95... $63.95 at 106% = $67.79 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,MOLINA HEALTHCARE,MOLINA MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,122.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,204.96,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $204.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,NAPHCARE,ALL COMMERICAL NAPHCARE,257.47,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,183.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $183.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,224.48,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $224.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,PREVEA HEALTH NETWORK,PREVEA360,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,155.75,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $155.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,115.57,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,175.68,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,TRIOLOGY,TRILOGY MEDICAID,67.79,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 106% = $67.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 301 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 301 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 301 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,UNITY HEALTH PLAN,UNITY HOSPICE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,175.68,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,151.28,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $151.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,175.68,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,175.68,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETAMINOPHEN,G0480,HCPCS,301,RC,30100156,CDM,,,,both,,,244.0000,161.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,146.40,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.00 in Billed Charges for Rev 301 Proc G0480 = $146.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,AETNA,AETNA HSHS,40.05,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $40.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,AETNA,AETNA MEDICARE,4.52,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,AETNA,ALL COMMERCIAL AETNA,62.00,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $62.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,ANTHEM,ANTEHM MEDICAID,4.67,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82009 at $4.67 (Fee Schedule) = $4.67 (Total Line Payment) at 100% = $4.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,4.52,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,ANTHEM,ANTHEM POS/HMO,15.82,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.82 from Fee Schedule WII28_25 for Rev 301 Proc 82009 Mod TC * Qty 1 = $15.82 at 100% = $15.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,ANTHEM,ANTHEM PPO,15.82,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.82 from Fee Schedule WII28_25 for Rev 301 Proc 82009 Mod TC * Qty 1 = $15.82 at 100% = $15.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,62.00,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $62.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,CENPATICO,ALL MEDICAID CENPATICO,62.00,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $62.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,52.70,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $52.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,CIGNA,ALL COMMERCIAL CIGNA,43.40,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $43.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,COFINITY,COFINITY,62.00,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $62.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,4.67,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82009 at $4.67 (Fee Schedule) = $4.67 (Total Line Payment) at 100% = $4.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,4.67,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82009 at $4.67 (Fee Schedule) = $4.67 (Total Line Payment) at 100% = $4.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,58.90,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $58.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,52.08,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $52.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,44.02,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $44.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,45.26,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $45.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,30.13,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $30.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,52.70,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $52.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HUMANA,HUMANA CHOICE CARE HMO,7.68,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.68 from Fee Schedule 005543_170 for Rev 301 Proc 82009 * Qty 1 = $7.68 at 100% = $7.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HUMANA,HUMANA CHOICE CARE PPO,52.70,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $52.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,4.52,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,HUMANA,HUMANA NATIIONAL POS HMO,7.68,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.68 from Fee Schedule 005543_170 for Rev 301 Proc 82009 * Qty 1 = $7.68 at 100% = $7.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,45.26,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $45.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,62.00,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $62.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,4.67,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82009 at $4.67 (Fee Schedule) = $4.67 (Total Line Payment) at 100% = $4.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,4.52,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,4.67,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82009 at $4.67 (Fee Schedule) = $4.67 (Total Line Payment) at 100% = $4.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,4.95,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82009 at $4.67 (Fee Schedule) = $4.67 (Total Line Payment) at 100% = $4.67... $4.67 at 106% = $4.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,4.52,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,31.00,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $31.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,52.08,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $52.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,10.17,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,46.50,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $46.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,57.04,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $57.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.88,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.88,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,PREVEA HEALTH NETWORK,PREVEA360,5.88,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.88,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,39.57,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $39.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,4.57,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,44.64,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $44.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,TRIOLOGY,TRILOGY MEDICAID,4.95,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82009 at $4.67 (Fee Schedule) = $4.67 (Total Line Payment) at 106% = $4.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.42,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.42 from Fee Schedule UHC_98227C for Rev 301 Proc 82009 * Qty 1 = $5.42 at 100% = $5.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,5.42,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.42 from Fee Schedule UHC_98227C for Rev 301 Proc 82009 * Qty 1 = $5.42 at 100% = $5.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,4.52,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,5.42,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.42 from Fee Schedule UHC_98227C for Rev 301 Proc 82009 * Qty 1 = $5.42 at 100% = $5.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,UNITY HEALTH PLAN,UNITY HOSPICE,4.52,,,,,,,4.5200,62.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,44.64,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $44.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,38.44,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $38.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,44.64,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $44.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,44.64,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $44.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE SERUM,82009,CPT,301,RC,30100157,CDM,,,,both,,,62.0000,40.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,37.20,,,,,,,4.5200,62.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $62.00 in Billed Charges for Rev 301 Proc 82009 = $37.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,AETNA,AETNA HSHS,43.28,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $43.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,AETNA,AETNA MEDICARE,8.17,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,AETNA,ALL COMMERCIAL AETNA,67.00,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,ANTHEM,ANTEHM MEDICAID,8.44,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82010 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.17,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,ANTHEM,ANTHEM POS/HMO,28.60,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.60 from Fee Schedule WII28_25 for Rev 301 Proc 82010 Mod TC * Qty 1 = $28.60 at 100% = $28.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,ANTHEM,ANTHEM PPO,28.60,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.60 from Fee Schedule WII28_25 for Rev 301 Proc 82010 Mod TC * Qty 1 = $28.60 at 100% = $28.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,67.00,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,CENPATICO,ALL MEDICAID CENPATICO,67.00,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,56.95,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $56.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,CIGNA,ALL COMMERCIAL CIGNA,46.90,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $46.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,COFINITY,COFINITY,67.00,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.44,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82010 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.44,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82010 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,63.65,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $63.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,56.28,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $56.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,47.57,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $47.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,48.91,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $48.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,32.56,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $32.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,56.95,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $56.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HUMANA,HUMANA CHOICE CARE HMO,13.89,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.89 from Fee Schedule 005543_170 for Rev 301 Proc 82010 * Qty 1 = $13.89 at 100% = $13.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HUMANA,HUMANA CHOICE CARE PPO,56.95,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $56.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,8.17,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,HUMANA,HUMANA NATIIONAL POS HMO,13.89,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.89 from Fee Schedule 005543_170 for Rev 301 Proc 82010 * Qty 1 = $13.89 at 100% = $13.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,48.91,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $48.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,67.00,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.44,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82010 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.17,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.44,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82010 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,8.95,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82010 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44... $8.44 at 106% = $8.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,8.17,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,33.50,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $33.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,56.28,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $56.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,18.38,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,50.25,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $50.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,61.64,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $61.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.62,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.62,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,PREVEA HEALTH NETWORK,PREVEA360,10.62,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.62,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,42.77,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $42.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.25,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,48.24,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $48.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,TRIOLOGY,TRILOGY MEDICAID,8.95,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82010 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 106% = $8.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.80,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.80 from Fee Schedule UHC_98227C for Rev 301 Proc 82010 * Qty 1 = $9.80 at 100% = $9.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,9.80,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.80 from Fee Schedule UHC_98227C for Rev 301 Proc 82010 * Qty 1 = $9.80 at 100% = $9.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.17,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,9.80,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.80 from Fee Schedule UHC_98227C for Rev 301 Proc 82010 * Qty 1 = $9.80 at 100% = $9.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,UNITY HEALTH PLAN,UNITY HOSPICE,8.17,,,,,,,8.1700,67.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,48.24,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $48.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,41.54,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $41.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,48.24,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $48.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,48.24,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $48.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACETONE KETONES SERUM QN,82010,CPT,301,RC,30100158,CDM,,,,both,,,67.0000,44.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,40.20,,,,,,,8.1700,67.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.00 in Billed Charges for Rev 301 Proc 82010 = $40.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,AETNA,AETNA HSHS,379.20,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $379.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,AETNA,AETNA MEDICARE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,AETNA,ALL COMMERCIAL AETNA,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,ANTHEM,ANTEHM MEDICAID,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,ANTHEM,ANTHEM POS/HMO,59.05,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82017 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,ANTHEM,ANTHEM PPO,59.05,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82017 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,CENPATICO,ALL MEDICAID CENPATICO,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,498.95,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $498.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,CIGNA,ALL COMMERCIAL CIGNA,410.90,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $410.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,COFINITY,COFINITY,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,557.65,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $557.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,493.08,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $493.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,416.77,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $416.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,428.51,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $428.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,285.28,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $285.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,498.95,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $498.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HUMANA,HUMANA CHOICE CARE HMO,28.68,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82017 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HUMANA,HUMANA CHOICE CARE PPO,498.95,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $498.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HUMANA,HUMANA MEDICARE ADVANTAGE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,HUMANA,HUMANA NATIIONAL POS HMO,28.68,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82017 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,428.51,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $428.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,MOLINA HEALTHCARE,MOLINA MEDICAID,18.48,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43... $17.43 at 106% = $18.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,MOLINA HEALTHCARE,MOLINA MEDICARE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,293.50,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $293.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,493.08,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $493.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,NAPHCARE,ALL COMMERICAL NAPHCARE,37.96,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,440.25,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $440.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,540.04,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $540.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.93,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.93,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,PREVEA HEALTH NETWORK,PREVEA360,21.93,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.93,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,374.68,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $374.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.04,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,422.64,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $422.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,TRIOLOGY,TRILOGY MEDICAID,18.48,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 106% = $18.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.24,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82017 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,20.24,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82017 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,20.24,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82017 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,UNITY HEALTH PLAN,UNITY HOSPICE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,422.64,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $422.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,363.94,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $363.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,422.64,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $422.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,422.64,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $422.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN EA SPEC,82017,CPT,301,RC,30100159,CDM,,,,both,,,587.0000,387.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,352.20,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $587.00 in Billed Charges for Rev 301 Proc 82017 = $352.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,AETNA,AETNA HSHS,228.68,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $228.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,AETNA,AETNA MEDICARE,38.62,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,AETNA,ALL COMMERCIAL AETNA,354.00,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $354.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,ANTHEM,ANTEHM MEDICAID,39.91,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82024 at $39.91 (Fee Schedule) = $39.91 (Total Line Payment) at 100% = $39.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,38.62,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,ANTHEM,ANTHEM POS/HMO,135.17,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $135.17 from Fee Schedule WII28_25 for Rev 301 Proc 82024 Mod TC * Qty 1 = $135.17 at 100% = $135.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,ANTHEM,ANTHEM PPO,135.17,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $135.17 from Fee Schedule WII28_25 for Rev 301 Proc 82024 Mod TC * Qty 1 = $135.17 at 100% = $135.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,354.00,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $354.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,CENPATICO,ALL MEDICAID CENPATICO,354.00,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $354.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,300.90,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $300.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,CIGNA,ALL COMMERCIAL CIGNA,247.80,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $247.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,COFINITY,COFINITY,354.00,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $354.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,39.91,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82024 at $39.91 (Fee Schedule) = $39.91 (Total Line Payment) at 100% = $39.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,39.91,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82024 at $39.91 (Fee Schedule) = $39.91 (Total Line Payment) at 100% = $39.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,336.30,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $336.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,297.36,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $297.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,251.34,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $251.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,258.42,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $258.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,172.04,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $172.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,300.90,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $300.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HUMANA,HUMANA CHOICE CARE HMO,65.65,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $65.65 from Fee Schedule 005543_170 for Rev 301 Proc 82024 * Qty 1 = $65.65 at 100% = $65.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HUMANA,HUMANA CHOICE CARE PPO,300.90,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $300.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,38.62,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,HUMANA,HUMANA NATIIONAL POS HMO,65.65,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $65.65 from Fee Schedule 005543_170 for Rev 301 Proc 82024 * Qty 1 = $65.65 at 100% = $65.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,258.42,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $258.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,354.00,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $354.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,39.91,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82024 at $39.91 (Fee Schedule) = $39.91 (Total Line Payment) at 100% = $39.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,38.62,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,39.91,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82024 at $39.91 (Fee Schedule) = $39.91 (Total Line Payment) at 100% = $39.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,42.30,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82024 at $39.91 (Fee Schedule) = $39.91 (Total Line Payment) at 100% = $39.91... $39.91 at 106% = $42.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,38.62,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,177.00,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,297.36,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $297.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,86.90,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,265.50,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $265.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,325.68,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $325.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,50.21,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,50.21,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,PREVEA HEALTH NETWORK,PREVEA360,50.21,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,50.21,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,225.96,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $225.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,39.01,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,254.88,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $254.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,TRIOLOGY,TRILOGY MEDICAID,42.30,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82024 at $39.91 (Fee Schedule) = $39.91 (Total Line Payment) at 106% = $42.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,46.34,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.34 from Fee Schedule UHC_98227C for Rev 301 Proc 82024 * Qty 1 = $46.34 at 100% = $46.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,46.34,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.34 from Fee Schedule UHC_98227C for Rev 301 Proc 82024 * Qty 1 = $46.34 at 100% = $46.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,38.62,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,46.34,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.34 from Fee Schedule UHC_98227C for Rev 301 Proc 82024 * Qty 1 = $46.34 at 100% = $46.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,UNITY HEALTH PLAN,UNITY HOSPICE,38.62,,,,,,,38.6200,354.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,254.88,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $254.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,219.48,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $219.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,254.88,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $254.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,254.88,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $254.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACTH,82024,CPT,301,RC,30100163,CDM,,,,both,,,354.0000,233.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,212.40,,,,,,,38.6200,354.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $354.00 in Billed Charges for Rev 301 Proc 82024 = $212.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,AETNA,AETNA HSHS,30.36,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $30.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,AETNA,AETNA MEDICARE,4.95,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,AETNA,ALL COMMERCIAL AETNA,47.00,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $47.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,ANTHEM,ANTEHM MEDICAID,5.11,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82040 at $5.11 (Fee Schedule) = $5.11 (Total Line Payment) at 100% = $5.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,4.95,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,ANTHEM,ANTHEM POS/HMO,17.33,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.33 from Fee Schedule WII28_25 for Rev 301 Proc 82040 Mod TC * Qty 1 = $17.33 at 100% = $17.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,ANTHEM,ANTHEM PPO,17.33,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.33 from Fee Schedule WII28_25 for Rev 301 Proc 82040 Mod TC * Qty 1 = $17.33 at 100% = $17.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,47.00,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $47.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,CENPATICO,ALL MEDICAID CENPATICO,47.00,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $47.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,39.95,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $39.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,CIGNA,ALL COMMERCIAL CIGNA,32.90,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $32.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,COFINITY,COFINITY,47.00,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $47.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.11,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82040 at $5.11 (Fee Schedule) = $5.11 (Total Line Payment) at 100% = $5.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.11,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82040 at $5.11 (Fee Schedule) = $5.11 (Total Line Payment) at 100% = $5.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,44.65,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $44.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,39.48,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $39.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,33.37,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $33.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,34.31,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $34.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,22.84,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $22.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,39.95,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $39.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HUMANA,HUMANA CHOICE CARE HMO,8.42,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.42 from Fee Schedule 005543_170 for Rev 301 Proc 82040 * Qty 1 = $8.42 at 100% = $8.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HUMANA,HUMANA CHOICE CARE PPO,39.95,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $39.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,4.95,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,HUMANA,HUMANA NATIIONAL POS HMO,8.42,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.42 from Fee Schedule 005543_170 for Rev 301 Proc 82040 * Qty 1 = $8.42 at 100% = $8.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,34.31,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $34.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,47.00,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $47.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.11,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82040 at $5.11 (Fee Schedule) = $5.11 (Total Line Payment) at 100% = $5.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,4.95,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.11,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82040 at $5.11 (Fee Schedule) = $5.11 (Total Line Payment) at 100% = $5.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,5.42,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82040 at $5.11 (Fee Schedule) = $5.11 (Total Line Payment) at 100% = $5.11... $5.11 at 106% = $5.42 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,4.95,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,23.50,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $23.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,39.48,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $39.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,11.14,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,35.25,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $35.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,43.24,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $43.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.44,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.44,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,PREVEA HEALTH NETWORK,PREVEA360,6.44,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.44,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,30.00,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $30.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5.00,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,33.84,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $33.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,TRIOLOGY,TRILOGY MEDICAID,5.42,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82040 at $5.11 (Fee Schedule) = $5.11 (Total Line Payment) at 106% = $5.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.94,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.94 from Fee Schedule UHC_98227C for Rev 301 Proc 82040 * Qty 1 = $5.94 at 100% = $5.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,5.94,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.94 from Fee Schedule UHC_98227C for Rev 301 Proc 82040 * Qty 1 = $5.94 at 100% = $5.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,4.95,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,5.94,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.94 from Fee Schedule UHC_98227C for Rev 301 Proc 82040 * Qty 1 = $5.94 at 100% = $5.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,UNITY HEALTH PLAN,UNITY HOSPICE,4.95,,,,,,,4.9500,47.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,33.84,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $33.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,29.14,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $29.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,33.84,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $33.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,33.84,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $33.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,30100164,CDM,,,,both,,,47.0000,31.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,28.20,,,,,,,4.9500,47.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $47.00 in Billed Charges for Rev 301 Proc 82040 = $28.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,AETNA,AETNA HSHS,52.97,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $52.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,AETNA,AETNA MEDICARE,7.78,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,AETNA,ALL COMMERCIAL AETNA,82.00,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTEHM MEDICAID,7.27,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82042 at $7.27 (Fee Schedule) = $7.27 (Total Line Payment) at 100% = $7.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.78,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM POS/HMO,27.23,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.23 from Fee Schedule WII28_25 for Rev 301 Proc 82042 Mod TC * Qty 1 = $27.23 at 100% = $27.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM PPO,27.23,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.23 from Fee Schedule WII28_25 for Rev 301 Proc 82042 Mod TC * Qty 1 = $27.23 at 100% = $27.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,82.00,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,CENPATICO,ALL MEDICAID CENPATICO,82.00,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.70,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,CIGNA,ALL COMMERCIAL CIGNA,57.40,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $57.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,COFINITY,COFINITY,82.00,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,7.27,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82042 at $7.27 (Fee Schedule) = $7.27 (Total Line Payment) at 100% = $7.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,7.27,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82042 at $7.27 (Fee Schedule) = $7.27 (Total Line Payment) at 100% = $7.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.90,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $77.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,68.88,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $68.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,58.22,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $58.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.86,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $59.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,39.85,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $39.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.70,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA CHOICE CARE HMO,13.23,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule 005543_170 for Rev 301 Proc 82042 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA CHOICE CARE PPO,69.70,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,7.78,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA NATIIONAL POS HMO,13.23,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule 005543_170 for Rev 301 Proc 82042 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.86,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $59.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,82.00,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,7.27,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82042 at $7.27 (Fee Schedule) = $7.27 (Total Line Payment) at 100% = $7.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.78,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,7.27,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82042 at $7.27 (Fee Schedule) = $7.27 (Total Line Payment) at 100% = $7.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,7.71,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82042 at $7.27 (Fee Schedule) = $7.27 (Total Line Payment) at 100% = $7.27... $7.27 at 106% = $7.71 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,7.78,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,41.00,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.88,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $68.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,17.51,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.50,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $61.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,75.44,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $75.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.11,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.11,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA360,10.11,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.11,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,52.34,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $52.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.86,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,59.04,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,TRIOLOGY,TRILOGY MEDICAID,7.71,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82042 at $7.27 (Fee Schedule) = $7.27 (Total Line Payment) at 106% = $7.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.34,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.34 from Fee Schedule UHC_98227C for Rev 301 Proc 82042 * Qty 1 = $9.34 at 100% = $9.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,9.34,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.34 from Fee Schedule UHC_98227C for Rev 301 Proc 82042 * Qty 1 = $9.34 at 100% = $9.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.78,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,9.34,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.34 from Fee Schedule UHC_98227C for Rev 301 Proc 82042 * Qty 1 = $9.34 at 100% = $9.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,UNITY HEALTH PLAN,UNITY HOSPICE,7.78,,,,,,,7.2700,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,59.04,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.84,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $50.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,59.04,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,59.04,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OTHER SOURCE ALBUMIN QUAN EA,82042,CPT,301,RC,30100166,CDM,,,,both,,,82.0000,54.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,49.20,,,,,,,7.2700,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $82.00 in Billed Charges for Rev 301 Proc 82042 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,AETNA,AETNA HSHS,246.77,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $246.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,AETNA,AETNA MEDICARE,40.75,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,AETNA,ALL COMMERCIAL AETNA,382.00,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,ANTHEM,ANTEHM MEDICAID,42.11,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82088 at $42.11 (Fee Schedule) = $42.11 (Total Line Payment) at 100% = $42.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,40.75,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,ANTHEM,ANTHEM POS/HMO,142.63,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $142.63 from Fee Schedule WII28_25 for Rev 301 Proc 82088 Mod TC * Qty 1 = $142.63 at 100% = $142.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,ANTHEM,ANTHEM PPO,142.63,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $142.63 from Fee Schedule WII28_25 for Rev 301 Proc 82088 Mod TC * Qty 1 = $142.63 at 100% = $142.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,382.00,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,CENPATICO,ALL MEDICAID CENPATICO,382.00,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,324.70,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $324.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,CIGNA,ALL COMMERCIAL CIGNA,267.40,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $267.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,COFINITY,COFINITY,382.00,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,42.11,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82088 at $42.11 (Fee Schedule) = $42.11 (Total Line Payment) at 100% = $42.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,42.11,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82088 at $42.11 (Fee Schedule) = $42.11 (Total Line Payment) at 100% = $42.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,362.90,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $362.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,320.88,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $320.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,271.22,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $271.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,278.86,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $278.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,185.65,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $185.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,324.70,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $324.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HUMANA,HUMANA CHOICE CARE HMO,69.28,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $69.28 from Fee Schedule 005543_170 for Rev 301 Proc 82088 * Qty 1 = $69.28 at 100% = $69.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HUMANA,HUMANA CHOICE CARE PPO,324.70,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $324.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,40.75,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,HUMANA,HUMANA NATIIONAL POS HMO,69.28,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $69.28 from Fee Schedule 005543_170 for Rev 301 Proc 82088 * Qty 1 = $69.28 at 100% = $69.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,278.86,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $278.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,382.00,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,42.11,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82088 at $42.11 (Fee Schedule) = $42.11 (Total Line Payment) at 100% = $42.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,40.75,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,42.11,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82088 at $42.11 (Fee Schedule) = $42.11 (Total Line Payment) at 100% = $42.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,44.64,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82088 at $42.11 (Fee Schedule) = $42.11 (Total Line Payment) at 100% = $42.11... $42.11 at 106% = $44.64 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,40.75,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,191.00,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,320.88,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $320.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,91.69,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,286.50,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $286.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,351.44,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $351.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,52.98,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,52.98,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,PREVEA HEALTH NETWORK,PREVEA360,52.98,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,52.98,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,243.83,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $243.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,41.16,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,275.04,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $275.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,TRIOLOGY,TRILOGY MEDICAID,44.64,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00399 Proc 82088 at $42.11 (Fee Schedule) = $42.11 (Total Line Payment) at 106% = $44.64. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,48.90,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.90 from Fee Schedule UHC_98227C for Rev 301 Proc 82088 * Qty 1 = $48.90 at 100% = $48.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,48.90,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.90 from Fee Schedule UHC_98227C for Rev 301 Proc 82088 * Qty 1 = $48.90 at 100% = $48.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,40.75,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,48.90,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.90 from Fee Schedule UHC_98227C for Rev 301 Proc 82088 * Qty 1 = $48.90 at 100% = $48.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,UNITY HEALTH PLAN,UNITY HOSPICE,40.75,,,,,,,40.7500,382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,275.04,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $275.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,236.84,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $236.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,275.04,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $275.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,275.04,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $275.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOSTERONE,82088,CPT,301,RC,30100171,CDM,,,,both,,,382.0000,252.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,229.20,,,,,,,40.7500,382.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $382.00 in Billed Charges for Rev 301 Proc 82088 = $229.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,AETNA,AETNA HSHS,116.28,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $116.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,AETNA,AETNA MEDICARE,14.46,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,AETNA,ALL COMMERCIAL AETNA,180.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,ANTHEM,ANTEHM MEDICAID,14.94,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82104 at $14.94 (Fee Schedule) = $14.94 (Total Line Payment) at 100% = $14.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.46,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,ANTHEM,ANTHEM POS/HMO,50.61,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.61 from Fee Schedule WII28_25 for Rev 301 Proc 82104 Mod TC * Qty 1 = $50.61 at 100% = $50.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,ANTHEM,ANTHEM PPO,50.61,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.61 from Fee Schedule WII28_25 for Rev 301 Proc 82104 Mod TC * Qty 1 = $50.61 at 100% = $50.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,180.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,CENPATICO,ALL MEDICAID CENPATICO,180.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,153.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $153.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,CIGNA,ALL COMMERCIAL CIGNA,126.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,COFINITY,COFINITY,180.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.94,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82104 at $14.94 (Fee Schedule) = $14.94 (Total Line Payment) at 100% = $14.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.94,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82104 at $14.94 (Fee Schedule) = $14.94 (Total Line Payment) at 100% = $14.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,171.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $171.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,151.20,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,127.80,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $127.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,131.40,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $131.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,87.48,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $87.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,153.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $153.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HUMANA,HUMANA CHOICE CARE HMO,24.58,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule 005543_170 for Rev 301 Proc 82104 * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HUMANA,HUMANA CHOICE CARE PPO,153.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $153.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,14.46,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,HUMANA,HUMANA NATIIONAL POS HMO,24.58,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule 005543_170 for Rev 301 Proc 82104 * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,131.40,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $131.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,180.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.94,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82104 at $14.94 (Fee Schedule) = $14.94 (Total Line Payment) at 100% = $14.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.46,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.94,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82104 at $14.94 (Fee Schedule) = $14.94 (Total Line Payment) at 100% = $14.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,15.84,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82104 at $14.94 (Fee Schedule) = $14.94 (Total Line Payment) at 100% = $14.94... $14.94 at 106% = $15.84 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,14.46,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,90.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,151.20,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,32.54,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,135.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,165.60,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $165.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.80,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.80,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,PREVEA HEALTH NETWORK,PREVEA360,18.80,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.80,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,114.89,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $114.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.60,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,129.60,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $129.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,TRIOLOGY,TRILOGY MEDICAID,15.84,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82104 at $14.94 (Fee Schedule) = $14.94 (Total Line Payment) at 106% = $15.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.35,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.35 from Fee Schedule UHC_98227C for Rev 301 Proc 82104 * Qty 1 = $17.35 at 100% = $17.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,17.35,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.35 from Fee Schedule UHC_98227C for Rev 301 Proc 82104 * Qty 1 = $17.35 at 100% = $17.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.46,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,17.35,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.35 from Fee Schedule UHC_98227C for Rev 301 Proc 82104 * Qty 1 = $17.35 at 100% = $17.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,UNITY HEALTH PLAN,UNITY HOSPICE,14.46,,,,,,,14.4600,180.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,129.60,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $129.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,111.60,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $111.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,129.60,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $129.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,129.60,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $129.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTITRYPSIN PHENO,82104,CPT,301,RC,30100174,CDM,,,,both,,,180.0000,118.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,108.00,,,,,,,14.4600,180.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $180.00 in Billed Charges for Rev 301 Proc 82104 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,AETNA,AETNA HSHS,552.33,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $552.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,AETNA,AETNA MEDICARE,16.87,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,AETNA,ALL COMMERCIAL AETNA,855.00,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $855.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,ANTHEM,ANTEHM MEDICAID,17.43,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.87,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,ANTHEM,ANTHEM POS/HMO,59.05,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82139 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,ANTHEM,ANTHEM PPO,59.05,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82139 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,855.00,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $855.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,CENPATICO,ALL MEDICAID CENPATICO,855.00,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $855.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,726.75,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $726.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,CIGNA,ALL COMMERCIAL CIGNA,598.50,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $598.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,COFINITY,COFINITY,855.00,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $855.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.43,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.43,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,812.25,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $812.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,718.20,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $718.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,607.05,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $607.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,624.15,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $624.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,415.53,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $415.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,726.75,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $726.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HUMANA,HUMANA CHOICE CARE HMO,28.68,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82139 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HUMANA,HUMANA CHOICE CARE PPO,726.75,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $726.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,16.87,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,HUMANA,HUMANA NATIIONAL POS HMO,28.68,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82139 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,624.15,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $624.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,855.00,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $855.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.43,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.87,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.43,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,18.48,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43... $17.43 at 106% = $18.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,16.87,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,427.50,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $427.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,718.20,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $718.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,37.96,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,641.25,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $641.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,786.60,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $786.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.93,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.93,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,PREVEA HEALTH NETWORK,PREVEA360,21.93,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.93,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,545.75,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $545.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.04,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,615.60,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $615.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,TRIOLOGY,TRILOGY MEDICAID,18.48,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 106% = $18.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.24,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,20.24,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.87,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,20.24,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,UNITY HEALTH PLAN,UNITY HOSPICE,16.87,,,,,,,16.8700,855.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,615.60,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $615.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,530.10,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $530.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,615.60,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $615.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,615.60,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $615.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN SERUM,82139,CPT,301,RC,30100184,CDM,,,,both,,,855.0000,564.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,513.00,,,,,,,16.8700,855.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $855.00 in Billed Charges for Rev 301 Proc 82139 = $513.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,AETNA,AETNA HSHS,87.86,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $87.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,AETNA,AETNA MEDICARE,14.57,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,AETNA,ALL COMMERCIAL AETNA,136.00,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTEHM MEDICAID,15.06,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82140 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.57,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTHEM POS/HMO,51.00,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule WII28_25 for Rev 301 Proc 82140 Mod TC * Qty 1 = $51.00 at 100% = $51.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTHEM PPO,51.00,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule WII28_25 for Rev 301 Proc 82140 Mod TC * Qty 1 = $51.00 at 100% = $51.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,136.00,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,CENPATICO,ALL MEDICAID CENPATICO,136.00,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,115.60,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,CIGNA,ALL COMMERCIAL CIGNA,95.20,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,COFINITY,COFINITY,136.00,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.06,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82140 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.06,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82140 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,129.20,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $129.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,114.24,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $114.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,96.56,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $96.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,99.28,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $99.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,66.10,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $66.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,115.60,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA CHOICE CARE HMO,24.77,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.77 from Fee Schedule 005543_170 for Rev 301 Proc 82140 * Qty 1 = $24.77 at 100% = $24.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA CHOICE CARE PPO,115.60,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,14.57,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA NATIIONAL POS HMO,24.77,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.77 from Fee Schedule 005543_170 for Rev 301 Proc 82140 * Qty 1 = $24.77 at 100% = $24.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,99.28,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $99.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,136.00,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.06,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82140 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.57,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.06,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82140 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,15.96,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82140 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06... $15.06 at 106% = $15.96 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,14.57,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,68.00,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $68.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,114.24,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $114.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,32.78,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,102.00,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,125.12,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $125.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.94,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.94,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA360,18.94,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.94,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,86.81,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $86.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.72,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,97.92,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,TRIOLOGY,TRILOGY MEDICAID,15.96,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82140 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 106% = $15.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.48,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.48 from Fee Schedule UHC_98227C for Rev 301 Proc 82140 * Qty 1 = $17.48 at 100% = $17.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,17.48,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.48 from Fee Schedule UHC_98227C for Rev 301 Proc 82140 * Qty 1 = $17.48 at 100% = $17.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.57,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,17.48,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.48 from Fee Schedule UHC_98227C for Rev 301 Proc 82140 * Qty 1 = $17.48 at 100% = $17.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,UNITY HEALTH PLAN,UNITY HOSPICE,14.57,,,,,,,14.5700,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,97.92,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,84.32,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $84.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,97.92,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,97.92,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF AMMONIA,82140,CPT,301,RC,30100186,CDM,,,,both,,,136.0000,89.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,81.60,,,,,,,14.5700,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $136.00 in Billed Charges for Rev 301 Proc 82140 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,AETNA,AETNA HSHS,52.97,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $52.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,AETNA,AETNA MEDICARE,6.48,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,AETNA,ALL COMMERCIAL AETNA,82.00,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTEHM MEDICAID,6.70,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82150 at $6.70 (Fee Schedule) = $6.70 (Total Line Payment) at 100% = $6.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,6.48,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM POS/HMO,22.68,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.68 from Fee Schedule WII28_25 for Rev 301 Proc 82150 Mod TC * Qty 1 = $22.68 at 100% = $22.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM PPO,22.68,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.68 from Fee Schedule WII28_25 for Rev 301 Proc 82150 Mod TC * Qty 1 = $22.68 at 100% = $22.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,82.00,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,CENPATICO,ALL MEDICAID CENPATICO,82.00,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.70,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,CIGNA,ALL COMMERCIAL CIGNA,57.40,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $57.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,COFINITY,COFINITY,82.00,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.70,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82150 at $6.70 (Fee Schedule) = $6.70 (Total Line Payment) at 100% = $6.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.70,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82150 at $6.70 (Fee Schedule) = $6.70 (Total Line Payment) at 100% = $6.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.90,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $77.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,68.88,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $68.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,58.22,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $58.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.86,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $59.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,39.85,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $39.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.70,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA CHOICE CARE HMO,11.02,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.02 from Fee Schedule 005543_170 for Rev 301 Proc 82150 * Qty 1 = $11.02 at 100% = $11.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA CHOICE CARE PPO,69.70,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,6.48,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA NATIIONAL POS HMO,11.02,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.02 from Fee Schedule 005543_170 for Rev 301 Proc 82150 * Qty 1 = $11.02 at 100% = $11.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.86,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $59.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,82.00,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.70,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82150 at $6.70 (Fee Schedule) = $6.70 (Total Line Payment) at 100% = $6.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,6.48,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.70,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82150 at $6.70 (Fee Schedule) = $6.70 (Total Line Payment) at 100% = $6.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,7.10,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82150 at $6.70 (Fee Schedule) = $6.70 (Total Line Payment) at 100% = $6.70... $6.70 at 106% = $7.10 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,6.48,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,41.00,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.88,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $68.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,14.58,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.50,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $61.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,75.44,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $75.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.42,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.42,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA360,8.42,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.42,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,52.34,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $52.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,6.54,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,59.04,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,TRIOLOGY,TRILOGY MEDICAID,7.10,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82150 at $6.70 (Fee Schedule) = $6.70 (Total Line Payment) at 106% = $7.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.78,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.78 from Fee Schedule UHC_98227C for Rev 301 Proc 82150 * Qty 1 = $7.78 at 100% = $7.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,7.78,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.78 from Fee Schedule UHC_98227C for Rev 301 Proc 82150 * Qty 1 = $7.78 at 100% = $7.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,6.48,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,7.78,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.78 from Fee Schedule UHC_98227C for Rev 301 Proc 82150 * Qty 1 = $7.78 at 100% = $7.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,UNITY HEALTH PLAN,UNITY HOSPICE,6.48,,,,,,,6.4800,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,59.04,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.84,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $50.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,59.04,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,59.04,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMYLASE,82150,CPT,301,RC,30100188,CDM,,,,both,,,82.0000,54.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,49.20,,,,,,,6.4800,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $82.00 in Billed Charges for Rev 301 Proc 82150 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,AETNA,AETNA HSHS,79.46,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $79.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,AETNA,AETNA MEDICARE,21.09,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,AETNA,ALL COMMERCIAL AETNA,123.00,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTEHM MEDICAID,21.79,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82172 at $21.79 (Fee Schedule) = $21.79 (Total Line Payment) at 100% = $21.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,21.09,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM POS/HMO,73.82,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $73.82 from Fee Schedule WII28_25 for Rev 301 Proc 82172 Mod TC * Qty 1 = $73.82 at 100% = $73.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM PPO,73.82,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $73.82 from Fee Schedule WII28_25 for Rev 301 Proc 82172 Mod TC * Qty 1 = $73.82 at 100% = $73.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,123.00,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,CENPATICO,ALL MEDICAID CENPATICO,123.00,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,104.55,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,CIGNA,ALL COMMERCIAL CIGNA,86.10,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $86.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,COFINITY,COFINITY,123.00,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,21.79,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82172 at $21.79 (Fee Schedule) = $21.79 (Total Line Payment) at 100% = $21.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,21.79,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82172 at $21.79 (Fee Schedule) = $21.79 (Total Line Payment) at 100% = $21.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,116.85,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $116.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,103.32,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $103.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,87.33,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $87.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.79,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $89.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,59.78,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $59.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,104.55,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA CHOICE CARE HMO,35.85,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $35.85 from Fee Schedule 005543_170 for Rev 301 Proc 82172 * Qty 1 = $35.85 at 100% = $35.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA CHOICE CARE PPO,104.55,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,21.09,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA NATIIONAL POS HMO,35.85,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $35.85 from Fee Schedule 005543_170 for Rev 301 Proc 82172 * Qty 1 = $35.85 at 100% = $35.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.79,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $89.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,123.00,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,21.79,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82172 at $21.79 (Fee Schedule) = $21.79 (Total Line Payment) at 100% = $21.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,21.09,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,21.79,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82172 at $21.79 (Fee Schedule) = $21.79 (Total Line Payment) at 100% = $21.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,23.10,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82172 at $21.79 (Fee Schedule) = $21.79 (Total Line Payment) at 100% = $21.79... $21.79 at 106% = $23.10 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,21.09,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.50,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $61.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,103.32,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $103.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,47.45,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,92.25,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $92.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,113.16,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $113.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,27.42,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,27.42,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA360,27.42,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,27.42,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,78.51,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $78.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,21.30,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,88.56,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,TRIOLOGY,TRILOGY MEDICAID,23.10,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82172 at $21.79 (Fee Schedule) = $21.79 (Total Line Payment) at 106% = $23.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,25.31,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.31 from Fee Schedule UHC_98227C for Rev 301 Proc 82172 * Qty 1 = $25.31 at 100% = $25.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,25.31,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.31 from Fee Schedule UHC_98227C for Rev 301 Proc 82172 * Qty 1 = $25.31 at 100% = $25.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,21.09,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,25.31,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.31 from Fee Schedule UHC_98227C for Rev 301 Proc 82172 * Qty 1 = $25.31 at 100% = $25.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,UNITY HEALTH PLAN,UNITY HOSPICE,21.09,,,,,,,21.0900,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,88.56,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,76.26,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $76.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,88.56,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,88.56,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APOLIPOPROTEIN SERUM,82172,CPT,301,RC,30100192,CDM,,,,both,,,123.0000,81.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.80,,,,,,,21.0900,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $123.00 in Billed Charges for Rev 301 Proc 82172 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,AETNA,AETNA HSHS,71.06,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $71.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,AETNA,AETNA MEDICARE,18.97,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,AETNA,ALL COMMERCIAL AETNA,110.00,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $110.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,ANTHEM,ANTEHM MEDICAID,19.60,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82175 at $19.60 (Fee Schedule) = $19.60 (Total Line Payment) at 100% = $19.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,18.97,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,ANTHEM,ANTHEM POS/HMO,66.40,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $66.40 from Fee Schedule WII28_25 for Rev 301 Proc 82175 Mod TC * Qty 1 = $66.40 at 100% = $66.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,ANTHEM,ANTHEM PPO,66.40,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $66.40 from Fee Schedule WII28_25 for Rev 301 Proc 82175 Mod TC * Qty 1 = $66.40 at 100% = $66.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,110.00,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $110.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,CENPATICO,ALL MEDICAID CENPATICO,110.00,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $110.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,93.50,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $93.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,CIGNA,ALL COMMERCIAL CIGNA,77.00,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $77.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,COFINITY,COFINITY,110.00,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $110.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,19.60,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82175 at $19.60 (Fee Schedule) = $19.60 (Total Line Payment) at 100% = $19.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,19.60,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82175 at $19.60 (Fee Schedule) = $19.60 (Total Line Payment) at 100% = $19.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,104.50,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $104.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,92.40,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $92.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,78.10,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $78.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,80.30,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $80.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,53.46,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $53.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,93.50,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $93.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HUMANA,HUMANA CHOICE CARE HMO,32.25,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.25 from Fee Schedule 005543_170 for Rev 301 Proc 82175 * Qty 1 = $32.25 at 100% = $32.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HUMANA,HUMANA CHOICE CARE PPO,93.50,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $93.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,18.97,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,HUMANA,HUMANA NATIIONAL POS HMO,32.25,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.25 from Fee Schedule 005543_170 for Rev 301 Proc 82175 * Qty 1 = $32.25 at 100% = $32.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,80.30,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $80.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,110.00,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $110.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,19.60,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82175 at $19.60 (Fee Schedule) = $19.60 (Total Line Payment) at 100% = $19.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,18.97,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,19.60,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82175 at $19.60 (Fee Schedule) = $19.60 (Total Line Payment) at 100% = $19.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,20.78,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82175 at $19.60 (Fee Schedule) = $19.60 (Total Line Payment) at 100% = $19.60... $19.60 at 106% = $20.78 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,18.97,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,55.00,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,92.40,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $92.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,42.68,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,82.50,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $82.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,101.20,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $101.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,24.66,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,24.66,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,PREVEA HEALTH NETWORK,PREVEA360,24.66,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,24.66,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,70.21,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $70.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,19.16,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,79.20,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $79.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,TRIOLOGY,TRILOGY MEDICAID,20.78,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82175 at $19.60 (Fee Schedule) = $19.60 (Total Line Payment) at 106% = $20.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,22.76,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.76 from Fee Schedule UHC_98227C for Rev 301 Proc 82175 * Qty 1 = $22.76 at 100% = $22.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,22.76,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.76 from Fee Schedule UHC_98227C for Rev 301 Proc 82175 * Qty 1 = $22.76 at 100% = $22.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,18.97,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,22.76,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.76 from Fee Schedule UHC_98227C for Rev 301 Proc 82175 * Qty 1 = $22.76 at 100% = $22.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,UNITY HEALTH PLAN,UNITY HOSPICE,18.97,,,,,,,18.9700,110.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,79.20,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $79.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,68.20,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $68.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,79.20,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $79.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,79.20,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $79.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ASSAY OF ARSENIC,82175,CPT,301,RC,30100193,CDM,,,,both,,,110.0000,72.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,66.00,,,,,,,18.9700,110.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $110.00 in Billed Charges for Rev 301 Proc 82175 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA HSHS,61.37,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA MEDICARE,9.89,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,AETNA,ALL COMMERCIAL AETNA,95.00,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTEHM MEDICAID,10.22,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82180 at $10.22 (Fee Schedule) = $10.22 (Total Line Payment) at 100% = $10.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,9.89,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM POS/HMO,34.62,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.62 from Fee Schedule WII28_25 for Rev 301 Proc 82180 Mod TC * Qty 1 = $34.62 at 100% = $34.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM PPO,34.62,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.62 from Fee Schedule WII28_25 for Rev 301 Proc 82180 Mod TC * Qty 1 = $34.62 at 100% = $34.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,95.00,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,CENPATICO,ALL MEDICAID CENPATICO,95.00,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,80.75,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,CIGNA,ALL COMMERCIAL CIGNA,66.50,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $66.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,COFINITY,COFINITY,95.00,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.22,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82180 at $10.22 (Fee Schedule) = $10.22 (Total Line Payment) at 100% = $10.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.22,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82180 at $10.22 (Fee Schedule) = $10.22 (Total Line Payment) at 100% = $10.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,90.25,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $90.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,79.80,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,67.45,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $67.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,69.35,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,46.17,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $46.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,80.75,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE HMO,16.81,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.81 from Fee Schedule 005543_170 for Rev 301 Proc 82180 * Qty 1 = $16.81 at 100% = $16.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE PPO,80.75,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,9.89,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA NATIIONAL POS HMO,16.81,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.81 from Fee Schedule 005543_170 for Rev 301 Proc 82180 * Qty 1 = $16.81 at 100% = $16.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,69.35,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,95.00,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.22,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82180 at $10.22 (Fee Schedule) = $10.22 (Total Line Payment) at 100% = $10.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,9.89,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.22,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82180 at $10.22 (Fee Schedule) = $10.22 (Total Line Payment) at 100% = $10.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,10.83,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82180 at $10.22 (Fee Schedule) = $10.22 (Total Line Payment) at 100% = $10.22... $10.22 at 106% = $10.83 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,9.89,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,47.50,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $47.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,79.80,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,22.25,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,71.25,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,87.40,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $87.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.86,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.86,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360,12.86,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.86,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,60.64,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $60.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,9.99,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,68.40,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,TRILOGY MEDICAID,10.83,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82180 at $10.22 (Fee Schedule) = $10.22 (Total Line Payment) at 106% = $10.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.87,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.87 from Fee Schedule UHC_98227C for Rev 301 Proc 82180 * Qty 1 = $11.87 at 100% = $11.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,11.87,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.87 from Fee Schedule UHC_98227C for Rev 301 Proc 82180 * Qty 1 = $11.87 at 100% = $11.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,9.89,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,11.87,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.87 from Fee Schedule UHC_98227C for Rev 301 Proc 82180 * Qty 1 = $11.87 at 100% = $11.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,UNITY HEALTH PLAN,UNITY HOSPICE,9.89,,,,,,,9.8900,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,68.40,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.90,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $58.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,68.40,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,68.40,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VITAMIN C (ASCORBIC ACID),82180,CPT,301,RC,30100197,CDM,,,,both,,,95.0000,62.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,57.00,,,,,,,9.8900,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $95.00 in Billed Charges for Rev 301 Proc 82180 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA HSHS,73.64,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $73.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA MEDICARE,14.43,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,AETNA,ALL COMMERCIAL AETNA,114.00,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTEHM MEDICAID,14.91,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87260 at $14.91 (Fee Schedule) = $14.91 (Total Line Payment) at 100% = $14.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.43,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM POS/HMO,50.51,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.51 from Fee Schedule WII28_25 for Rev 306 Proc 87260 Mod TC * Qty 1 = $50.51 at 100% = $50.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM PPO,50.51,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.51 from Fee Schedule WII28_25 for Rev 306 Proc 87260 Mod TC * Qty 1 = $50.51 at 100% = $50.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,114.00,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,CENPATICO,ALL MEDICAID CENPATICO,114.00,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,96.90,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,CIGNA,ALL COMMERCIAL CIGNA,79.80,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,COFINITY,COFINITY,114.00,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.91,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87260 at $14.91 (Fee Schedule) = $14.91 (Total Line Payment) at 100% = $14.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.91,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87260 at $14.91 (Fee Schedule) = $14.91 (Total Line Payment) at 100% = $14.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,108.30,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $108.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,95.76,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.94,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $80.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,83.22,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,55.40,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $55.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,96.90,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE HMO,24.53,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.53 from Fee Schedule 005543_170 for Rev 306 Proc 87260 * Qty 1 = $24.53 at 100% = $24.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE PPO,96.90,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,14.43,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA NATIIONAL POS HMO,24.53,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.53 from Fee Schedule 005543_170 for Rev 306 Proc 87260 * Qty 1 = $24.53 at 100% = $24.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,83.22,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,114.00,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.91,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87260 at $14.91 (Fee Schedule) = $14.91 (Total Line Payment) at 100% = $14.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.43,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.91,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87260 at $14.91 (Fee Schedule) = $14.91 (Total Line Payment) at 100% = $14.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,15.80,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87260 at $14.91 (Fee Schedule) = $14.91 (Total Line Payment) at 100% = $14.91... $14.91 at 106% = $15.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,14.43,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,57.00,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,95.76,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,32.47,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,85.50,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,104.88,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $104.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.76,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.76,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360,18.76,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.76,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,72.77,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $72.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.57,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,82.08,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,TRILOGY MEDICAID,15.80,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87260 at $14.91 (Fee Schedule) = $14.91 (Total Line Payment) at 106% = $15.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.32,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.32 from Fee Schedule UHC_98227C for Rev 306 Proc 87260 * Qty 1 = $17.32 at 100% = $17.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,17.32,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.32 from Fee Schedule UHC_98227C for Rev 306 Proc 87260 * Qty 1 = $17.32 at 100% = $17.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.43,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,17.32,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.32 from Fee Schedule UHC_98227C for Rev 306 Proc 87260 * Qty 1 = $17.32 at 100% = $17.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,UNITY HEALTH PLAN,UNITY HOSPICE,14.43,,,,,,,14.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,82.08,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,70.68,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $70.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,82.08,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,82.08,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF ADENOVIRUS AG,87260,CPT,306,RC,30600200,CDM,,,,both,,,114.0000,75.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,68.40,,,,,,,14.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $114.00 in Billed Charges for Rev 306 Proc 87260 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA HSHS,73.64,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $73.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,AETNA,ALL COMMERCIAL AETNA,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87273 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87273 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87273 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,CENPATICO,ALL MEDICAID CENPATICO,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,96.90,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,CIGNA,ALL COMMERCIAL CIGNA,79.80,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,COFINITY,COFINITY,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87273 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87273 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,108.30,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $108.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,95.76,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.94,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $80.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,83.22,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,55.40,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $55.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,96.90,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87273 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE PPO,96.90,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87273 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,83.22,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87273 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87273 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87273 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,57.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,95.76,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,85.50,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,104.88,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $104.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,72.77,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $72.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,82.08,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87273 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87273 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87273 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87273 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,82.08,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,70.68,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $70.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,82.08,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,82.08,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 2 AG,87273,CPT,306,RC,30600202,CDM,,,,both,,,114.0000,75.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,68.40,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $114.00 in Billed Charges for Rev 306 Proc 87273 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA HSHS,94.32,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA MEDICARE,16.07,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,AETNA,ALL COMMERCIAL AETNA,146.00,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTEHM MEDICAID,16.61,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87276 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.07,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM POS/HMO,56.25,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $56.25 from Fee Schedule WII28_25 for Rev 306 Proc 87276 Mod TC * Qty 1 = $56.25 at 100% = $56.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM PPO,56.25,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $56.25 from Fee Schedule WII28_25 for Rev 306 Proc 87276 Mod TC * Qty 1 = $56.25 at 100% = $56.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,146.00,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,CENPATICO,ALL MEDICAID CENPATICO,146.00,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.10,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,CIGNA,ALL COMMERCIAL CIGNA,102.20,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,COFINITY,COFINITY,146.00,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.61,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87276 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.61,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87276 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.70,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $138.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,122.64,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.66,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $103.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.58,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,70.96,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $70.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.10,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE HMO,27.32,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.32 from Fee Schedule 005543_170 for Rev 306 Proc 87276 * Qty 1 = $27.32 at 100% = $27.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE PPO,124.10,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,16.07,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA NATIIONAL POS HMO,27.32,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.32 from Fee Schedule 005543_170 for Rev 306 Proc 87276 * Qty 1 = $27.32 at 100% = $27.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.58,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,146.00,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.61,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87276 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.07,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.61,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87276 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,17.61,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87276 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61... $16.61 at 106% = $17.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,16.07,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.00,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.64,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,36.16,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.50,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,134.32,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $134.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,20.89,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,20.89,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360,20.89,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,20.89,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.19,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $93.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.23,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.12,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,TRILOGY MEDICAID,17.61,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87276 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 106% = $17.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.28,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87276 * Qty 1 = $19.28 at 100% = $19.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,19.28,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87276 * Qty 1 = $19.28 at 100% = $19.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.07,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,19.28,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87276 * Qty 1 = $19.28 at 100% = $19.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,UNITY HEALTH PLAN,UNITY HOSPICE,16.07,,,,,,,16.0700,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.12,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.52,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $90.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.12,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.12,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA A AG,87276,CPT,306,RC,30600205,CDM,,,,both,,,146.0000,96.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.60,,,,,,,16.0700,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.00 in Billed Charges for Rev 306 Proc 87276 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA HSHS,58.14,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $58.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA MEDICARE,15.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,AETNA,ALL COMMERCIAL AETNA,90.00,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTEHM MEDICAID,16.12,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87278 at $16.12 (Fee Schedule) = $16.12 (Total Line Payment) at 100% = $16.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,15.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM POS/HMO,54.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $54.60 from Fee Schedule WII28_25 for Rev 306 Proc 87278 Mod TC * Qty 1 = $54.60 at 100% = $54.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM PPO,54.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $54.60 from Fee Schedule WII28_25 for Rev 306 Proc 87278 Mod TC * Qty 1 = $54.60 at 100% = $54.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,90.00,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,CENPATICO,ALL MEDICAID CENPATICO,90.00,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,76.50,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,CIGNA,ALL COMMERCIAL CIGNA,63.00,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,COFINITY,COFINITY,90.00,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.12,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87278 at $16.12 (Fee Schedule) = $16.12 (Total Line Payment) at 100% = $16.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.12,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87278 at $16.12 (Fee Schedule) = $16.12 (Total Line Payment) at 100% = $16.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,85.50,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,75.60,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.90,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $63.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,65.70,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,43.74,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $43.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,76.50,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE HMO,26.52,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.52 from Fee Schedule 005543_170 for Rev 306 Proc 87278 * Qty 1 = $26.52 at 100% = $26.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE PPO,76.50,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,15.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA NATIIONAL POS HMO,26.52,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.52 from Fee Schedule 005543_170 for Rev 306 Proc 87278 * Qty 1 = $26.52 at 100% = $26.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,65.70,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,90.00,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.12,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87278 at $16.12 (Fee Schedule) = $16.12 (Total Line Payment) at 100% = $16.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.12,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87278 at $16.12 (Fee Schedule) = $16.12 (Total Line Payment) at 100% = $16.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,17.09,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87278 at $16.12 (Fee Schedule) = $16.12 (Total Line Payment) at 100% = $16.12... $16.12 at 106% = $17.09 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,15.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.00,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,75.60,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,35.10,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,67.50,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,82.80,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,20.28,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,20.28,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360,20.28,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,20.28,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,57.45,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $57.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,15.76,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,64.80,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,TRILOGY MEDICAID,17.09,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87278 at $16.12 (Fee Schedule) = $16.12 (Total Line Payment) at 106% = $17.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,18.72,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87278 * Qty 1 = $18.72 at 100% = $18.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,18.72,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87278 * Qty 1 = $18.72 at 100% = $18.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,15.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,18.72,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87278 * Qty 1 = $18.72 at 100% = $18.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,UNITY HEALTH PLAN,UNITY HOSPICE,15.60,,,,,,,15.6000,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,64.80,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.80,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,64.80,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,64.80,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF LEGIONELLA AG,87278,CPT,306,RC,30600206,CDM,,,,both,,,90.0000,59.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,54.00,,,,,,,15.6000,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $90.00 in Billed Charges for Rev 306 Proc 87278 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,13.42,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,13.87,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87280 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.42,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,46.97,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.97 from Fee Schedule WII28_25 for Rev 306 Proc 87280 Mod TC * Qty 1 = $46.97 at 100% = $46.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,46.97,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.97 from Fee Schedule WII28_25 for Rev 306 Proc 87280 Mod TC * Qty 1 = $46.97 at 100% = $46.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.87,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87280 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.87,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87280 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,22.81,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.81 from Fee Schedule 005543_170 for Rev 306 Proc 87280 * Qty 1 = $22.81 at 100% = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,13.42,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,22.81,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.81 from Fee Schedule 005543_170 for Rev 306 Proc 87280 * Qty 1 = $22.81 at 100% = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.87,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87280 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.42,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.87,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87280 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,14.70,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87280 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87... $13.87 at 106% = $14.70 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,13.42,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,30.20,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.45,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.45,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,17.45,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.45,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.55,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,14.70,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87280 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 106% = $14.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.10,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87280 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,16.10,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87280 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.42,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,16.10,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87280 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,13.42,,,,,,,13.4200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF RSV AG,87280,CPT,306,RC,30600208,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,13.4200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 306 Proc 87280 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87281 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87281 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87281 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87281 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87281 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87281 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87281 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87281 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87281 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87281 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87281 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87281 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87281 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87281 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PNEUMOCYST CARINII AG,87281,CPT,306,RC,30600209,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,11.9800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 306 Proc 87281 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA HSHS,94.32,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA MEDICARE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,AETNA,ALL COMMERCIAL AETNA,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTEHM MEDICAID,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87290 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM POS/HMO,46.97,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.97 from Fee Schedule WII28_25 for Rev 306 Proc 87290 Mod TC * Qty 1 = $46.97 at 100% = $46.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM PPO,46.97,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.97 from Fee Schedule WII28_25 for Rev 306 Proc 87290 Mod TC * Qty 1 = $46.97 at 100% = $46.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,CENPATICO,ALL MEDICAID CENPATICO,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.10,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,CIGNA,ALL COMMERCIAL CIGNA,102.20,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,COFINITY,COFINITY,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87290 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87290 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.70,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $138.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,122.64,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.66,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $103.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.58,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,70.96,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $70.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.10,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE HMO,22.81,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.81 from Fee Schedule 005543_170 for Rev 306 Proc 87290 * Qty 1 = $22.81 at 100% = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE PPO,124.10,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA NATIIONAL POS HMO,22.81,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.81 from Fee Schedule 005543_170 for Rev 306 Proc 87290 * Qty 1 = $22.81 at 100% = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.58,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87290 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87290 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,14.70,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87290 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87... $13.87 at 106% = $14.70 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.64,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,30.20,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.50,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,134.32,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $134.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.45,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.45,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360,17.45,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.45,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.19,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $93.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.55,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.12,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,TRILOGY MEDICAID,14.70,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87290 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 106% = $14.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.10,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87290 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,16.10,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87290 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,16.10,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87290 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,UNITY HEALTH PLAN,UNITY HOSPICE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.12,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.52,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $90.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.12,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.12,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF VARICELLA ZOETER AG,87290,CPT,306,RC,30600210,CDM,,,,both,,,146.0000,96.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.60,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.00 in Billed Charges for Rev 306 Proc 87290 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA HSHS,73.64,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $73.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA MEDICARE,11.98,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,AETNA,ALL COMMERCIAL AETNA,114.00,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTEHM MEDICAID,8.66,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87300 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87300 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM PPO,41.93,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87300 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,114.00,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,CENPATICO,ALL MEDICAID CENPATICO,114.00,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,96.90,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,CIGNA,ALL COMMERCIAL CIGNA,79.80,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,COFINITY,COFINITY,114.00,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.66,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87300 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.66,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87300 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,108.30,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $108.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,95.76,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.94,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $80.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,83.22,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,55.40,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $55.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,96.90,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87300 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE PPO,96.90,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87300 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,83.22,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,114.00,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.66,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87300 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.66,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87300 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,9.18,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87300 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66... $8.66 at 106% = $9.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,57.00,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,95.76,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,85.50,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,104.88,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $104.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,72.77,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $72.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,82.08,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,TRILOGY MEDICAID,9.18,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87300 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 106% = $9.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87300 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87300 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87300 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,8.6600,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,82.08,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,70.68,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $70.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,82.08,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,82.08,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF POLYVALENT MLT ORG AG,87300,CPT,306,RC,30600211,CDM,,,,both,,,114.0000,75.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,68.40,,,,,,,8.6600,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $114.00 in Billed Charges for Rev 306 Proc 87300 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA HSHS,94.32,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA MEDICARE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,AETNA,ALL COMMERCIAL AETNA,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTEHM MEDICAID,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87327 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM POS/HMO,46.97,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.97 from Fee Schedule WII28_25 for Rev 306 Proc 87327 Mod TC * Qty 1 = $46.97 at 100% = $46.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM PPO,46.97,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.97 from Fee Schedule WII28_25 for Rev 306 Proc 87327 Mod TC * Qty 1 = $46.97 at 100% = $46.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,CENPATICO,ALL MEDICAID CENPATICO,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.10,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,CIGNA,ALL COMMERCIAL CIGNA,102.20,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,COFINITY,COFINITY,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87327 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87327 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.70,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $138.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,122.64,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.66,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $103.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.58,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,70.96,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $70.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.10,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE HMO,22.81,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.81 from Fee Schedule 005543_170 for Rev 306 Proc 87327 * Qty 1 = $22.81 at 100% = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE PPO,124.10,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA NATIIONAL POS HMO,22.81,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.81 from Fee Schedule 005543_170 for Rev 306 Proc 87327 * Qty 1 = $22.81 at 100% = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.58,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,146.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87327 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.87,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87327 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,14.70,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87327 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 100% = $13.87... $13.87 at 106% = $14.70 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.00,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.64,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,30.20,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.50,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,134.32,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $134.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.45,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.45,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360,17.45,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.45,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.19,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $93.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.55,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.12,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,TRILOGY MEDICAID,14.70,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87327 at $13.87 (Fee Schedule) = $13.87 (Total Line Payment) at 106% = $14.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.10,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87327 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,16.10,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87327 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,16.10,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.10 from Fee Schedule UHC_98227C for Rev 306 Proc 87327 * Qty 1 = $16.10 at 100% = $16.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,UNITY HEALTH PLAN,UNITY HOSPICE,13.42,,,,,,,13.4200,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.12,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.52,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $90.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.12,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.12,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOCOCCUS AG,87327,CPT,306,RC,30600214,CDM,,,,both,,,146.0000,96.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.60,,,,,,,13.4200,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.00 in Billed Charges for Rev 306 Proc 87327 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,AETNA,AETNA HSHS,41.99,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $41.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,AETNA,AETNA MEDICARE,13.82,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,AETNA,ALL COMMERCIAL AETNA,65.00,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,ANTHEM,ANTEHM MEDICAID,14.28,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87328 at $14.28 (Fee Schedule) = $14.28 (Total Line Payment) at 100% = $14.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.82,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,ANTHEM,ANTHEM POS/HMO,48.37,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.37 from Fee Schedule WII28_25 for Rev 306 Proc 87328 Mod TC * Qty 1 = $48.37 at 100% = $48.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,ANTHEM,ANTHEM PPO,48.37,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.37 from Fee Schedule WII28_25 for Rev 306 Proc 87328 Mod TC * Qty 1 = $48.37 at 100% = $48.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,65.00,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,CENPATICO,ALL MEDICAID CENPATICO,65.00,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,55.25,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $55.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,CIGNA,ALL COMMERCIAL CIGNA,45.50,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $45.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,COFINITY,COFINITY,65.00,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.28,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87328 at $14.28 (Fee Schedule) = $14.28 (Total Line Payment) at 100% = $14.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.28,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87328 at $14.28 (Fee Schedule) = $14.28 (Total Line Payment) at 100% = $14.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,61.75,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $61.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,54.60,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $54.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,46.15,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $46.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,47.45,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $47.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,31.59,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $31.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,55.25,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $55.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HUMANA,HUMANA CHOICE CARE HMO,23.49,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.49 from Fee Schedule 005543_170 for Rev 306 Proc 87328 * Qty 1 = $23.49 at 100% = $23.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HUMANA,HUMANA CHOICE CARE PPO,55.25,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $55.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,13.82,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,HUMANA,HUMANA NATIIONAL POS HMO,23.49,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.49 from Fee Schedule 005543_170 for Rev 306 Proc 87328 * Qty 1 = $23.49 at 100% = $23.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,47.45,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $47.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,65.00,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.28,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87328 at $14.28 (Fee Schedule) = $14.28 (Total Line Payment) at 100% = $14.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.82,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.28,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87328 at $14.28 (Fee Schedule) = $14.28 (Total Line Payment) at 100% = $14.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,15.14,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87328 at $14.28 (Fee Schedule) = $14.28 (Total Line Payment) at 100% = $14.28... $14.28 at 106% = $15.14 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,13.82,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,32.50,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $32.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,54.60,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $54.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,31.10,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,48.75,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $48.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,59.80,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $59.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.97,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.97,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,PREVEA HEALTH NETWORK,PREVEA360,17.97,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.97,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,41.49,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $41.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.96,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,46.80,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $46.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,TRIOLOGY,TRILOGY MEDICAID,15.14,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87328 at $14.28 (Fee Schedule) = $14.28 (Total Line Payment) at 106% = $15.14. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.58,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.58 from Fee Schedule UHC_98227C for Rev 306 Proc 87328 * Qty 1 = $16.58 at 100% = $16.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,16.58,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.58 from Fee Schedule UHC_98227C for Rev 306 Proc 87328 * Qty 1 = $16.58 at 100% = $16.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.82,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,16.58,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.58 from Fee Schedule UHC_98227C for Rev 306 Proc 87328 * Qty 1 = $16.58 at 100% = $16.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,UNITY HEALTH PLAN,UNITY HOSPICE,13.82,,,,,,,13.8200,65.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,46.80,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $46.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,40.30,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $40.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,46.80,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $46.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,46.80,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $46.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CRYPTOSPORIDIUM AG,87328,CPT,306,RC,30600215,CDM,,,,both,,,65.0000,42.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,39.00,,,,,,,13.8200,65.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $65.00 in Billed Charges for Rev 306 Proc 87328 = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA HSHS,58.14,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $58.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,AETNA,ALL COMMERCIAL AETNA,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87329 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87329 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87329 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,CENPATICO,ALL MEDICAID CENPATICO,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,76.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,CIGNA,ALL COMMERCIAL CIGNA,63.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,COFINITY,COFINITY,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87329 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87329 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,85.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,75.60,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.90,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $63.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,65.70,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,43.74,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $43.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,76.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87329 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE PPO,76.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87329 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,65.70,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87329 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87329 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87329 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,75.60,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,67.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,82.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,57.45,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $57.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,64.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87329 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87329 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87329 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87329 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,64.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,64.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,64.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL GIARDIA AG,87329,CPT,306,RC,30600216,CDM,,,,both,,,90.0000,59.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,54.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $90.00 in Billed Charges for Rev 306 Proc 87329 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA HSHS,67.18,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,AETNA,ALL COMMERCIAL AETNA,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTEHM MEDICAID,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM POS/HMO,36.16,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.16 from Fee Schedule WII28_25 for Rev 306 Proc 87340 Mod TC * Qty 1 = $36.16 at 100% = $36.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM PPO,36.16,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.16 from Fee Schedule WII28_25 for Rev 306 Proc 87340 Mod TC * Qty 1 = $36.16 at 100% = $36.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,CENPATICO,ALL MEDICAID CENPATICO,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,CIGNA,ALL COMMERCIAL CIGNA,72.80,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,COFINITY,COFINITY,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,98.80,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $98.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,87.36,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,73.84,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $73.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,75.92,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,50.54,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE HMO,17.56,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.56 from Fee Schedule 005543_170 for Rev 306 Proc 87340 * Qty 1 = $17.56 at 100% = $17.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE PPO,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA NATIIONAL POS HMO,17.56,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.56 from Fee Schedule 005543_170 for Rev 306 Proc 87340 * Qty 1 = $17.56 at 100% = $17.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,75.92,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,11.31,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67... $10.67 at 106% = $11.31 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,52.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,87.36,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,23.24,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,78.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,95.68,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $95.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,66.38,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $66.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,10.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,TRILOGY MEDICAID,11.31,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 106% = $11.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87340 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87340 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87340 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,UNITY HEALTH PLAN,UNITY HOSPICE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,64.48,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $64.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS ABC B AG,87340,CPT,306,RC,30600219,CDM,,,,both,,,104.0000,68.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,62.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $62.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA HSHS,126.62,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $126.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA MEDICARE,13.25,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,AETNA,ALL COMMERCIAL AETNA,196.00,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTEHM MEDICAID,13.69,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87385 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.25,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM POS/HMO,46.38,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 306 Proc 87385 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM PPO,46.38,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 306 Proc 87385 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,196.00,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,CENPATICO,ALL MEDICAID CENPATICO,196.00,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,166.60,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,CIGNA,ALL COMMERCIAL CIGNA,137.20,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $137.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,COFINITY,COFINITY,196.00,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.69,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87385 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.69,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87385 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,186.20,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $186.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,164.64,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.16,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $139.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.08,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,95.26,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $95.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,166.60,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE HMO,22.53,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 306 Proc 87385 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE PPO,166.60,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,13.25,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA NATIIONAL POS HMO,22.53,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 306 Proc 87385 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.08,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,196.00,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.69,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87385 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.25,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.69,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87385 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,14.51,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87385 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69... $13.69 at 106% = $14.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,13.25,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.00,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,164.64,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,29.81,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.00,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,180.32,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $180.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.23,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.23,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360,17.23,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.23,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.11,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $125.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.38,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.12,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,TRILOGY MEDICAID,14.51,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87385 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 106% = $14.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.90,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 306 Proc 87385 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,15.90,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 306 Proc 87385 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.25,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,15.90,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 306 Proc 87385 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,UNITY HEALTH PLAN,UNITY HOSPICE,13.25,,,,,,,13.2500,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.12,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,121.52,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $121.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.12,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.12,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HISTOPLASMA CAPSUL AG IA,87385,CPT,306,RC,30600222,CDM,,,,both,,,196.0000,129.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,117.60,,,,,,,13.2500,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $196.00 in Billed Charges for Rev 306 Proc 87385 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,AETNA,AETNA HSHS,122.09,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $122.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,AETNA,AETNA MEDICARE,24.06,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,AETNA,ALL COMMERCIAL AETNA,189.00,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,ANTHEM,ANTEHM MEDICAID,24.81,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87390 at $24.81 (Fee Schedule) = $24.81 (Total Line Payment) at 100% = $24.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,24.06,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,ANTHEM,ANTHEM POS/HMO,84.21,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.21 from Fee Schedule WII28_25 for Rev 306 Proc 87390 Mod TC * Qty 1 = $84.21 at 100% = $84.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,ANTHEM,ANTHEM PPO,84.21,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.21 from Fee Schedule WII28_25 for Rev 306 Proc 87390 Mod TC * Qty 1 = $84.21 at 100% = $84.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,189.00,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,CENPATICO,ALL MEDICAID CENPATICO,189.00,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,160.65,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $160.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,CIGNA,ALL COMMERCIAL CIGNA,132.30,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $132.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,COFINITY,COFINITY,189.00,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,24.81,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87390 at $24.81 (Fee Schedule) = $24.81 (Total Line Payment) at 100% = $24.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,24.81,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87390 at $24.81 (Fee Schedule) = $24.81 (Total Line Payment) at 100% = $24.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,179.55,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $179.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,158.76,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,134.19,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $134.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,137.97,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $137.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,91.85,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $91.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,160.65,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $160.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HUMANA,HUMANA CHOICE CARE HMO,40.90,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.90 from Fee Schedule 005543_170 for Rev 306 Proc 87390 * Qty 1 = $40.90 at 100% = $40.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HUMANA,HUMANA CHOICE CARE PPO,160.65,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $160.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,24.06,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,HUMANA,HUMANA NATIIONAL POS HMO,40.90,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.90 from Fee Schedule 005543_170 for Rev 306 Proc 87390 * Qty 1 = $40.90 at 100% = $40.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,137.97,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $137.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,189.00,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,24.81,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87390 at $24.81 (Fee Schedule) = $24.81 (Total Line Payment) at 100% = $24.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,24.06,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,24.81,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87390 at $24.81 (Fee Schedule) = $24.81 (Total Line Payment) at 100% = $24.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,26.30,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87390 at $24.81 (Fee Schedule) = $24.81 (Total Line Payment) at 100% = $24.81... $24.81 at 106% = $26.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,24.06,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,94.50,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $94.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,158.76,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $158.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,54.14,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,141.75,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $141.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,173.88,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $173.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,31.28,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,31.28,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,PREVEA HEALTH NETWORK,PREVEA360,31.28,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,31.28,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,120.64,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $120.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,24.30,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,136.08,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $136.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,TRIOLOGY,TRILOGY MEDICAID,26.30,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87390 at $24.81 (Fee Schedule) = $24.81 (Total Line Payment) at 106% = $26.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,28.87,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.87 from Fee Schedule UHC_98227C for Rev 306 Proc 87390 * Qty 1 = $28.87 at 100% = $28.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,28.87,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.87 from Fee Schedule UHC_98227C for Rev 306 Proc 87390 * Qty 1 = $28.87 at 100% = $28.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,24.06,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,28.87,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.87 from Fee Schedule UHC_98227C for Rev 306 Proc 87390 * Qty 1 = $28.87 at 100% = $28.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,UNITY HEALTH PLAN,UNITY HOSPICE,24.06,,,,,,,24.0600,189.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,136.08,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $136.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,117.18,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $117.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,136.08,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $136.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,136.08,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $136.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV 1 AG QL,87390,CPT,306,RC,30600224,CDM,,,,both,,,189.0000,124.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,113.40,,,,,,,24.0600,189.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.00 in Billed Charges for Rev 306 Proc 87390 = $113.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,AETNA,AETNA HSHS,70.41,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $70.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,AETNA,AETNA MEDICARE,14.13,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,AETNA,ALL COMMERCIAL AETNA,109.00,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,ANTHEM,ANTEHM MEDICAID,8.66,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87400 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.13,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,ANTHEM,ANTHEM POS/HMO,49.46,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $49.46 from Fee Schedule WII28_25 for Rev 306 Proc 87400 Mod TC * Qty 1 = $49.46 at 100% = $49.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,ANTHEM,ANTHEM PPO,49.46,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $49.46 from Fee Schedule WII28_25 for Rev 306 Proc 87400 Mod TC * Qty 1 = $49.46 at 100% = $49.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,109.00,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,CENPATICO,ALL MEDICAID CENPATICO,109.00,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,92.65,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $92.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,CIGNA,ALL COMMERCIAL CIGNA,76.30,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $76.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,COFINITY,COFINITY,109.00,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.66,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87400 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.66,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87400 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,103.55,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $103.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,91.56,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $91.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,77.39,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $77.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,79.57,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $79.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,52.97,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $52.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,92.65,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $92.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HUMANA,HUMANA CHOICE CARE HMO,24.02,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.02 from Fee Schedule 005543_170 for Rev 306 Proc 87400 * Qty 1 = $24.02 at 100% = $24.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HUMANA,HUMANA CHOICE CARE PPO,92.65,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $92.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,14.13,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,HUMANA,HUMANA NATIIONAL POS HMO,24.02,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.02 from Fee Schedule 005543_170 for Rev 306 Proc 87400 * Qty 1 = $24.02 at 100% = $24.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,79.57,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $79.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,109.00,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.66,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87400 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.13,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.66,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87400 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,9.18,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87400 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 100% = $8.66... $8.66 at 106% = $9.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,14.13,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,54.50,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $54.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,91.56,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $91.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,31.79,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,81.75,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $81.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,100.28,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $100.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.37,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.37,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,PREVEA HEALTH NETWORK,PREVEA360,18.37,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.37,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,69.57,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $69.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.27,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,78.48,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $78.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,TRIOLOGY,TRILOGY MEDICAID,9.18,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87400 at $8.66 (Fee Schedule) = $8.66 (Total Line Payment) at 106% = $9.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.96,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.96 from Fee Schedule UHC_98227C for Rev 306 Proc 87400 * Qty 1 = $16.96 at 100% = $16.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,16.96,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.96 from Fee Schedule UHC_98227C for Rev 306 Proc 87400 * Qty 1 = $16.96 at 100% = $16.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.13,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,16.96,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.96 from Fee Schedule UHC_98227C for Rev 306 Proc 87400 * Qty 1 = $16.96 at 100% = $16.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,UNITY HEALTH PLAN,UNITY HOSPICE,14.13,,,,,,,8.6600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,78.48,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $78.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,67.58,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $67.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,78.48,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $78.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,78.48,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $78.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL INFLUENZA A/B AG,87400,CPT,306,RC,30600225,CDM,,,,both,,,109.0000,71.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,65.40,,,,,,,8.6600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $109.00 in Billed Charges for Rev 306 Proc 87400 = $65.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,13.91,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,14.37,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87420 at $14.37 (Fee Schedule) = $14.37 (Total Line Payment) at 100% = $14.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.91,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,48.69,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.69 from Fee Schedule WII28_25 for Rev 306 Proc 87420 Mod TC * Qty 1 = $48.69 at 100% = $48.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,48.69,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.69 from Fee Schedule WII28_25 for Rev 306 Proc 87420 Mod TC * Qty 1 = $48.69 at 100% = $48.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.37,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87420 at $14.37 (Fee Schedule) = $14.37 (Total Line Payment) at 100% = $14.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.37,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87420 at $14.37 (Fee Schedule) = $14.37 (Total Line Payment) at 100% = $14.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,23.65,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.65 from Fee Schedule 005543_170 for Rev 306 Proc 87420 * Qty 1 = $23.65 at 100% = $23.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,13.91,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,23.65,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.65 from Fee Schedule 005543_170 for Rev 306 Proc 87420 * Qty 1 = $23.65 at 100% = $23.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.37,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87420 at $14.37 (Fee Schedule) = $14.37 (Total Line Payment) at 100% = $14.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.91,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.37,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87420 at $14.37 (Fee Schedule) = $14.37 (Total Line Payment) at 100% = $14.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,15.23,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87420 at $14.37 (Fee Schedule) = $14.37 (Total Line Payment) at 100% = $14.37... $14.37 at 106% = $15.23 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,13.91,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,31.30,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.08,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.08,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,18.08,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.08,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.05,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,15.23,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87420 at $14.37 (Fee Schedule) = $14.37 (Total Line Payment) at 106% = $15.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.69,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.69 from Fee Schedule UHC_98227C for Rev 306 Proc 87420 * Qty 1 = $16.69 at 100% = $16.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,16.69,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.69 from Fee Schedule UHC_98227C for Rev 306 Proc 87420 * Qty 1 = $16.69 at 100% = $16.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.91,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,16.69,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.69 from Fee Schedule UHC_98227C for Rev 306 Proc 87420 * Qty 1 = $16.69 at 100% = $16.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,13.91,,,,,,,13.9100,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RSV AG QL,87420,CPT,306,RC,30600226,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,13.9100,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 306 Proc 87420 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA HSHS,67.18,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,AETNA,ALL COMMERCIAL AETNA,104.00,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87425 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87425 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87425 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,104.00,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,CENPATICO,ALL MEDICAID CENPATICO,104.00,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,88.40,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,CIGNA,ALL COMMERCIAL CIGNA,72.80,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,COFINITY,COFINITY,104.00,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87425 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87425 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,98.80,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $98.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,87.36,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,73.84,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $73.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,75.92,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,50.54,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,88.40,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87425 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE PPO,88.40,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87425 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,75.92,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,104.00,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87425 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87425 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87425 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,52.00,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,87.36,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,78.00,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,95.68,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $95.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,66.38,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $66.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,74.88,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87425 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87425 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87425 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87425 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,74.88,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,64.48,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $64.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,74.88,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,74.88,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ROTAVIRUS AG,87425,CPT,306,RC,30600227,CDM,,,,both,,,104.0000,68.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,62.40,,,,,,,11.9800,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.00 in Billed Charges for Rev 306 Proc 87425 = $62.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA HSHS,58.14,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $58.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,AETNA,ALL COMMERCIAL AETNA,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87449 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87449 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,CENPATICO,ALL MEDICAID CENPATICO,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,76.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,CIGNA,ALL COMMERCIAL CIGNA,63.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,COFINITY,COFINITY,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,85.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,75.60,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.90,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $63.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,65.70,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,43.74,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $43.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,76.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87449 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE PPO,76.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87449 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,65.70,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,90.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,75.60,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,67.50,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,82.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,57.45,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $57.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,64.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87449 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87449 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87449 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,64.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,64.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,64.80,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,30600229,CDM,,,,both,,,90.0000,59.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,54.00,,,,,,,11.9800,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $90.00 in Billed Charges for Rev 306 Proc 87449 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,AETNA,AETNA HSHS,306.20,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $306.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,AETNA,ALL COMMERCIAL AETNA,474.00,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87476 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87476 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87476 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,474.00,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,CENPATICO,ALL MEDICAID CENPATICO,474.00,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,402.90,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $402.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,CIGNA,ALL COMMERCIAL CIGNA,331.80,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $331.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,COFINITY,COFINITY,474.00,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87476 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87476 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,450.30,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $450.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,398.16,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $398.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,336.54,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $336.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,346.02,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $346.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,230.36,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $230.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,402.90,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $402.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87476 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HUMANA,HUMANA CHOICE CARE PPO,402.90,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $402.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87476 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,346.02,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $346.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,474.00,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87476 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87476 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87476 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,237.00,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $237.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,398.16,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $398.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,355.50,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $355.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,436.08,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $436.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,302.55,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $302.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,341.28,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $341.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87476 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87476 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87476 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87476 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,341.28,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $341.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,293.88,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $293.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,341.28,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $341.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,341.28,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $341.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LYMES DNA DETECT PCR,87476,CPT,306,RC,30600235,CDM,,,,both,,,474.0000,312.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,284.40,,,,,,,35.0900,474.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $474.00 in Billed Charges for Rev 306 Proc 87476 = $284.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,AETNA,AETNA HSHS,222.87,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $222.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,AETNA,AETNA MEDICARE,42.84,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,AETNA,ALL COMMERCIAL AETNA,345.00,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $345.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,ANTHEM,ANTEHM MEDICAID,44.27,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87497 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,42.84,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,ANTHEM,ANTHEM POS/HMO,149.94,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87497 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,ANTHEM,ANTHEM PPO,149.94,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87497 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,345.00,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $345.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,CENPATICO,ALL MEDICAID CENPATICO,345.00,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $345.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,293.25,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $293.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,CIGNA,ALL COMMERCIAL CIGNA,241.50,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $241.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,COFINITY,COFINITY,345.00,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $345.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,44.27,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87497 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,44.27,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87497 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,327.75,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $327.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,289.80,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,244.95,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $244.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,251.85,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $251.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,167.67,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $167.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,293.25,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $293.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HUMANA,HUMANA CHOICE CARE HMO,72.83,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87497 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HUMANA,HUMANA CHOICE CARE PPO,293.25,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $293.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,42.84,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,HUMANA,HUMANA NATIIONAL POS HMO,72.83,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87497 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,251.85,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $251.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,345.00,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $345.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,44.27,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87497 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,42.84,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,44.27,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87497 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,46.93,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87497 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27... $44.27 at 106% = $46.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,42.84,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,172.50,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $172.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,289.80,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,96.39,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,258.75,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $258.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,317.40,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $317.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,55.69,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,55.69,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,PREVEA HEALTH NETWORK,PREVEA360,55.69,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,55.69,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,220.21,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $220.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,43.27,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,248.40,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $248.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,TRIOLOGY,TRILOGY MEDICAID,46.93,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87497 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 106% = $46.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,51.41,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87497 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,51.41,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87497 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,42.84,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,51.41,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87497 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,UNITY HEALTH PLAN,UNITY HOSPICE,42.84,,,,,,,42.8400,345.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,248.40,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $248.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,213.90,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $213.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,248.40,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $248.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,248.40,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $248.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CMV QN,87497,CPT,306,RC,30600238,CDM,,,,both,,,345.0000,227.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,207.00,,,,,,,42.8400,345.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $345.00 in Billed Charges for Rev 306 Proc 87497 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,AETNA,AETNA HSHS,155.04,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $155.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,AETNA,ALL COMMERCIAL AETNA,240.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87529 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87529 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87529 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,240.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,CENPATICO,ALL MEDICAID CENPATICO,240.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,204.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,CIGNA,ALL COMMERCIAL CIGNA,168.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $168.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,COFINITY,COFINITY,240.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87529 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87529 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,228.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,201.60,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,170.40,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $170.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,175.20,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $175.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,116.64,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $116.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,204.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87529 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HUMANA,HUMANA CHOICE CARE PPO,204.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87529 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,175.20,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $175.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,240.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87529 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87529 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87529 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,120.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,201.60,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,180.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,220.80,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $220.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,153.19,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $153.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,172.80,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $172.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87529 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87529 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87529 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87529 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,240.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,172.80,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $172.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,148.80,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $148.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,172.80,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $172.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,172.80,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $172.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HSV DNA AMP PROBE,87529,CPT,306,RC,30600244,CDM,,,,both,,,240.0000,158.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,144.00,,,,,,,35.0900,240.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $240.00 in Billed Charges for Rev 306 Proc 87529 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,AETNA,AETNA HSHS,193.80,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,AETNA,AETNA MEDICARE,41.68,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,AETNA,ALL COMMERCIAL AETNA,300.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTEHM MEDICAID,43.07,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87556 at $43.07 (Fee Schedule) = $43.07 (Total Line Payment) at 100% = $43.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,41.68,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM POS/HMO,145.88,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $145.88 from Fee Schedule WII28_25 for Rev 306 Proc 87556 Mod TC * Qty 1 = $145.88 at 100% = $145.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM PPO,145.88,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $145.88 from Fee Schedule WII28_25 for Rev 306 Proc 87556 Mod TC * Qty 1 = $145.88 at 100% = $145.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,300.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,CENPATICO,ALL MEDICAID CENPATICO,300.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,255.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,CIGNA,ALL COMMERCIAL CIGNA,210.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,COFINITY,COFINITY,300.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,43.07,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87556 at $43.07 (Fee Schedule) = $43.07 (Total Line Payment) at 100% = $43.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,43.07,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87556 at $43.07 (Fee Schedule) = $43.07 (Total Line Payment) at 100% = $43.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,285.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $285.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,252.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,213.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $213.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,219.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,145.80,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $145.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,255.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA CHOICE CARE HMO,70.86,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $70.86 from Fee Schedule 005543_170 for Rev 306 Proc 87556 * Qty 1 = $70.86 at 100% = $70.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA CHOICE CARE PPO,255.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,41.68,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA NATIIONAL POS HMO,70.86,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $70.86 from Fee Schedule 005543_170 for Rev 306 Proc 87556 * Qty 1 = $70.86 at 100% = $70.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,219.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,300.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,43.07,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87556 at $43.07 (Fee Schedule) = $43.07 (Total Line Payment) at 100% = $43.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,41.68,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,43.07,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87556 at $43.07 (Fee Schedule) = $43.07 (Total Line Payment) at 100% = $43.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,45.65,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87556 at $43.07 (Fee Schedule) = $43.07 (Total Line Payment) at 100% = $43.07... $43.07 at 106% = $45.65 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,41.68,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,150.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,252.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,93.78,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,225.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,276.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $276.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,54.18,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,54.18,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA360,54.18,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,54.18,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,191.49,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $191.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,42.10,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,216.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,TRIOLOGY,TRILOGY MEDICAID,45.65,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87556 at $43.07 (Fee Schedule) = $43.07 (Total Line Payment) at 106% = $45.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,50.02,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.02 from Fee Schedule UHC_98227C for Rev 306 Proc 87556 * Qty 1 = $50.02 at 100% = $50.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,50.02,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.02 from Fee Schedule UHC_98227C for Rev 306 Proc 87556 * Qty 1 = $50.02 at 100% = $50.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,41.68,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,50.02,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.02 from Fee Schedule UHC_98227C for Rev 306 Proc 87556 * Qty 1 = $50.02 at 100% = $50.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,UNITY HEALTH PLAN,UNITY HOSPICE,41.68,,,,,,,41.6800,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,216.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,186.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,216.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,216.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB COMPLEX PCR,87556,CPT,306,RC,30600248,CDM,,,,both,,,300.0000,198.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,180.00,,,,,,,41.6800,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $300.00 in Billed Charges for Rev 306 Proc 87556 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,AETNA,AETNA HSHS,135.66,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $135.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,AETNA,ALL COMMERCIAL AETNA,210.00,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87624 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87624 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87624 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,210.00,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,CENPATICO,ALL MEDICAID CENPATICO,210.00,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,178.50,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,CIGNA,ALL COMMERCIAL CIGNA,147.00,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,COFINITY,COFINITY,210.00,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87624 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87624 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,199.50,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $199.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,176.40,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,149.10,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $149.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,153.30,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $153.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,102.06,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $102.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,178.50,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87624 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA CHOICE CARE PPO,178.50,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87624 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,153.30,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $153.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,210.00,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87624 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87624 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87624 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,105.00,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,176.40,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,157.50,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,193.20,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $193.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,134.04,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $134.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,151.20,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87624 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87624 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87624 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87624 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,151.20,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,130.20,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $130.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,151.20,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,151.20,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HPV HI-RISK TYP POOLED RSLT,87624,CPT,306,RC,30600250,CDM,,,,both,,,210.0000,138.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,126.00,,,,,,,35.0900,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $210.00 in Billed Charges for Rev 306 Proc 87624 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87798 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87798 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87798 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87798 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA AMP,87798,CPT,306,RC,30600256,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,AETNA,AETNA HSHS,465.77,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $465.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,AETNA,AETNA MEDICARE,70.20,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,AETNA,ALL COMMERCIAL AETNA,721.00,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $721.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,ANTHEM,ANTEHM MEDICAID,50.62,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87801 at $50.62 (Fee Schedule) = $50.62 (Total Line Payment) at 100% = $50.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,70.20,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,ANTHEM,ANTHEM POS/HMO,245.70,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $245.70 from Fee Schedule WII28_25 for Rev 306 Proc 87801 Mod TC * Qty 1 = $245.70 at 100% = $245.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,ANTHEM,ANTHEM PPO,245.70,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $245.70 from Fee Schedule WII28_25 for Rev 306 Proc 87801 Mod TC * Qty 1 = $245.70 at 100% = $245.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,721.00,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $721.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,CENPATICO,ALL MEDICAID CENPATICO,721.00,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $721.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,612.85,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $612.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,CIGNA,ALL COMMERCIAL CIGNA,504.70,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $504.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,COFINITY,COFINITY,721.00,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $721.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.62,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87801 at $50.62 (Fee Schedule) = $50.62 (Total Line Payment) at 100% = $50.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.62,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87801 at $50.62 (Fee Schedule) = $50.62 (Total Line Payment) at 100% = $50.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,684.95,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $684.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,605.64,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $605.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,511.91,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $511.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,526.33,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $526.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,350.41,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $350.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,612.85,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $612.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HUMANA,HUMANA CHOICE CARE HMO,119.34,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $119.34 from Fee Schedule 005543_170 for Rev 306 Proc 87801 * Qty 1 = $119.34 at 100% = $119.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HUMANA,HUMANA CHOICE CARE PPO,612.85,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $612.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,70.20,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,HUMANA,HUMANA NATIIONAL POS HMO,119.34,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $119.34 from Fee Schedule 005543_170 for Rev 306 Proc 87801 * Qty 1 = $119.34 at 100% = $119.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,526.33,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $526.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,721.00,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $721.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.62,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87801 at $50.62 (Fee Schedule) = $50.62 (Total Line Payment) at 100% = $50.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,70.20,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.62,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87801 at $50.62 (Fee Schedule) = $50.62 (Total Line Payment) at 100% = $50.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,53.66,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87801 at $50.62 (Fee Schedule) = $50.62 (Total Line Payment) at 100% = $50.62... $50.62 at 106% = $53.66 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,70.20,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,360.50,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $360.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,605.64,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $605.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,157.95,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,540.75,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $540.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,663.32,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $663.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,91.26,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,91.26,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,PREVEA HEALTH NETWORK,PREVEA360,91.26,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,91.26,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,460.21,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $460.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,70.90,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,519.12,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $519.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,TRIOLOGY,TRILOGY MEDICAID,53.66,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87801 at $50.62 (Fee Schedule) = $50.62 (Total Line Payment) at 106% = $53.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,84.24,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.24 from Fee Schedule UHC_98227C for Rev 306 Proc 87801 * Qty 1 = $84.24 at 100% = $84.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,84.24,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.24 from Fee Schedule UHC_98227C for Rev 306 Proc 87801 * Qty 1 = $84.24 at 100% = $84.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,70.20,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,84.24,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.24 from Fee Schedule UHC_98227C for Rev 306 Proc 87801 * Qty 1 = $84.24 at 100% = $84.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,UNITY HEALTH PLAN,UNITY HOSPICE,70.20,,,,,,,50.6200,721.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,519.12,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $519.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,447.02,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $447.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,519.12,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $519.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,519.12,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $519.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGNT MULT DNA AMPLI,87801,CPT,306,RC,30600273,CDM,,,,both,,,721.0000,475.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,432.60,,,,,,,50.6200,721.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $721.00 in Billed Charges for Rev 306 Proc 87801 = $432.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,AETNA,AETNA HSHS,582.05,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $582.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,AETNA,AETNA MEDICARE,115.36,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,AETNA,ALL COMMERCIAL AETNA,901.00,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,ANTHEM,ANTEHM MEDICAID,119.20,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87153 at $119.20 (Fee Schedule) = $119.20 (Total Line Payment) at 100% = $119.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,115.36,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,ANTHEM,ANTHEM POS/HMO,403.76,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $403.76 from Fee Schedule WII28_25 for Rev 306 Proc 87153 Mod TC * Qty 1 = $403.76 at 100% = $403.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,ANTHEM,ANTHEM PPO,403.76,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $403.76 from Fee Schedule WII28_25 for Rev 306 Proc 87153 Mod TC * Qty 1 = $403.76 at 100% = $403.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,901.00,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,CENPATICO,ALL MEDICAID CENPATICO,901.00,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,765.85,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $765.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,CIGNA,ALL COMMERCIAL CIGNA,630.70,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $630.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,COFINITY,COFINITY,901.00,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,119.20,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87153 at $119.20 (Fee Schedule) = $119.20 (Total Line Payment) at 100% = $119.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,119.20,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87153 at $119.20 (Fee Schedule) = $119.20 (Total Line Payment) at 100% = $119.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,855.95,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $855.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,756.84,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $756.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,639.71,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $639.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,657.73,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $657.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,437.89,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $437.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,765.85,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $765.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HUMANA,HUMANA CHOICE CARE HMO,196.11,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.11 from Fee Schedule 005543_170 for Rev 306 Proc 87153 * Qty 1 = $196.11 at 100% = $196.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HUMANA,HUMANA CHOICE CARE PPO,765.85,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $765.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,115.36,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,HUMANA,HUMANA NATIIONAL POS HMO,196.11,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.11 from Fee Schedule 005543_170 for Rev 306 Proc 87153 * Qty 1 = $196.11 at 100% = $196.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,657.73,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $657.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,901.00,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,119.20,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87153 at $119.20 (Fee Schedule) = $119.20 (Total Line Payment) at 100% = $119.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,115.36,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,119.20,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87153 at $119.20 (Fee Schedule) = $119.20 (Total Line Payment) at 100% = $119.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,126.35,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87153 at $119.20 (Fee Schedule) = $119.20 (Total Line Payment) at 100% = $119.20... $119.20 at 106% = $126.35 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,115.36,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,450.50,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $450.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,756.84,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $756.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,259.56,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,675.75,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $675.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,828.92,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $828.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,149.97,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,149.97,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,PREVEA HEALTH NETWORK,PREVEA360,149.97,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,149.97,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,575.11,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $575.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,116.51,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,648.72,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $648.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,TRIOLOGY,TRILOGY MEDICAID,126.35,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87153 at $119.20 (Fee Schedule) = $119.20 (Total Line Payment) at 106% = $126.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,138.43,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $138.43 from Fee Schedule UHC_98227C for Rev 306 Proc 87153 * Qty 1 = $138.43 at 100% = $138.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,138.43,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $138.43 from Fee Schedule UHC_98227C for Rev 306 Proc 87153 * Qty 1 = $138.43 at 100% = $138.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,115.36,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,138.43,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $138.43 from Fee Schedule UHC_98227C for Rev 306 Proc 87153 * Qty 1 = $138.43 at 100% = $138.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,UNITY HEALTH PLAN,UNITY HOSPICE,115.36,,,,,,,115.3600,901.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,648.72,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $648.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,558.62,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $558.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,648.72,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $648.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,648.72,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $648.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA ID BY DNA SEQUENCING,87153,CPT,306,RC,30600275,CDM,,,,both,,,901.0000,594.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,540.60,,,,,,,115.3600,901.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $901.00 in Billed Charges for Rev 306 Proc 87153 = $540.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,AETNA,AETNA HSHS,135.66,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $135.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,AETNA,AETNA MEDICARE,40.55,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,AETNA,ALL COMMERCIAL AETNA,210.00,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTEHM MEDICAID,38.30,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87625 at $38.30 (Fee Schedule) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,40.55,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM POS/HMO,141.93,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $141.93 from Fee Schedule WII28_25 for Rev 306 Proc 87625 Mod TC * Qty 1 = $141.93 at 100% = $141.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM PPO,141.93,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $141.93 from Fee Schedule WII28_25 for Rev 306 Proc 87625 Mod TC * Qty 1 = $141.93 at 100% = $141.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,210.00,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,CENPATICO,ALL MEDICAID CENPATICO,210.00,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,178.50,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,CIGNA,ALL COMMERCIAL CIGNA,147.00,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,COFINITY,COFINITY,210.00,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,38.30,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87625 at $38.30 (Fee Schedule) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,38.30,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87625 at $38.30 (Fee Schedule) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,199.50,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $199.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,176.40,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,149.10,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $149.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,153.30,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $153.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,102.06,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $102.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,178.50,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA CHOICE CARE HMO,68.94,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.94 from Fee Schedule 005543_170 for Rev 306 Proc 87625 * Qty 1 = $68.94 at 100% = $68.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA CHOICE CARE PPO,178.50,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,40.55,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA NATIIONAL POS HMO,68.94,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.94 from Fee Schedule 005543_170 for Rev 306 Proc 87625 * Qty 1 = $68.94 at 100% = $68.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,153.30,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $153.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,210.00,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,38.30,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87625 at $38.30 (Fee Schedule) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,40.55,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,38.30,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87625 at $38.30 (Fee Schedule) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,40.60,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87625 at $38.30 (Fee Schedule) = $38.30 (Total Line Payment) at 100% = $38.30... $38.30 at 106% = $40.60 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,40.55,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,105.00,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,176.40,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,91.24,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,157.50,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,193.20,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $193.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,52.72,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,52.72,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA360,52.72,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,52.72,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,134.04,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $134.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,40.96,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,151.20,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,TRIOLOGY,TRILOGY MEDICAID,40.60,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87625 at $38.30 (Fee Schedule) = $38.30 (Total Line Payment) at 106% = $40.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,48.66,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.66 from Fee Schedule UHC_98227C for Rev 306 Proc 87625 * Qty 1 = $48.66 at 100% = $48.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,48.66,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.66 from Fee Schedule UHC_98227C for Rev 306 Proc 87625 * Qty 1 = $48.66 at 100% = $48.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,40.55,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,48.66,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.66 from Fee Schedule UHC_98227C for Rev 306 Proc 87625 * Qty 1 = $48.66 at 100% = $48.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,UNITY HEALTH PLAN,UNITY HOSPICE,40.55,,,,,,,38.3000,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,151.20,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,130.20,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $130.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,151.20,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,151.20,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPV GENOTYPE 16 18/45,87625,CPT,306,RC,30600286,CDM,,,,both,,,210.0000,138.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,126.00,,,,,,,38.3000,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $210.00 in Billed Charges for Rev 306 Proc 87625 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,AETNA,AETNA HSHS,892.13,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $892.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,AETNA,AETNA MEDICARE,416.78,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,AETNA,ALL COMMERCIAL AETNA,1381.00,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,ANTHEM,ANTEHM MEDICAID,430.66,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87633 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,416.78,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,ANTHEM,ANTHEM POS/HMO,1381.00,,,,,,,416.7800,1381.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,458.73 from Fee Schedule WII28_25 for Rev 306 Proc 87633 Mod TC * Qty 1 = $1,458.73 at 100% = $1,458.73 (Limited to $1,381.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,ANTHEM,ANTHEM PPO,1381.00,,,,,,,416.7800,1381.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,458.73 from Fee Schedule WII28_25 for Rev 306 Proc 87633 Mod TC * Qty 1 = $1,458.73 at 100% = $1,458.73 (Limited to $1,381.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1381.00,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,CENPATICO,ALL MEDICAID CENPATICO,1381.00,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1173.85,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,173.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,CIGNA,ALL COMMERCIAL CIGNA,966.70,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $966.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,COFINITY,COFINITY,1381.00,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,430.66,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87633 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,430.66,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87633 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1311.95,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,311.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,1160.04,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,160.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,980.51,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $980.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1008.13,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,008.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,671.17,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $671.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1173.85,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,173.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HUMANA,HUMANA CHOICE CARE HMO,708.53,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.53 from Fee Schedule 005543_170 for Rev 306 Proc 87633 * Qty 1 = $708.53 at 100% = $708.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HUMANA,HUMANA CHOICE CARE PPO,1173.85,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,173.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,416.78,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,HUMANA,HUMANA NATIIONAL POS HMO,708.53,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.53 from Fee Schedule 005543_170 for Rev 306 Proc 87633 * Qty 1 = $708.53 at 100% = $708.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1008.13,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,008.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1381.00,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,430.66,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87633 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,416.78,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,430.66,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87633 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,456.50,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87633 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66... $430.66 at 106% = $456.50 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,416.78,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,690.50,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $690.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1160.04,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,160.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,937.76,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1035.75,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,035.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1270.52,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $1,270.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,541.81,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,541.81,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,PREVEA HEALTH NETWORK,PREVEA360,541.81,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,541.81,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,881.49,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $881.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,420.95,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,994.32,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $994.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,TRIOLOGY,TRILOGY MEDICAID,456.50,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87633 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 106% = $456.50. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,500.14,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87633 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,500.14,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87633 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,416.78,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,500.14,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87633 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,UNITY HEALTH PLAN,UNITY HOSPICE,416.78,,,,,,,416.7800,1381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,994.32,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $994.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,856.22,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $856.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,994.32,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $994.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,994.32,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $994.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RESP VIRUS 12-25 TARGETS,87633,CPT,306,RC,30600288,CDM,,,,both,,,1381.0000,911.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,828.60,,,,,,,416.7800,1381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,381.00 in Billed Charges for Rev 306 Proc 87633 = $828.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,AETNA,AETNA HSHS,194.45,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $194.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,AETNA,ALL COMMERCIAL AETNA,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87486 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87486 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87486 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,CENPATICO,ALL MEDICAID CENPATICO,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,255.85,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $255.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,CIGNA,ALL COMMERCIAL CIGNA,210.70,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $210.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,COFINITY,COFINITY,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87486 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87486 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,285.95,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $285.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,252.84,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $252.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,213.71,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $213.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,219.73,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $219.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,146.29,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $146.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,255.85,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $255.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87486 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HUMANA,HUMANA CHOICE CARE PPO,255.85,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $255.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87486 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,219.73,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $219.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87486 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87486 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87486 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,150.50,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $150.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,252.84,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $252.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,225.75,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $225.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,276.92,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $276.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,192.13,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $192.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,216.72,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $216.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87486 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87486 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87486 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87486 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,216.72,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $216.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,186.62,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $186.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,216.72,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $216.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,216.72,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $216.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC C PNEUMONIAE AP-TECH,87486,CPT,306,RC,30600290,CDM,,,,both,,,301.0000,198.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,180.60,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $301.00 in Billed Charges for Rev 306 Proc 87486 = $180.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,AETNA,AETNA HSHS,136.95,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $136.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,AETNA,ALL COMMERCIAL AETNA,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87532 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87532 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87532 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,CENPATICO,ALL MEDICAID CENPATICO,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,180.20,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,CIGNA,ALL COMMERCIAL CIGNA,148.40,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $148.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,COFINITY,COFINITY,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87532 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87532 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,201.40,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $201.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,178.08,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $178.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,150.52,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $150.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,154.76,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $154.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,103.03,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $103.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,180.20,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87532 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA CHOICE CARE PPO,180.20,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87532 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,154.76,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $154.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87532 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87532 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87532 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,106.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,178.08,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $178.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,159.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,195.04,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $195.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,135.32,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $135.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,152.64,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87532 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87532 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87532 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87532 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,152.64,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,131.44,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $131.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,152.64,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,152.64,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (HHSV6) MENI,87532,CPT,306,RC,30600295,CDM,,,,both,,,212.0000,139.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,127.20,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $212.00 in Billed Charges for Rev 306 Proc 87532 = $127.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,24.08,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,24.88,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87389 at $24.88 (Fee Schedule) = $24.88 (Total Line Payment) at 100% = $24.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,24.08,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,84.28,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.28 from Fee Schedule WII28_25 for Rev 306 Proc 87389 Mod TC * Qty 1 = $84.28 at 100% = $84.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,84.28,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.28 from Fee Schedule WII28_25 for Rev 306 Proc 87389 Mod TC * Qty 1 = $84.28 at 100% = $84.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,24.88,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87389 at $24.88 (Fee Schedule) = $24.88 (Total Line Payment) at 100% = $24.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,24.88,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87389 at $24.88 (Fee Schedule) = $24.88 (Total Line Payment) at 100% = $24.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,40.94,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.94 from Fee Schedule 005543_170 for Rev 306 Proc 87389 * Qty 1 = $40.94 at 100% = $40.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,24.08,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,40.94,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.94 from Fee Schedule 005543_170 for Rev 306 Proc 87389 * Qty 1 = $40.94 at 100% = $40.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,24.88,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87389 at $24.88 (Fee Schedule) = $24.88 (Total Line Payment) at 100% = $24.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,24.08,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,24.88,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87389 at $24.88 (Fee Schedule) = $24.88 (Total Line Payment) at 100% = $24.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,26.37,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87389 at $24.88 (Fee Schedule) = $24.88 (Total Line Payment) at 100% = $24.88... $24.88 at 106% = $26.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,24.08,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,54.18,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,31.30,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,31.30,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,31.30,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,31.30,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,24.32,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,26.37,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87389 at $24.88 (Fee Schedule) = $24.88 (Total Line Payment) at 106% = $26.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,28.90,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.90 from Fee Schedule UHC_98227C for Rev 306 Proc 87389 * Qty 1 = $28.90 at 100% = $28.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,28.90,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.90 from Fee Schedule UHC_98227C for Rev 306 Proc 87389 * Qty 1 = $28.90 at 100% = $28.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,24.08,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,28.90,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.90 from Fee Schedule UHC_98227C for Rev 306 Proc 87389 * Qty 1 = $28.90 at 100% = $28.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,24.08,,,,,,,24.0800,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,306,RC,30600316,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,24.0800,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 306 Proc 87389 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,AETNA,AETNA HSHS,249.57,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $249.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,AETNA,ALL COMMERCIAL AETNA,386.33,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $386.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,386.33,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $386.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,CENPATICO,ALL MEDICAID CENPATICO,386.33,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $386.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,328.38,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $328.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,CIGNA,ALL COMMERCIAL CIGNA,270.43,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $270.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,COFINITY,COFINITY,386.33,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $386.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,367.01,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $367.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,324.52,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $324.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,274.29,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $274.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,282.02,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $282.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,187.76,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $187.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,328.38,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $328.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,HUMANA,HUMANA CHOICE CARE PPO,328.38,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $328.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,282.02,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $282.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,386.33,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $386.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,193.17,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $193.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,324.52,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $324.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,289.75,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $289.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,355.42,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $355.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,246.59,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $246.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,278.16,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $278.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,278.16,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $278.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,239.52,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $239.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,278.16,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $278.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,278.16,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $278.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"STENT, NON-COR, TEM W/O DEL",C2617,HCPCS,278,RC,10011250,CDM,,,,both,,,386.3300,254.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,231.80,,,,,,,187.7600,386.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $386.33 in Billed Charges for Rev 278 Proc C2617 = $231.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,AETNA,AETNA HSHS,402.78,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $402.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,AETNA,ALL COMMERCIAL AETNA,623.50,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $623.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,623.50,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $623.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,CENPATICO,ALL MEDICAID CENPATICO,623.50,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $623.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,529.98,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $529.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,CIGNA,ALL COMMERCIAL CIGNA,436.45,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $436.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,COFINITY,COFINITY,623.50,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $623.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,592.33,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $592.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,523.74,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $523.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,442.69,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $442.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,455.16,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $455.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,303.02,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $303.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,529.98,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $529.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,HUMANA,HUMANA CHOICE CARE PPO,529.98,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $529.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,455.16,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $455.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,623.50,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $623.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,311.75,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $311.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,523.74,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $523.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,467.63,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $467.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,573.62,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $573.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,397.98,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $397.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,448.92,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $448.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,448.92,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $448.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,386.57,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $386.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,448.92,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $448.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,448.92,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $448.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TISSUE CYMETRA 2CC  (603020) CHARGE PER CC,Q4112,HCPCS,278,RC,10011072,CDM,,,,both,,,623.5000,411.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,374.10,,,,,,,303.0200,623.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $623.50 in Billed Charges for Rev 278 Proc Q4112 = $374.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,AETNA,AETNA HSHS,860.80,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $860.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,AETNA,ALL COMMERCIAL AETNA,1332.50,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,332.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,ANTHEM,ANTHEM POS/HMO,692.90,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $692.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,ANTHEM,ANTHEM PPO,692.90,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $692.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1332.50,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,332.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,CENPATICO,ALL MEDICAID CENPATICO,1332.50,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,332.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1132.63,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,132.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,CIGNA,ALL COMMERCIAL CIGNA,932.75,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $932.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,COFINITY,COFINITY,1332.50,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,332.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1265.88,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,265.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,1119.30,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,119.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,946.08,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $946.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,972.73,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $972.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,647.60,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $647.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1132.63,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,132.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,HUMANA,HUMANA CHOICE CARE PPO,1132.63,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,132.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,972.73,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $972.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,1332.50,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,332.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,666.25,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $666.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1119.30,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,119.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,999.38,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $999.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1225.90,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $1,225.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,850.53,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $850.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,959.40,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $959.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,959.40,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $959.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,826.15,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $826.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,959.40,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $959.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,959.40,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $959.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IMPLANT ORBITAL HA 20MM,L8610,HCPCS,278,RC,10004614,CDM,,,,both,,,1332.5000,879.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,799.50,,,,,,,647.6000,1332.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,332.50 in Billed Charges for Rev 278 Proc L8610 = $799.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,AETNA,AETNA HSHS,84.30,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $84.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,AETNA,ALL COMMERCIAL AETNA,130.50,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $130.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,130.50,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $130.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,CENPATICO,ALL MEDICAID CENPATICO,130.50,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $130.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,110.93,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $110.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,CIGNA,ALL COMMERCIAL CIGNA,91.35,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $91.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,COFINITY,COFINITY,130.50,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $130.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,123.98,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $123.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,HEALTH CARE ALLIANCE,THE ALLIANCE,109.62,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $109.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,92.66,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $92.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,95.27,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $95.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,HSHS EMPLOYEES,HSHS EMPLOYEES,63.42,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $63.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,110.93,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $110.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,HUMANA,HUMANA CHOICE CARE PPO,110.93,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $110.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,95.27,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $95.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,LIVE360,LIVE360 HSHS HEALTHY PLAN,130.50,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $130.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.25,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $65.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,109.62,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $109.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,97.88,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $97.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,120.06,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $120.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,83.30,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $83.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,93.96,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $93.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,93.96,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $93.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,80.91,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $80.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,93.96,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $93.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,93.96,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $93.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPHERE EYE 16MM SILICONE WITHOUT PERFORATION,L8610,HCPCS,278,RC,10073747,CDM,,,,both,,,130.5000,86.1300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,78.30,,,,,,,63.4200,130.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.50 in Billed Charges for Rev 278 Proc L8610 = $78.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,AETNA,AETNA HSHS,87.21,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $87.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,AETNA,ALL COMMERCIAL AETNA,135.00,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,135.00,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,CENPATICO,ALL MEDICAID CENPATICO,135.00,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,114.75,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $114.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,CIGNA,ALL COMMERCIAL CIGNA,94.50,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $94.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,COFINITY,COFINITY,135.00,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,128.25,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $128.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,113.40,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $113.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,95.85,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $95.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,98.55,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $98.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,65.61,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $65.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,114.75,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $114.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,HUMANA,HUMANA CHOICE CARE PPO,114.75,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $114.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,98.55,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $98.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,135.00,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,67.50,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,113.40,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $113.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,101.25,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $101.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,124.20,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $124.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,86.17,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $86.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,97.20,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,97.20,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,83.70,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $83.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,97.20,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,97.20,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OCULAR IMPLANT,L8610,HCPCS,278,RC,10085910,CDM,,,,both,,,135.0000,89.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,81.00,,,,,,,65.6100,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $135.00 in Billed Charges for Rev 278 Proc L8610 = $81.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,AETNA,AETNA HSHS,83.55,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $83.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,AETNA,ALL COMMERCIAL AETNA,129.33,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $129.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,129.33,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $129.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,CENPATICO,ALL MEDICAID CENPATICO,129.33,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $129.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,109.93,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $109.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,CIGNA,ALL COMMERCIAL CIGNA,90.53,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $90.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,COFINITY,COFINITY,129.33,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $129.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,122.86,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $122.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,108.64,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $108.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,91.82,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $91.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,94.41,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $94.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,62.85,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $62.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,109.93,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $109.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,HUMANA,HUMANA CHOICE CARE PPO,109.93,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $109.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,94.41,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $94.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,129.33,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $129.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,64.67,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $64.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,108.64,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $108.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,97.00,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $97.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,118.98,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $118.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,82.55,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $82.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,93.12,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $93.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,93.12,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $93.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,80.18,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $80.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,93.12,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $93.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,93.12,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $93.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SPONGE RETINAL 80X5X2.5MM SILICONE,L8610,HCPCS,278,RC,10010011,CDM,,,,both,,,129.3300,85.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,77.60,,,,,,,62.8500,129.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $129.33 in Billed Charges for Rev 278 Proc L8610 = $77.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,AETNA,AETNA HSHS,2325.60,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,325.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,AETNA,ALL COMMERCIAL AETNA,3600.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,ANTHEM,ANTHEM POS/HMO,1872.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $1,872.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,ANTHEM,ANTHEM PPO,1872.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $1,872.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3600.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,CENPATICO,ALL MEDICAID CENPATICO,3600.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3060.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,CIGNA,ALL COMMERCIAL CIGNA,2520.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,COFINITY,COFINITY,3600.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3420.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,3024.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,024.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2556.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,556.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2628.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,628.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,1749.60,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $1,749.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3060.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,HUMANA,HUMANA CHOICE CARE HMO,1800.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $1,800.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,HUMANA,HUMANA CHOICE CARE PPO,3060.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,HUMANA,HUMANA NATIIONAL POS HMO,1800.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $1,800.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2628.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,628.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3600.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1800.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $1,800.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3024.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,024.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2700.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,700.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3312.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $3,312.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2297.88,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,297.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2592.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2592.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2232.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,232.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2592.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2592.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PROSTHESIS OSSICULAR INCUS WEHRS DOUBLE NOTCH 4.5MM,L8613,HCPCS,278,RC,10055413,CDM,,,,both,,,3600.0000,2376.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2160.00,,,,,,,1749.6000,3600.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,600.00 in Billed Charges for Rev 278 Proc L8613 = $2,160.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,AETNA,AETNA HSHS,3951.31,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,951.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,AETNA,ALL COMMERCIAL AETNA,6116.58,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $6,116.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,ANTHEM,ANTHEM POS/HMO,3180.62,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,180.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,ANTHEM,ANTHEM PPO,3180.62,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 52% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,180.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6116.58,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $6,116.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,CENPATICO,ALL MEDICAID CENPATICO,6116.58,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $6,116.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5199.09,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $5,199.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,CIGNA,ALL COMMERCIAL CIGNA,4281.61,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,281.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,COFINITY,COFINITY,6116.58,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $6,116.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5810.75,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $5,810.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,5137.93,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $5,137.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4342.77,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,342.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4465.10,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,465.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,2972.66,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $2,972.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5199.09,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $5,199.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,HUMANA,HUMANA CHOICE CARE HMO,3058.29,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,058.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,HUMANA,HUMANA CHOICE CARE PPO,5199.09,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $5,199.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,HUMANA,HUMANA NATIIONAL POS HMO,3058.29,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,058.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4465.10,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,465.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,6116.58,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $6,116.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3058.29,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,058.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5137.93,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $5,137.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4587.44,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,587.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5627.25,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $5,627.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3058.29,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,058.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3058.29,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,058.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,PREVEA HEALTH NETWORK,PREVEA360,3058.29,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,058.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3058.29,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,058.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3904.21,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,904.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4403.94,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,403.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4403.94,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,403.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3792.28,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,792.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4403.94,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,403.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4403.94,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $4,403.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"AUD OSSEO DEV, INT/EXT COMP",L8690,HCPCS,278,RC,10065080,CDM,,,,both,,,6116.5800,4036.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3669.95,,,,,,,2972.6600,6116.5800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,116.58 in Billed Charges for Rev 278 Proc L8690 = $3,669.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,AETNA,AETNA HSHS,59.43,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $92.00 in Billed Charges for Rev 271 = $59.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,AETNA,ALL COMMERCIAL AETNA,92.00,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.00 in Billed Charges for Rev 271 = $92.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,ANTHEM,ANTHEM POS/HMO,62.56,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $92.00 in Billed Charges for Rev 271 = $62.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,ANTHEM,ANTHEM PPO,62.56,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $92.00 in Billed Charges for Rev 271 = $62.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,92.00,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.00 in Billed Charges for Rev 271 = $92.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,CENPATICO,ALL MEDICAID CENPATICO,92.00,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.00 in Billed Charges for Rev 271 = $92.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,78.20,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $92.00 in Billed Charges for Rev 271 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,CIGNA,ALL COMMERCIAL CIGNA,64.40,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $92.00 in Billed Charges for Rev 271 = $64.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,COFINITY,COFINITY,92.00,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.00 in Billed Charges for Rev 271 = $92.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,87.40,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $92.00 in Billed Charges for Rev 271 = $87.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,77.28,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $92.00 in Billed Charges for Rev 271 = $77.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,65.32,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $92.00 in Billed Charges for Rev 271 = $65.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,67.16,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $92.00 in Billed Charges for Rev 271 = $67.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,44.71,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $92.00 in Billed Charges for Rev 271 = $44.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,78.20,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $92.00 in Billed Charges for Rev 271 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,HUMANA,HUMANA CHOICE CARE HMO,58.42,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $92.00 in Billed Charges for Rev 271 = $58.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,HUMANA,HUMANA CHOICE CARE PPO,78.20,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $92.00 in Billed Charges for Rev 271 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,HUMANA,HUMANA NATIIONAL POS HMO,58.42,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $92.00 in Billed Charges for Rev 271 = $58.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,67.16,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $92.00 in Billed Charges for Rev 271 = $67.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,92.00,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $92.00 in Billed Charges for Rev 271 = $92.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.00,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $92.00 in Billed Charges for Rev 271 = $46.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,77.28,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $92.00 in Billed Charges for Rev 271 = $77.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,69.00,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $92.00 in Billed Charges for Rev 271 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,84.64,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $92.00 in Billed Charges for Rev 271 = $84.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,55.20,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $92.00 in Billed Charges for Rev 271 = $55.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,55.20,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $92.00 in Billed Charges for Rev 271 = $55.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,PREVEA HEALTH NETWORK,PREVEA360,55.20,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $92.00 in Billed Charges for Rev 271 = $55.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,55.20,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $92.00 in Billed Charges for Rev 271 = $55.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,58.72,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $92.00 in Billed Charges for Rev 271 = $58.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,66.24,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $92.00 in Billed Charges for Rev 271 = $66.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,50.88,,,,,,,44.7100,92.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $92.00 in Billed Charges for Rev 271 = $50.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,50.88,,,,,,,44.7100,92.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $92.00 in Billed Charges for Rev 271 = $50.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,50.88,,,,,,,44.7100,92.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $92.00 in Billed Charges for Rev 271 = $50.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,66.24,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $92.00 in Billed Charges for Rev 271 = $66.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,57.04,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $92.00 in Billed Charges for Rev 271 = $57.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,66.24,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $92.00 in Billed Charges for Rev 271 = $66.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,66.24,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $92.00 in Billed Charges for Rev 271 = $66.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CRUTCHES PER PAIR,271,RC,29200003,CDM,,,,,,both,,,92.0000,60.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.20,,,,,,,44.7100,92.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $92.00 in Billed Charges for Rev 271 = $55.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,AETNA,AETNA HSHS,16.15,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $25.00 in Billed Charges for Rev 300 = $16.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,AETNA,ALL COMMERCIAL AETNA,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,ANTHEM,ANTHEM POS/HMO,17.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $25.00 in Billed Charges at 68% = $17.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,ANTHEM,ANTHEM PPO,17.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $25.00 in Billed Charges at 68% = $17.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,CENPATICO,ALL MEDICAID CENPATICO,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,21.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,CIGNA,ALL COMMERCIAL CIGNA,17.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $25.00 in Billed Charges for Rev 300 = $17.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,COFINITY,COFINITY,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.75,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $25.00 in Billed Charges for Rev 300 = $23.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,21.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.00 in Billed Charges for Rev 300 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.75,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $25.00 in Billed Charges for Rev 300 = $17.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.00 in Billed Charges for Rev 300 = $18.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,12.15,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $25.00 in Billed Charges for Rev 300 = $12.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,21.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,HUMANA,HUMANA CHOICE CARE PPO,21.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.00 in Billed Charges for Rev 300 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.25,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.00 in Billed Charges for Rev 300 = $18.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,25.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.00 in Billed Charges for Rev 300 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $25.00 in Billed Charges for Rev 300 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,21.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.00 in Billed Charges for Rev 300 = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.75,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $25.00 in Billed Charges for Rev 300 = $18.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,23.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $25.00 in Billed Charges for Rev 300 = $23.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.00,,,,,,,12.1500,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.00,,,,,,,12.1500,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA360,15.00,,,,,,,12.1500,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.00,,,,,,,12.1500,25.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.96,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $25.00 in Billed Charges for Rev 300 = $15.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,18.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $25.00 in Billed Charges at 50% = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,12.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $25.00 in Billed Charges at 50% = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,12.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 $25.00 in Billed Charges at 50% = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,18.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.50,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $25.00 in Billed Charges for Rev 300 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,18.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,18.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.00 in Billed Charges for Rev 300 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BLOOD GLUCOSE TEST,300,RC,30000001,CDM,,,,,,both,,,25.0000,16.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.00,,,,,,,12.1500,25.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.00 in Billed Charges for Rev 300 = $15.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,AETNA,AETNA HSHS,32.30,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,AETNA,AETNA MEDICARE,9.34,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,AETNA,ALL COMMERCIAL AETNA,50.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,ANTHEM,ANTEHM MEDICAID,1.23,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,9.34,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,ANTHEM,ANTHEM POS/HMO,10.00,,,,,,,1.2300,50.0000,other,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36415 Qty 1 * $10.00 = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,ANTHEM,ANTHEM PPO,10.00,,,,,,,1.2300,50.0000,other,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36415 Qty 1 * $10.00 = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,50.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,CENPATICO,ALL MEDICAID CENPATICO,50.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,42.50,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,COFINITY,COFINITY,50.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1.23,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1.23,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,47.50,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $47.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,42.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,35.50,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $35.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,36.50,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $36.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,24.30,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $24.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,42.50,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HUMANA,HUMANA CHOICE CARE HMO,15.01,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.01 from Fee Schedule 005543_170 for Rev 300 Proc 36415 * Qty 1 = $15.01 at 100% = $15.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HUMANA,HUMANA CHOICE CARE PPO,42.50,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,9.34,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,HUMANA,HUMANA NATIIONAL POS HMO,15.01,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.01 from Fee Schedule 005543_170 for Rev 300 Proc 36415 * Qty 1 = $15.01 at 100% = $15.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,36.50,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $36.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,50.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1.23,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,9.34,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1.23,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,1.30,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 100% = $1.23... $1.23 at 106% = $1.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,9.34,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,25.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,42.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,21.02,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,37.50,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $37.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,46.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $46.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.14,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.14,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,PREVEA HEALTH NETWORK,PREVEA360,12.14,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.14,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.92,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $31.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,9.43,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,36.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,TRIOLOGY,TRILOGY MEDICAID,1.30,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00304 Proc 36415 at $125.60 (Base Rate) * 0.0098 (Relative Weight) = $1.23 (Total Line Payment) at 106% = $1.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.28,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.28 from Fee Schedule UHC_98227C for Rev 300 Proc 36415 * Qty 1 = $10.28 at 100% = $10.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,10.28,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.28 from Fee Schedule UHC_98227C for Rev 300 Proc 36415 * Qty 1 = $10.28 at 100% = $10.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,9.34,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,10.28,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.28 from Fee Schedule UHC_98227C for Rev 300 Proc 36415 * Qty 1 = $10.28 at 100% = $10.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,UNITY HEALTH PLAN,UNITY HOSPICE,9.34,,,,,,,1.2300,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,36.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,31.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $31.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,36.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,36.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLL VENOUS BLD VENIPUNCTURE,36415,CPT,300,RC,30000005,CDM,,,,both,,,50.0000,33.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,30.00,,,,,,,1.2300,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $50.00 in Billed Charges for Rev 300 Proc 36415 = $30.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA HSHS,126.62,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $126.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA MEDICARE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,AETNA,ALL COMMERCIAL AETNA,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTEHM MEDICAID,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36591 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM POS/HMO,133.28,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36591 $196.00 in Billed Charges at 68% = $133.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM PPO,133.28,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36591 $196.00 in Billed Charges at 68% = $133.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,CENPATICO,ALL MEDICAID CENPATICO,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,166.60,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,COFINITY,COFINITY,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36591 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36591 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,186.20,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $186.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,164.64,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.16,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $139.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.08,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,95.26,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $95.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,166.60,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE HMO,44.59,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $44.59 from Fee Schedule 005543_170 for Rev 300 Proc 36591 * Qty 1 = $44.59 at 100% = $44.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE PPO,166.60,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA NATIIONAL POS HMO,44.59,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $44.59 from Fee Schedule 005543_170 for Rev 300 Proc 36591 * Qty 1 = $44.59 at 100% = $44.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.08,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,196.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36591 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,34.44,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36591 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,36.51,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36591 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44... $34.44 at 106% = $36.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,164.64,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,290.78,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.00,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,180.32,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $180.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,117.60,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,117.60,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360,117.60,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,117.60,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.11,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $125.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.52,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.12,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,TRILOGY MEDICAID,36.51,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36591 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 106% = $36.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,UNITY HEALTH PLAN,UNITY HOSPICE,129.23,,,,,,,34.4400,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.12,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,121.52,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $121.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.12,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.12,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRAW BLOOD OFF VENOUS DEVICE,36591,CPT,300,RC,30000014,CDM,,,,both,,,196.0000,129.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,117.60,,,,,,,34.4400,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $196.00 in Billed Charges for Rev 300 Proc 36591 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA HSHS,126.62,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $126.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA MEDICARE,129.23,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,AETNA,ALL COMMERCIAL AETNA,196.00,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTEHM MEDICAID,34.44,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36600 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,129.23,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM POS/HMO,133.28,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36600 $196.00 in Billed Charges at 68% = $133.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM PPO,133.28,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36600 $196.00 in Billed Charges at 68% = $133.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,196.00,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,CENPATICO,ALL MEDICAID CENPATICO,196.00,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,166.60,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,CIGNA,ALL COMMERCIAL CIGNA,137.20,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $137.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,COFINITY,COFINITY,196.00,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,34.44,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36600 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,34.44,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36600 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,186.20,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $186.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,164.64,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.16,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $139.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.08,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,95.26,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $95.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,166.60,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE HMO,23.90,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $23.90 from Fee Schedule 005543_170 for Rev 300 Proc 36600 * Qty 1 = $23.90 at 100% = $23.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE PPO,166.60,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,129.23,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA NATIIONAL POS HMO,23.90,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $23.90 from Fee Schedule 005543_170 for Rev 300 Proc 36600 * Qty 1 = $23.90 at 100% = $23.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.08,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,196.00,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,34.44,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36600 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,129.23,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,34.44,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36600 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,36.51,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36600 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44... $34.44 at 106% = $36.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,129.23,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.00,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,164.64,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,290.78,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.00,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,180.32,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $180.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,117.60,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,117.60,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360,117.60,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,117.60,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.11,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $125.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.52,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.12,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,TRILOGY MEDICAID,36.51,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36600 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 106% = $36.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,129.23,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,UNITY HEALTH PLAN,UNITY HOSPICE,129.23,,,,,,,23.9000,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.12,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,121.52,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $121.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.12,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.12,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTERIAL PUNCTURE,36600,CPT,300,RC,30000015,CDM,,,,both,,,196.0000,129.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,117.60,,,,,,,23.9000,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $196.00 in Billed Charges for Rev 300 Proc 36600 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,AETNA,AETNA HSHS,35.53,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $35.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,AETNA,AETNA MEDICARE,4.27,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,AETNA,ALL COMMERCIAL AETNA,55.00,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,ANTHEM,ANTEHM MEDICAID,4.41,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89055 at $4.41 (Fee Schedule) = $4.41 (Total Line Payment) at 100% = $4.41. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,4.27,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,ANTHEM,ANTHEM POS/HMO,14.95,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.95 from Fee Schedule WII28_25 for Rev 300 Proc 89055 Mod TC * Qty 1 = $14.95 at 100% = $14.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,ANTHEM,ANTHEM PPO,14.95,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.95 from Fee Schedule WII28_25 for Rev 300 Proc 89055 Mod TC * Qty 1 = $14.95 at 100% = $14.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,55.00,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,CENPATICO,ALL MEDICAID CENPATICO,55.00,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,46.75,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $46.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,CIGNA,ALL COMMERCIAL CIGNA,38.50,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $38.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,COFINITY,COFINITY,55.00,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,4.41,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89055 at $4.41 (Fee Schedule) = $4.41 (Total Line Payment) at 100% = $4.41. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,4.41,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89055 at $4.41 (Fee Schedule) = $4.41 (Total Line Payment) at 100% = $4.41. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,52.25,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $52.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,46.20,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,39.05,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $39.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,40.15,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $40.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,26.73,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $26.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,46.75,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $46.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HUMANA,HUMANA CHOICE CARE HMO,7.26,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.26 from Fee Schedule 005543_170 for Rev 300 Proc 89055 * Qty 1 = $7.26 at 100% = $7.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HUMANA,HUMANA CHOICE CARE PPO,46.75,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $46.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,4.27,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,HUMANA,HUMANA NATIIONAL POS HMO,7.26,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.26 from Fee Schedule 005543_170 for Rev 300 Proc 89055 * Qty 1 = $7.26 at 100% = $7.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,40.15,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $40.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,55.00,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,4.41,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89055 at $4.41 (Fee Schedule) = $4.41 (Total Line Payment) at 100% = $4.41. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,4.27,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,4.41,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89055 at $4.41 (Fee Schedule) = $4.41 (Total Line Payment) at 100% = $4.41. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,4.67,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89055 at $4.41 (Fee Schedule) = $4.41 (Total Line Payment) at 100% = $4.41... $4.41 at 106% = $4.67 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,4.27,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27.50,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $27.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,46.20,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,9.61,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,41.25,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $41.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,50.60,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $50.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.55,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.55,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,PREVEA HEALTH NETWORK,PREVEA360,5.55,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.55,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,35.11,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $35.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,4.31,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,39.60,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,TRIOLOGY,TRILOGY MEDICAID,4.67,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89055 at $4.41 (Fee Schedule) = $4.41 (Total Line Payment) at 106% = $4.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.12,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.12 from Fee Schedule UHC_98227C for Rev 300 Proc 89055 * Qty 1 = $5.12 at 100% = $5.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,5.12,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.12 from Fee Schedule UHC_98227C for Rev 300 Proc 89055 * Qty 1 = $5.12 at 100% = $5.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,4.27,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,5.12,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.12 from Fee Schedule UHC_98227C for Rev 300 Proc 89055 * Qty 1 = $5.12 at 100% = $5.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,UNITY HEALTH PLAN,UNITY HOSPICE,4.27,,,,,,,4.2700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,39.60,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,34.10,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $34.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,39.60,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,39.60,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LEUKO ASSESS STOOL QN/SEMI,89055,CPT,300,RC,30000104,CDM,,,,both,,,55.0000,36.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,33.00,,,,,,,4.2700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $55.00 in Billed Charges for Rev 300 Proc 89055 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,AETNA,AETNA HSHS,32.30,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,AETNA,AETNA MEDICARE,5.79,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,AETNA,ALL COMMERCIAL AETNA,50.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,ANTHEM,ANTEHM MEDICAID,5.98,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89190 at $5.98 (Fee Schedule) = $5.98 (Total Line Payment) at 100% = $5.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5.79,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,ANTHEM,ANTHEM POS/HMO,20.27,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.27 from Fee Schedule WII28_25 for Rev 300 Proc 89190 Mod TC * Qty 1 = $20.27 at 100% = $20.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,ANTHEM,ANTHEM PPO,20.27,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.27 from Fee Schedule WII28_25 for Rev 300 Proc 89190 Mod TC * Qty 1 = $20.27 at 100% = $20.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,50.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,CENPATICO,ALL MEDICAID CENPATICO,50.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,42.50,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,CIGNA,ALL COMMERCIAL CIGNA,35.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $35.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,COFINITY,COFINITY,50.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.98,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89190 at $5.98 (Fee Schedule) = $5.98 (Total Line Payment) at 100% = $5.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.98,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89190 at $5.98 (Fee Schedule) = $5.98 (Total Line Payment) at 100% = $5.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,47.50,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $47.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,42.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,35.50,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $35.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,36.50,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $36.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,24.30,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $24.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,42.50,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HUMANA,HUMANA CHOICE CARE HMO,9.84,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.84 from Fee Schedule 005543_170 for Rev 300 Proc 89190 * Qty 1 = $9.84 at 100% = $9.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HUMANA,HUMANA CHOICE CARE PPO,42.50,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,5.79,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,HUMANA,HUMANA NATIIONAL POS HMO,9.84,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.84 from Fee Schedule 005543_170 for Rev 300 Proc 89190 * Qty 1 = $9.84 at 100% = $9.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,36.50,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $36.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,50.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.98,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89190 at $5.98 (Fee Schedule) = $5.98 (Total Line Payment) at 100% = $5.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5.79,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.98,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89190 at $5.98 (Fee Schedule) = $5.98 (Total Line Payment) at 100% = $5.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,6.34,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89190 at $5.98 (Fee Schedule) = $5.98 (Total Line Payment) at 100% = $5.98... $5.98 at 106% = $6.34 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,5.79,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,25.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $25.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,42.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,13.03,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,37.50,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $37.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,46.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $46.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.53,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.53,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,PREVEA HEALTH NETWORK,PREVEA360,7.53,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.53,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.92,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $31.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5.85,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,36.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,TRIOLOGY,TRILOGY MEDICAID,6.34,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89190 at $5.98 (Fee Schedule) = $5.98 (Total Line Payment) at 106% = $6.34. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.95,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.95 from Fee Schedule UHC_98227C for Rev 300 Proc 89190 * Qty 1 = $6.95 at 100% = $6.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,6.95,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.95 from Fee Schedule UHC_98227C for Rev 300 Proc 89190 * Qty 1 = $6.95 at 100% = $6.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5.79,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,6.95,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.95 from Fee Schedule UHC_98227C for Rev 300 Proc 89190 * Qty 1 = $6.95 at 100% = $6.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,UNITY HEALTH PLAN,UNITY HOSPICE,5.79,,,,,,,5.7900,50.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,36.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,31.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $31.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,36.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,36.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SMEAR NASAL EOSINOPHILS,89190,CPT,300,RC,30000107,CDM,,,,both,,,50.0000,33.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,30.00,,,,,,,5.7900,50.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $50.00 in Billed Charges for Rev 300 Proc 89190 = $30.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,AETNA,AETNA HSHS,193.80,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,AETNA,AETNA MEDICARE,165.49,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,AETNA,ALL COMMERCIAL AETNA,300.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTEHM MEDICAID,67.75,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 89220 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,165.49,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM POS/HMO,61.19,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $61.19 from Fee Schedule WII28_25 for Rev 300 Proc 89220 Mod TC * Qty 1 = $61.19 at 100% = $61.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM PPO,61.19,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $61.19 from Fee Schedule WII28_25 for Rev 300 Proc 89220 Mod TC * Qty 1 = $61.19 at 100% = $61.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,300.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,CENPATICO,ALL MEDICAID CENPATICO,300.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,255.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,CIGNA,ALL COMMERCIAL CIGNA,210.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,COFINITY,COFINITY,300.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,67.75,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 89220 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,67.75,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 89220 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,285.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $285.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,252.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,213.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $213.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,219.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,145.80,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $145.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,255.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA CHOICE CARE HMO,31.06,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $31.06 from Fee Schedule 005543_170 for Rev 300 Proc 89220 * Qty 1 = $31.06 at 100% = $31.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA CHOICE CARE PPO,255.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,165.49,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA NATIIONAL POS HMO,31.06,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $31.06 from Fee Schedule 005543_170 for Rev 300 Proc 89220 * Qty 1 = $31.06 at 100% = $31.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,219.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,300.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,67.75,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 89220 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,165.49,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,67.75,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 89220 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,71.82,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 89220 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75... $67.75 at 106% = $71.82 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,165.49,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,150.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,252.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,372.34,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,225.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,276.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $276.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,180.00,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,180.00,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA360,180.00,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,180.00,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,191.49,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $191.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,167.14,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,216.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,TRIOLOGY,TRILOGY MEDICAID,71.81,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 89220 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 106% = $71.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,188.70,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 300 Proc 89220 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,188.70,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 300 Proc 89220 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,165.49,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,188.70,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 300 Proc 89220 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,UNITY HEALTH PLAN,UNITY HOSPICE,165.49,,,,,,,31.0600,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,216.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,186.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,216.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,216.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPUTUM COLLECTION,89220,CPT,300,RC,30000108,CDM,,,,both,,,300.0000,198.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,180.00,,,,,,,31.0600,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $300.00 in Billed Charges for Rev 300 Proc 89220 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,AETNA,AETNA HSHS,152.46,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $152.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,AETNA,AETNA MEDICARE,50.62,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,AETNA,ALL COMMERCIAL AETNA,236.00,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 89230 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,50.62,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,ANTHEM,ANTHEM POS/HMO,7.20,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.20 from Fee Schedule WII28_25 for Rev 300 Proc 89230 Mod TC * Qty 1 = $7.20 at 100% = $7.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,ANTHEM,ANTHEM PPO,7.20,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.20 from Fee Schedule WII28_25 for Rev 300 Proc 89230 Mod TC * Qty 1 = $7.20 at 100% = $7.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,236.00,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,CENPATICO,ALL MEDICAID CENPATICO,236.00,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,200.60,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $200.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,CIGNA,ALL COMMERCIAL CIGNA,165.20,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $165.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,COFINITY,COFINITY,236.00,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 89230 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 89230 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,224.20,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $224.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,198.24,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $198.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,167.56,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $167.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,172.28,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $172.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,114.70,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $114.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,200.60,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $200.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HUMANA,HUMANA CHOICE CARE HMO,4.52,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.52 from Fee Schedule 005543_170 for Rev 300 Proc 89230 * Qty 1 = $4.52 at 100% = $4.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HUMANA,HUMANA CHOICE CARE PPO,200.60,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $200.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,50.62,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,HUMANA,HUMANA NATIIONAL POS HMO,4.52,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.52 from Fee Schedule 005543_170 for Rev 300 Proc 89230 * Qty 1 = $4.52 at 100% = $4.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,172.28,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $172.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,236.00,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $236.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 89230 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,50.62,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 89230 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 89230 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,50.62,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,118.00,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,198.24,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $198.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,113.89,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,177.00,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,217.12,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $217.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,141.60,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,141.60,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,PREVEA HEALTH NETWORK,PREVEA360,141.60,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,141.60,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,150.64,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $150.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.13,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,169.92,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $169.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 89230 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.17,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 300 Proc 89230 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,60.17,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 300 Proc 89230 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,50.62,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,60.17,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 300 Proc 89230 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,UNITY HEALTH PLAN,UNITY HOSPICE,50.62,,,,,,,4.5200,236.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,169.92,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $169.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,146.32,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $146.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,169.92,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $169.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,169.92,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $169.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SWEAT COLLECTION,89230,CPT,300,RC,30000109,CDM,,,,both,,,236.0000,155.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,141.60,,,,,,,4.5200,236.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $236.00 in Billed Charges for Rev 300 Proc 89230 = $141.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,AETNA,AETNA HSHS,47.16,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $47.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,AETNA,AETNA MEDICARE,12.31,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,AETNA,ALL COMMERCIAL AETNA,73.00,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,ANTHEM,ANTEHM MEDICAID,12.72,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89320 at $12.72 (Fee Schedule) = $12.72 (Total Line Payment) at 100% = $12.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,12.31,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,ANTHEM,ANTHEM POS/HMO,43.09,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.09 from Fee Schedule WII28_25 for Rev 300 Proc 89320 Mod TC * Qty 1 = $43.09 at 100% = $43.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,ANTHEM,ANTHEM PPO,43.09,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.09 from Fee Schedule WII28_25 for Rev 300 Proc 89320 Mod TC * Qty 1 = $43.09 at 100% = $43.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,73.00,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,CENPATICO,ALL MEDICAID CENPATICO,73.00,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,62.05,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $62.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,CIGNA,ALL COMMERCIAL CIGNA,51.10,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $51.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,COFINITY,COFINITY,73.00,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.72,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89320 at $12.72 (Fee Schedule) = $12.72 (Total Line Payment) at 100% = $12.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.72,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89320 at $12.72 (Fee Schedule) = $12.72 (Total Line Payment) at 100% = $12.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,69.35,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,61.32,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,51.83,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $51.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,53.29,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $53.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,35.48,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $35.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,62.05,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $62.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HUMANA,HUMANA CHOICE CARE HMO,20.93,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.93 from Fee Schedule 005543_170 for Rev 300 Proc 89320 * Qty 1 = $20.93 at 100% = $20.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HUMANA,HUMANA CHOICE CARE PPO,62.05,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $62.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,12.31,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,HUMANA,HUMANA NATIIONAL POS HMO,20.93,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.93 from Fee Schedule 005543_170 for Rev 300 Proc 89320 * Qty 1 = $20.93 at 100% = $20.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,53.29,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $53.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,73.00,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.72,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89320 at $12.72 (Fee Schedule) = $12.72 (Total Line Payment) at 100% = $12.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.31,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.72,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89320 at $12.72 (Fee Schedule) = $12.72 (Total Line Payment) at 100% = $12.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,13.48,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89320 at $12.72 (Fee Schedule) = $12.72 (Total Line Payment) at 100% = $12.72... $12.72 at 106% = $13.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,12.31,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,36.50,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $36.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,61.32,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,27.70,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,54.75,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,67.16,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $67.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.00,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.00,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,PREVEA HEALTH NETWORK,PREVEA360,16.00,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.00,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,46.60,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $46.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.43,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,52.56,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $52.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,TRIOLOGY,TRILOGY MEDICAID,13.48,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89320 at $12.72 (Fee Schedule) = $12.72 (Total Line Payment) at 106% = $13.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.77,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.77 from Fee Schedule UHC_98227C for Rev 300 Proc 89320 * Qty 1 = $14.77 at 100% = $14.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,14.77,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.77 from Fee Schedule UHC_98227C for Rev 300 Proc 89320 * Qty 1 = $14.77 at 100% = $14.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,12.31,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,14.77,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.77 from Fee Schedule UHC_98227C for Rev 300 Proc 89320 * Qty 1 = $14.77 at 100% = $14.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,UNITY HEALTH PLAN,UNITY HOSPICE,12.31,,,,,,,12.3100,73.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,52.56,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $52.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.26,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $45.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,52.56,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $52.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,52.56,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $52.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SEMEN ANAL VOL/COUNT/MOT,89320,CPT,300,RC,30000112,CDM,,,,both,,,73.0000,48.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,43.80,,,,,,,12.3100,73.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.00 in Billed Charges for Rev 300 Proc 89320 = $43.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,AETNA,AETNA HSHS,54.26,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,AETNA,AETNA MEDICARE,10.67,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,AETNA,ALL COMMERCIAL AETNA,84.00,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,ANTHEM,ANTEHM MEDICAID,1.85,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89325 at $125.60 (Base Rate) * 0.0147 (Relative Weight) = $1.85 (Total Line Payment) at 100% = $1.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,10.67,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,ANTHEM,ANTHEM POS/HMO,37.35,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $37.35 from Fee Schedule WII28_25 for Rev 300 Proc 89325 Mod TC * Qty 1 = $37.35 at 100% = $37.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,ANTHEM,ANTHEM PPO,37.35,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $37.35 from Fee Schedule WII28_25 for Rev 300 Proc 89325 Mod TC * Qty 1 = $37.35 at 100% = $37.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,84.00,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,CENPATICO,ALL MEDICAID CENPATICO,84.00,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,71.40,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,CIGNA,ALL COMMERCIAL CIGNA,58.80,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $58.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,COFINITY,COFINITY,84.00,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1.85,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89325 at $125.60 (Base Rate) * 0.0147 (Relative Weight) = $1.85 (Total Line Payment) at 100% = $1.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1.85,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89325 at $125.60 (Base Rate) * 0.0147 (Relative Weight) = $1.85 (Total Line Payment) at 100% = $1.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,79.80,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,70.56,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $70.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,59.64,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $59.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,61.32,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,40.82,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $40.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,71.40,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HUMANA,HUMANA CHOICE CARE HMO,18.14,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.14 from Fee Schedule 005543_170 for Rev 300 Proc 89325 * Qty 1 = $18.14 at 100% = $18.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HUMANA,HUMANA CHOICE CARE PPO,71.40,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,10.67,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,HUMANA,HUMANA NATIIONAL POS HMO,18.14,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.14 from Fee Schedule 005543_170 for Rev 300 Proc 89325 * Qty 1 = $18.14 at 100% = $18.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,61.32,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $61.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,84.00,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1.85,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89325 at $125.60 (Base Rate) * 0.0147 (Relative Weight) = $1.85 (Total Line Payment) at 100% = $1.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.67,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1.85,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89325 at $125.60 (Base Rate) * 0.0147 (Relative Weight) = $1.85 (Total Line Payment) at 100% = $1.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,1.96,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89325 at $125.60 (Base Rate) * 0.0147 (Relative Weight) = $1.85 (Total Line Payment) at 100% = $1.85... $1.85 at 106% = $1.96 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,10.67,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,42.00,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,70.56,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $70.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,24.01,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,63.00,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,77.28,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $77.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.87,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.87,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,PREVEA HEALTH NETWORK,PREVEA360,13.87,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.87,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,53.62,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $53.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,10.78,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,60.48,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $60.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,TRIOLOGY,TRILOGY MEDICAID,1.96,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89325 at $125.60 (Base Rate) * 0.0147 (Relative Weight) = $1.85 (Total Line Payment) at 106% = $1.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.80,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.80 from Fee Schedule UHC_98227C for Rev 300 Proc 89325 * Qty 1 = $12.80 at 100% = $12.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,12.80,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.80 from Fee Schedule UHC_98227C for Rev 300 Proc 89325 * Qty 1 = $12.80 at 100% = $12.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,10.67,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,12.80,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.80 from Fee Schedule UHC_98227C for Rev 300 Proc 89325 * Qty 1 = $12.80 at 100% = $12.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,UNITY HEALTH PLAN,UNITY HOSPICE,10.67,,,,,,,1.8500,84.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,60.48,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $60.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,52.08,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $52.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,60.48,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $60.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,60.48,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $60.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPERM ANTIBODIES,89325,CPT,300,RC,30000114,CDM,,,,both,,,84.0000,55.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,50.40,,,,,,,1.8500,84.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $84.00 in Billed Charges for Rev 300 Proc 89325 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,AETNA,AETNA HSHS,15.50,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,AETNA,ALL COMMERCIAL AETNA,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,ANTHEM,ANTHEM POS/HMO,16.32,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 99080 $24.00 in Billed Charges at 68% = $16.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,ANTHEM,ANTHEM PPO,16.32,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 99080 $24.00 in Billed Charges at 68% = $16.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,CENPATICO,ALL MEDICAID CENPATICO,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.40,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,CIGNA,ALL COMMERCIAL CIGNA,16.80,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $16.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,COFINITY,COFINITY,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,22.80,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,20.16,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $20.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.04,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $17.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.52,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,11.66,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $11.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.40,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,HUMANA,HUMANA CHOICE CARE PPO,20.40,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.52,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.16,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $20.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.08,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $22.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.40,,,,,,,11.6600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.40,,,,,,,11.6600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA360,14.40,,,,,,,11.6600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.40,,,,,,,11.6600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.32,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $15.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.28,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.28,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.88,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $14.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.28,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.28,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LAB PROCESS FEE,99080,CPT,300,RC,30000117,CDM,,,,both,,,24.0000,15.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.40,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.00 in Billed Charges for Rev 300 Proc 99080 = $14.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,AETNA,AETNA HSHS,205.43,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $205.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,AETNA,AETNA MEDICARE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,AETNA,ALL COMMERCIAL AETNA,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,ANTHEM,ANTEHM MEDICAID,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,ANTHEM,ANTHEM POS/HMO,59.99,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.99 from Fee Schedule WII28_25 for Rev 301 Proc 80306 Mod TC * Qty 1 = $59.99 at 100% = $59.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,ANTHEM,ANTHEM PPO,59.99,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.99 from Fee Schedule WII28_25 for Rev 301 Proc 80306 Mod TC * Qty 1 = $59.99 at 100% = $59.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,CENPATICO,ALL MEDICAID CENPATICO,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,270.30,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $270.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,CIGNA,ALL COMMERCIAL CIGNA,222.60,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $222.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,COFINITY,COFINITY,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,302.10,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $302.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,267.12,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $267.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,225.78,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $225.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,232.14,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $232.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,154.55,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $154.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,270.30,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $270.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HUMANA,HUMANA CHOICE CARE HMO,29.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.14 from Fee Schedule 005543_170 for Rev 301 Proc 80306 * Qty 1 = $29.14 at 100% = $29.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HUMANA,HUMANA CHOICE CARE PPO,270.30,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $270.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,HUMANA,HUMANA NATIIONAL POS HMO,29.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.14 from Fee Schedule 005543_170 for Rev 301 Proc 80306 * Qty 1 = $29.14 at 100% = $29.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,232.14,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $232.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,318.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.71,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,18.77,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71... $17.71 at 106% = $18.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,159.00,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,267.12,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $267.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,38.57,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,238.50,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $238.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,292.56,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $292.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,22.28,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,22.28,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,PREVEA HEALTH NETWORK,PREVEA360,22.28,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,22.28,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,202.98,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $202.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.31,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,228.96,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $228.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,TRIOLOGY,TRILOGY MEDICAID,18.77,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 106% = $18.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.57,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,20.57,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,20.57,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,UNITY HEALTH PLAN,UNITY HOSPICE,17.14,,,,,,,17.1400,318.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,228.96,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $228.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,197.16,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $197.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,228.96,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $228.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,228.96,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $228.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SCRN CLS A NON-TLC DVCS,80306,CPT,301,RC,30000130,CDM,,,,both,,,318.0000,209.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,190.80,,,,,,,17.1400,318.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $318.00 in Billed Charges for Rev 301 Proc 80306 = $190.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,AETNA,AETNA HSHS,157.62,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $157.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,AETNA,AETNA MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,AETNA,ALL COMMERCIAL AETNA,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,ANTHEM,ANTEHM MEDICAID,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,ANTHEM,ANTHEM POS/HMO,244.00,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $400.51 from Fee Schedule WII28_25 for Rev 300 Proc G0480 Mod TC * Qty 1 = $400.51 at 100% = $400.51 (Limited to $244.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,ANTHEM,ANTHEM PPO,244.00,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $400.51 from Fee Schedule WII28_25 for Rev 300 Proc G0480 Mod TC * Qty 1 = $400.51 at 100% = $400.51 (Limited to $244.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,CENPATICO,ALL MEDICAID CENPATICO,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,207.40,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $207.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,CIGNA,ALL COMMERCIAL CIGNA,170.80,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $170.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,COFINITY,COFINITY,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,231.80,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $231.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,204.96,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $204.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,173.24,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $173.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,178.12,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $178.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,118.58,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $118.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,207.40,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $207.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HUMANA,HUMANA CHOICE CARE HMO,194.53,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $194.53 from Fee Schedule 005543_170 for Rev 300 Proc G0480 * Qty 1 = $194.53 at 100% = $194.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HUMANA,HUMANA CHOICE CARE PPO,207.40,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $207.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HUMANA,HUMANA MEDICARE ADVANTAGE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,HUMANA,HUMANA NATIIONAL POS HMO,194.53,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $194.53 from Fee Schedule 005543_170 for Rev 300 Proc G0480 * Qty 1 = $194.53 at 100% = $194.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,178.12,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $178.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,244.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $244.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,MOLINA HEALTHCARE,MOLINA MEDICAID,67.79,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95... $63.95 at 106% = $67.79 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,MOLINA HEALTHCARE,MOLINA MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,122.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,204.96,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $204.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,NAPHCARE,ALL COMMERICAL NAPHCARE,257.47,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,183.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $183.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,224.48,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $224.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,PREVEA HEALTH NETWORK,PREVEA360,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,155.75,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $155.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,115.57,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,175.68,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,TRIOLOGY,TRILOGY MEDICAID,67.79,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 106% = $67.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 300 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 300 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 300 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,UNITY HEALTH PLAN,UNITY HOSPICE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,175.68,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,151.28,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $151.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,175.68,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,175.68,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $175.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,300,RC,30000209,CDM,,,,both,,,244.0000,161.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,146.40,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.00 in Billed Charges for Rev 300 Proc G0480 = $146.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,AETNA,AETNA HSHS,136.95,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $136.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,AETNA,AETNA MEDICARE,17.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,AETNA,ALL COMMERCIAL AETNA,212.00,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTEHM MEDICAID,17.71,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,17.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM POS/HMO,59.99,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.99 from Fee Schedule WII28_25 for Rev 300 Proc 80306 Mod TC * Qty 1 = $59.99 at 100% = $59.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM PPO,59.99,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.99 from Fee Schedule WII28_25 for Rev 300 Proc 80306 Mod TC * Qty 1 = $59.99 at 100% = $59.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,212.00,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,CENPATICO,ALL MEDICAID CENPATICO,212.00,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,180.20,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,CIGNA,ALL COMMERCIAL CIGNA,148.40,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $148.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,COFINITY,COFINITY,212.00,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.71,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.71,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,201.40,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $201.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,178.08,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $178.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,150.52,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $150.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,154.76,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $154.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,103.03,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $103.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,180.20,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA CHOICE CARE HMO,29.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.14 from Fee Schedule 005543_170 for Rev 300 Proc 80306 * Qty 1 = $29.14 at 100% = $29.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA CHOICE CARE PPO,180.20,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,17.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA NATIIONAL POS HMO,29.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.14 from Fee Schedule 005543_170 for Rev 300 Proc 80306 * Qty 1 = $29.14 at 100% = $29.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,154.76,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $154.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,212.00,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.71,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.71,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,18.77,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 100% = $17.71... $17.71 at 106% = $18.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,17.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,106.00,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,178.08,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $178.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,38.57,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,159.00,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,195.04,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $195.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,22.28,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,22.28,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA360,22.28,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,22.28,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,135.32,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $135.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.31,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,152.64,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,TRIOLOGY,TRILOGY MEDICAID,18.77,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80306 at $17.71 (Fee Schedule) = $17.71 (Total Line Payment) at 106% = $18.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.57,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,20.57,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,17.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,20.57,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.57 from Fee Schedule UHC_98227C for Rev 300 Proc 80306 * Qty 1 = $20.57 at 100% = $20.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,UNITY HEALTH PLAN,UNITY HOSPICE,17.14,,,,,,,17.1400,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,152.64,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,131.44,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $131.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,152.64,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,152.64,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BUPRENORPHINE SCR/QN URINE,80306,CPT,300,RC,30000211,CDM,,,,both,,,212.0000,139.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,127.20,,,,,,,17.1400,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $212.00 in Billed Charges for Rev 300 Proc 80306 = $127.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,AETNA,AETNA HSHS,253.23,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $253.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,AETNA,AETNA MEDICARE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,AETNA,ALL COMMERCIAL AETNA,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,ANTHEM,ANTEHM MEDICAID,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,ANTHEM,ANTHEM POS/HMO,217.49,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $217.49 from Fee Schedule WII28_25 for Rev 301 Proc 80307 Mod TC * Qty 1 = $217.49 at 100% = $217.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,ANTHEM,ANTHEM PPO,217.49,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $217.49 from Fee Schedule WII28_25 for Rev 301 Proc 80307 Mod TC * Qty 1 = $217.49 at 100% = $217.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,CENPATICO,ALL MEDICAID CENPATICO,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,333.20,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,CIGNA,ALL COMMERCIAL CIGNA,274.40,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $274.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,COFINITY,COFINITY,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,372.40,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $372.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,329.28,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $329.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,278.32,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $278.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,286.16,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $286.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,190.51,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $190.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,333.20,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HUMANA,HUMANA CHOICE CARE HMO,105.64,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $105.64 from Fee Schedule 005543_170 for Rev 301 Proc 80307 * Qty 1 = $105.64 at 100% = $105.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HUMANA,HUMANA CHOICE CARE PPO,333.20,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,HUMANA,HUMANA NATIIONAL POS HMO,105.64,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $105.64 from Fee Schedule 005543_170 for Rev 301 Proc 80307 * Qty 1 = $105.64 at 100% = $105.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,286.16,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $286.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,392.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,63.40,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,67.20,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40... $63.40 at 106% = $67.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,196.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,329.28,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $329.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,139.82,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,294.00,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $294.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,360.64,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $360.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,80.78,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,80.78,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,PREVEA HEALTH NETWORK,PREVEA360,80.78,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,80.78,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,250.21,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $250.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,62.76,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,282.24,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,TRIOLOGY,TRILOGY MEDICAID,67.20,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 106% = $67.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,74.57,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,74.57,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,74.57,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,UNITY HEALTH PLAN,UNITY HOSPICE,62.14,,,,,,,62.1400,392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,282.24,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,243.04,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $243.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,282.24,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,282.24,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,30000236,CDM,,,,both,,,392.0000,258.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,235.20,,,,,,,62.1400,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $392.00 in Billed Charges for Rev 301 Proc 80307 = $235.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,AETNA,AETNA HSHS,328.81,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $328.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,AETNA,AETNA MEDICARE,101.55,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,AETNA,ALL COMMERCIAL AETNA,509.00,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $509.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,ANTHEM,ANTEHM MEDICAID,25.74,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00471 Proc 76120 at $125.60 (Base Rate) * 0.2049 (Relative Weight) = $25.74 (Total Line Payment) at 100% = $25.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,ANTHEM,ANTHEM POS/HMO,402.22,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $402.22 from Fee Schedule WII28_25 for Rev 320 Proc 76120 Mod TC * Qty 1 = $402.22 at 100% = $402.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,ANTHEM,ANTHEM PPO,402.22,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $402.22 from Fee Schedule WII28_25 for Rev 320 Proc 76120 Mod TC * Qty 1 = $402.22 at 100% = $402.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,509.00,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $509.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,CENPATICO,ALL MEDICAID CENPATICO,509.00,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $509.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,432.65,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $432.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,CIGNA,ALL COMMERCIAL CIGNA,356.30,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $356.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,COFINITY,COFINITY,509.00,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $509.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,25.74,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00471 Proc 76120 at $125.60 (Base Rate) * 0.2049 (Relative Weight) = $25.74 (Total Line Payment) at 100% = $25.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,25.74,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00471 Proc 76120 at $125.60 (Base Rate) * 0.2049 (Relative Weight) = $25.74 (Total Line Payment) at 100% = $25.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,483.55,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $483.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,427.56,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $427.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,361.39,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $361.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,371.57,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $371.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,247.37,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $247.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,432.65,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $432.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HUMANA,HUMANA CHOICE CARE HMO,193.52,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $193.52 from Fee Schedule 005543_205 for Rev 320 Proc 76120 Mod TC * Qty 1 = $193.52 at 100% = $193.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HUMANA,HUMANA CHOICE CARE PPO,432.65,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $432.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,HUMANA,HUMANA NATIIONAL POS HMO,193.52,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $193.52 from Fee Schedule 005543_205 for Rev 320 Proc 76120 Mod TC * Qty 1 = $193.52 at 100% = $193.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,371.57,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $371.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,509.00,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $509.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,25.74,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00471 Proc 76120 at $125.60 (Base Rate) * 0.2049 (Relative Weight) = $25.74 (Total Line Payment) at 100% = $25.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,25.74,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00471 Proc 76120 at $125.60 (Base Rate) * 0.2049 (Relative Weight) = $25.74 (Total Line Payment) at 100% = $25.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,27.28,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00471 Proc 76120 at $125.60 (Base Rate) * 0.2049 (Relative Weight) = $25.74 (Total Line Payment) at 100% = $25.74... $25.74 at 106% = $27.28 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,254.50,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $254.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,427.56,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $427.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,381.75,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $381.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,468.28,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $468.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,456.60,,,,,,,25.7400,509.0000,other,ST VINCENT HOSPITAL (ACU). Rev 320 Proc 76120 1 Visit at $456.60 per Visit = $456.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,456.60,,,,,,,25.7400,509.0000,other,ST VINCENT HOSPITAL (ACU). Rev 320 Proc 76120 1 Visit at $456.60 per Visit = $456.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,PREVEA HEALTH NETWORK,PREVEA360,456.60,,,,,,,25.7400,509.0000,other,ST VINCENT HOSPITAL (ACU). Rev 320 Proc 76120 1 Visit at $456.60 per Visit = $456.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,456.60,,,,,,,25.7400,509.0000,other,ST VINCENT HOSPITAL (ACU). Rev 320 Proc 76120 1 Visit at $456.60 per Visit = $456.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,324.89,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $324.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,366.48,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $366.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,TRIOLOGY,TRILOGY MEDICAID,27.28,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00471 Proc 76120 at $125.60 (Base Rate) * 0.2049 (Relative Weight) = $25.74 (Total Line Payment) at 106% = $27.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,495.60,,,,,,,25.7400,509.0000,other,ST VINCENT HOSPITAL (ACU). Rev 320 Proc 76120 1 Visit at $495.60 per Visit = $495.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,495.60,,,,,,,25.7400,509.0000,other,ST VINCENT HOSPITAL (ACU). Rev 320 Proc 76120 1 Visit at $495.60 per Visit = $495.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,495.60,,,,,,,25.7400,509.0000,other,ST VINCENT HOSPITAL (ACU). Rev 320 Proc 76120 1 Visit at $495.60 per Visit = $495.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,25.7400,509.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,366.48,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $366.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,315.58,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $315.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,366.48,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $366.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,366.48,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $366.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CINERADIOGRAPHY 76120,76120,CPT,320,RC,30000463,CDM,,,,both,,,509.0000,335.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,305.40,,,,,,,25.7400,509.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $509.00 in Billed Charges for Rev 320 Proc 76120 = $305.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,AETNA,AETNA HSHS,416.67,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $416.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,AETNA,AETNA MEDICARE,142.63,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,AETNA,ALL COMMERCIAL AETNA,645.00,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,ANTHEM,ANTEHM MEDICAID,140.78,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87631 at $140.78 (Fee Schedule) = $140.78 (Total Line Payment) at 100% = $140.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,142.63,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,ANTHEM,ANTHEM POS/HMO,499.21,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $499.21 from Fee Schedule WII28_25 for Rev 300 Proc 87631 Mod TC * Qty 1 = $499.21 at 100% = $499.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,ANTHEM,ANTHEM PPO,499.21,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $499.21 from Fee Schedule WII28_25 for Rev 300 Proc 87631 Mod TC * Qty 1 = $499.21 at 100% = $499.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,645.00,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,CENPATICO,ALL MEDICAID CENPATICO,645.00,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,548.25,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $548.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,CIGNA,ALL COMMERCIAL CIGNA,451.50,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $451.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,COFINITY,COFINITY,645.00,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,140.78,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87631 at $140.78 (Fee Schedule) = $140.78 (Total Line Payment) at 100% = $140.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,140.78,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87631 at $140.78 (Fee Schedule) = $140.78 (Total Line Payment) at 100% = $140.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,612.75,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $612.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,541.80,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $541.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,457.95,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $457.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,470.85,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $470.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,313.47,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $313.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,548.25,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $548.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HUMANA,HUMANA CHOICE CARE HMO,242.47,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.47 from Fee Schedule 005543_170 for Rev 300 Proc 87631 * Qty 1 = $242.47 at 100% = $242.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HUMANA,HUMANA CHOICE CARE PPO,548.25,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $548.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,142.63,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,HUMANA,HUMANA NATIIONAL POS HMO,242.47,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.47 from Fee Schedule 005543_170 for Rev 300 Proc 87631 * Qty 1 = $242.47 at 100% = $242.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,470.85,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $470.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,645.00,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,140.78,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87631 at $140.78 (Fee Schedule) = $140.78 (Total Line Payment) at 100% = $140.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,142.63,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,140.78,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87631 at $140.78 (Fee Schedule) = $140.78 (Total Line Payment) at 100% = $140.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,149.23,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87631 at $140.78 (Fee Schedule) = $140.78 (Total Line Payment) at 100% = $140.78... $140.78 at 106% = $149.23 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,142.63,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,322.50,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $322.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,541.80,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $541.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,320.92,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,483.75,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $483.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,593.40,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $593.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,185.42,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,185.42,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,PREVEA HEALTH NETWORK,PREVEA360,185.42,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,185.42,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,411.70,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $411.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,144.06,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,464.40,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $464.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,TRIOLOGY,TRILOGY MEDICAID,149.23,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87631 at $140.78 (Fee Schedule) = $140.78 (Total Line Payment) at 106% = $149.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,171.16,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 300 Proc 87631 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,171.16,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 300 Proc 87631 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,142.63,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,171.16,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 300 Proc 87631 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,UNITY HEALTH PLAN,UNITY HOSPICE,142.63,,,,,,,140.7800,645.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,464.40,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $464.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,399.90,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $399.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,464.40,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $464.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,464.40,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $464.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC RESP VIRUS, 3-5 TARGETS",87631,CPT,300,RC,30002037,CDM,,,,both,,,645.0000,425.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,387.00,,,,,,,140.7800,645.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $645.00 in Billed Charges for Rev 300 Proc 87631 = $387.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,AETNA,AETNA HSHS,226.75,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $226.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,AETNA,AETNA MEDICARE,11.53,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,AETNA,ALL COMMERCIAL AETNA,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,ANTHEM,ANTEHM MEDICAID,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0279U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.53,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,ANTHEM,ANTHEM POS/HMO,40.36,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.36 from Fee Schedule WII28_25 for Rev 300 Proc 0279U Mod TC * Qty 1 = $40.36 at 100% = $40.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,ANTHEM,ANTHEM PPO,40.36,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.36 from Fee Schedule WII28_25 for Rev 300 Proc 0279U Mod TC * Qty 1 = $40.36 at 100% = $40.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,CENPATICO,ALL MEDICAID CENPATICO,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,298.35,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $298.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,CIGNA,ALL COMMERCIAL CIGNA,245.70,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $245.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,COFINITY,COFINITY,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0279U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0279U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,333.45,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $333.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,294.84,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $294.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,249.21,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $249.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,256.23,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $256.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,170.59,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $170.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,298.35,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $298.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HUMANA,HUMANA CHOICE CARE HMO,19.60,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.60 from Fee Schedule 005543_170 for Rev 300 Proc 0279U * Qty 1 = $19.60 at 100% = $19.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HUMANA,HUMANA CHOICE CARE PPO,298.35,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $298.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,11.53,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,HUMANA,HUMANA NATIIONAL POS HMO,19.60,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.60 from Fee Schedule 005543_170 for Rev 300 Proc 0279U * Qty 1 = $19.60 at 100% = $19.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,256.23,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $256.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,351.00,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $351.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0279U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.53,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0279U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,1.75,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0279U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65... $1.65 at 106% = $1.75 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,11.53,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,175.50,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $175.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,294.84,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $294.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,25.94,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,263.25,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $263.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,322.92,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $322.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.99,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.99,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,PREVEA HEALTH NETWORK,PREVEA360,14.99,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.99,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,224.04,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $224.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,11.65,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,252.72,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,TRIOLOGY,TRILOGY MEDICAID,1.74,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0279U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 106% = $1.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,13.84,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.84 from Fee Schedule UHC_98227C for Rev 300 Proc 0279U * Qty 1 = $13.84 at 100% = $13.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,13.84,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.84 from Fee Schedule UHC_98227C for Rev 300 Proc 0279U * Qty 1 = $13.84 at 100% = $13.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.53,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,13.84,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.84 from Fee Schedule UHC_98227C for Rev 300 Proc 0279U * Qty 1 = $13.84 at 100% = $13.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,UNITY HEALTH PLAN,UNITY HOSPICE,11.53,,,,,,,1.6500,351.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,252.72,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,217.62,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $217.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,252.72,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,252.72,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $252.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VON WILLEBRAND FACTOR & COLLAGEN III BNDG,0279U,CPT,300,RC,30002047,CDM,,,,both,,,351.0000,231.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,210.60,,,,,,,1.6500,351.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.00 in Billed Charges for Rev 300 Proc 0279U = $210.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,AETNA,AETNA HSHS,611.76,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $611.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,AETNA,AETNA MEDICARE,540.99,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,AETNA,ALL COMMERCIAL AETNA,947.00,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $947.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,ANTHEM,ANTEHM MEDICAID,133.58,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0035U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,540.99,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,ANTHEM,ANTHEM POS/HMO,947.00,,,,,,,133.5800,1217.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,893.47 from Fee Schedule WII28_25 for Rev 300 Proc 0035U Mod TC * Qty 1 = $1,893.47 at 100% = $1,893.47 (Limited to $947.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,ANTHEM,ANTHEM PPO,947.00,,,,,,,133.5800,1217.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,893.47 from Fee Schedule WII28_25 for Rev 300 Proc 0035U Mod TC * Qty 1 = $1,893.47 at 100% = $1,893.47 (Limited to $947.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,947.00,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $947.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,CENPATICO,ALL MEDICAID CENPATICO,947.00,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $947.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,804.95,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $804.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,CIGNA,ALL COMMERCIAL CIGNA,662.90,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $662.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,COFINITY,COFINITY,947.00,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $947.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,133.58,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0035U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,133.58,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0035U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,899.65,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $899.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,795.48,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $795.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,672.37,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $672.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,691.31,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $691.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,460.24,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $460.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,804.95,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $804.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HUMANA,HUMANA CHOICE CARE HMO,919.68,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $919.68 from Fee Schedule 005543_170 for Rev 300 Proc 0035U * Qty 1 = $919.68 at 100% = $919.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HUMANA,HUMANA CHOICE CARE PPO,804.95,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $804.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,540.99,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,HUMANA,HUMANA NATIIONAL POS HMO,919.68,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $919.68 from Fee Schedule 005543_170 for Rev 300 Proc 0035U * Qty 1 = $919.68 at 100% = $919.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,691.31,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $691.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,947.00,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $947.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,133.58,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0035U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,540.99,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,133.58,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0035U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,141.59,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0035U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58... $133.58 at 106% = $141.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,540.99,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,473.50,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $473.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,795.48,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $795.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,1217.23,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,710.25,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $710.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,871.24,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $871.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,703.29,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,703.29,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,PREVEA HEALTH NETWORK,PREVEA360,703.29,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,703.29,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,604.47,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $604.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,546.40,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,681.84,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $681.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,TRIOLOGY,TRILOGY MEDICAID,141.59,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0035U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 106% = $141.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,649.19,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $649.19 from Fee Schedule UHC_98227C for Rev 300 Proc 0035U * Qty 1 = $649.19 at 100% = $649.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,649.19,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $649.19 from Fee Schedule UHC_98227C for Rev 300 Proc 0035U * Qty 1 = $649.19 at 100% = $649.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,540.99,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,649.19,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $649.19 from Fee Schedule UHC_98227C for Rev 300 Proc 0035U * Qty 1 = $649.19 at 100% = $649.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,UNITY HEALTH PLAN,UNITY HOSPICE,540.99,,,,,,,133.5800,1217.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,681.84,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $681.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,587.14,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $587.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,681.84,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $681.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,681.84,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $681.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEURO CSF DETECT PRION PROTEIN QUAKING CONF QL,0035U,CPT,300,RC,30002049,CDM,,,,both,,,947.0000,625.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,568.20,,,,,,,133.5800,1217.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $947.00 in Billed Charges for Rev 300 Proc 0035U = $568.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,AETNA,AETNA HSHS,925.07,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $925.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,AETNA,AETNA MEDICARE,174.81,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,AETNA,ALL COMMERCIAL AETNA,1432.00,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,ANTHEM,ANTEHM MEDICAID,61.22,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 0032U at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,174.81,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,ANTHEM,ANTHEM POS/HMO,611.84,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $611.84 from Fee Schedule WII28_25 for Rev 300 Proc 0032U Mod TC * Qty 1 = $611.84 at 100% = $611.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,ANTHEM,ANTHEM PPO,611.84,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $611.84 from Fee Schedule WII28_25 for Rev 300 Proc 0032U Mod TC * Qty 1 = $611.84 at 100% = $611.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1432.00,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,CENPATICO,ALL MEDICAID CENPATICO,1432.00,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1217.20,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,217.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,CIGNA,ALL COMMERCIAL CIGNA,1002.40,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,002.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,COFINITY,COFINITY,1432.00,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,61.22,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 0032U at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,61.22,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 0032U at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1360.40,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,360.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,1202.88,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,202.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1016.72,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,016.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1045.36,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,045.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,695.95,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $695.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1217.20,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,217.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HUMANA,HUMANA CHOICE CARE HMO,297.18,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $297.18 from Fee Schedule 005543_170 for Rev 300 Proc 0032U * Qty 1 = $297.18 at 100% = $297.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HUMANA,HUMANA CHOICE CARE PPO,1217.20,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,217.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,174.81,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,HUMANA,HUMANA NATIIONAL POS HMO,297.18,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $297.18 from Fee Schedule 005543_170 for Rev 300 Proc 0032U * Qty 1 = $297.18 at 100% = $297.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1045.36,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,045.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1432.00,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,61.22,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 0032U at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,174.81,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,61.22,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 0032U at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,64.89,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 0032U at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22... $61.22 at 106% = $64.89 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,174.81,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,716.00,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $716.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1202.88,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,202.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,393.32,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1074.00,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1317.44,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,317.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,227.25,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,227.25,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,PREVEA HEALTH NETWORK,PREVEA360,227.25,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,227.25,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,914.05,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $914.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,176.56,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1031.04,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,031.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,TRIOLOGY,TRILOGY MEDICAID,64.89,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 0032U at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 106% = $64.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,209.77,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $209.77 from Fee Schedule UHC_98227C for Rev 300 Proc 0032U * Qty 1 = $209.77 at 100% = $209.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,209.77,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $209.77 from Fee Schedule UHC_98227C for Rev 300 Proc 0032U * Qty 1 = $209.77 at 100% = $209.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,174.81,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,209.77,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $209.77 from Fee Schedule UHC_98227C for Rev 300 Proc 0032U * Qty 1 = $209.77 at 100% = $209.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,UNITY HEALTH PLAN,UNITY HOSPICE,174.81,,,,,,,61.2200,1432.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1031.04,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,031.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,887.84,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $887.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1031.04,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,031.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1031.04,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $1,031.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COMT GENE ANALYSIS,0032U,CPT,300,RC,30002061,CDM,,,,both,,,1432.0000,945.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,859.20,,,,,,,61.2200,1432.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,432.00 in Billed Charges for Rev 300 Proc 0032U = $859.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,AETNA,AETNA HSHS,71.71,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $71.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,AETNA,ALL COMMERCIAL AETNA,111.00,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $111.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80340 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,ANTHEM,ANTHEM POS/HMO,75.48,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 80340 $111.00 in Billed Charges at 68% = $75.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,ANTHEM,ANTHEM PPO,75.48,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 80340 $111.00 in Billed Charges at 68% = $75.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,111.00,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $111.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,CENPATICO,ALL MEDICAID CENPATICO,111.00,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $111.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,94.35,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $94.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,CIGNA,ALL COMMERCIAL CIGNA,77.70,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $77.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,COFINITY,COFINITY,111.00,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $111.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80340 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80340 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,105.45,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $105.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,93.24,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $93.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,78.81,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $78.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,81.03,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $81.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,53.95,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $53.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,94.35,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $94.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,HUMANA,HUMANA CHOICE CARE HMO,13.02,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.02 from Fee Schedule 005543_170 for Rev 300 Proc 80340 * Qty 1 = $13.02 at 100% = $13.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,HUMANA,HUMANA CHOICE CARE PPO,94.35,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $94.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,HUMANA,HUMANA NATIIONAL POS HMO,13.02,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.02 from Fee Schedule 005543_170 for Rev 300 Proc 80340 * Qty 1 = $13.02 at 100% = $13.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,81.03,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $81.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,111.00,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $111.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80340 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80340 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80340 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,55.50,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $55.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,93.24,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $93.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,83.25,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $83.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,102.12,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $102.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,66.60,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,66.60,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,PREVEA HEALTH NETWORK,PREVEA360,66.60,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,66.60,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,70.85,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $70.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,79.92,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $79.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,111.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80340 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,79.92,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $79.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,68.82,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $68.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,79.92,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $79.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,79.92,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $79.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANTIEPILEPTICS NOS 4-6,80340,CPT,300,RC,30002064,CDM,,,,both,,,111.0000,73.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,66.60,,,,,,,5.1700,111.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $111.00 in Billed Charges for Rev 300 Proc 80340 = $66.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,AETNA,AETNA HSHS,48.45,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $48.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,AETNA,ALL COMMERCIAL AETNA,75.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80376 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM POS/HMO,75.00,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 300 Proc 80376 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $75.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM PPO,75.00,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 300 Proc 80376 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $75.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,75.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,CENPATICO,ALL MEDICAID CENPATICO,75.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,63.75,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,CIGNA,ALL COMMERCIAL CIGNA,52.50,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $52.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,COFINITY,COFINITY,75.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80376 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80376 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,71.25,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,63.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,53.25,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $53.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.75,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,36.45,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $36.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,63.75,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 300 Proc 80376 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA CHOICE CARE PPO,63.75,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 300 Proc 80376 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.75,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,75.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80376 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80376 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80376 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.50,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $37.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,63.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,56.25,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $56.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,69.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.00,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.00,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA360,45.00,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.00,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.87,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $47.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,54.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80376 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,54.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,46.50,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $46.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,54.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,54.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRUG SUBSTANCE NOS 4-6,80376,CPT,300,RC,30002065,CDM,,,,both,,,75.0000,49.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,45.00,,,,,,,5.1700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $75.00 in Billed Charges for Rev 300 Proc 80376 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,AETNA,AETNA HSHS,458.66,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $458.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,AETNA,AETNA MEDICARE,128.92,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,AETNA,ALL COMMERCIAL AETNA,710.00,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,128.92,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,ANTHEM,ANTHEM POS/HMO,482.80,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 84394 $710.00 in Billed Charges at 68% = $482.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,ANTHEM,ANTHEM PPO,482.80,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 84394 $710.00 in Billed Charges at 68% = $482.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,710.00,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,CENPATICO,ALL MEDICAID CENPATICO,710.00,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,603.50,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $603.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,CIGNA,ALL COMMERCIAL CIGNA,497.00,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $497.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,COFINITY,COFINITY,710.00,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,674.50,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $674.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,596.40,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $596.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,504.10,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $504.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,518.30,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $518.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,345.06,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $345.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,603.50,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $603.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,HUMANA,HUMANA CHOICE CARE PPO,603.50,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $603.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,128.92,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,518.30,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $518.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,710.00,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,128.92,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,128.92,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,355.00,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $355.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,596.40,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $596.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,290.07,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,532.50,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $532.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,653.20,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $653.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,167.60,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,167.60,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,PREVEA HEALTH NETWORK,PREVEA360,167.60,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,167.60,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,453.19,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $453.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.21,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,511.20,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,154.70,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $154.70 from Fee Schedule UHC_98227C for Rev 300 Proc 84394 * Qty 1 = $154.70 at 100% = $154.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,154.70,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $154.70 from Fee Schedule UHC_98227C for Rev 300 Proc 84394 * Qty 1 = $154.70 at 100% = $154.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,128.92,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,154.70,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $154.70 from Fee Schedule UHC_98227C for Rev 300 Proc 84394 * Qty 1 = $154.70 at 100% = $154.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,UNITY HEALTH PLAN,UNITY HOSPICE,128.92,,,,,,,128.9200,710.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,511.20,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,440.20,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $440.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,511.20,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,511.20,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TAU TOTAL,84394,CPT,300,RC,30002067,CDM,,,,both,,,710.0000,468.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,426.00,,,,,,,128.9200,710.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $710.00 in Billed Charges for Rev 300 Proc 84394 = $426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,AETNA,AETNA HSHS,83.98,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $83.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,AETNA,AETNA MEDICARE,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,AETNA,ALL COMMERCIAL AETNA,130.00,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,ANTHEM,ANTEHM MEDICAID,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0202U at $416.78 (Fee Schedule) = $416.78 (Total Line Payment) at 100% = $416.78 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,ANTHEM,ANTHEM POS/HMO,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,458.73 from Fee Schedule WII28_25 for Rev 300 Proc 0202U Mod TC * Qty 1 = $1,458.73 at 100% = $1,458.73 (Limited to $130.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,ANTHEM,ANTHEM PPO,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,458.73 from Fee Schedule WII28_25 for Rev 300 Proc 0202U Mod TC * Qty 1 = $1,458.73 at 100% = $1,458.73 (Limited to $130.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,130.00,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,CENPATICO,ALL MEDICAID CENPATICO,130.00,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,110.50,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,CIGNA,ALL COMMERCIAL CIGNA,91.00,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $91.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,COFINITY,COFINITY,130.00,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0202U at $416.78 (Fee Schedule) = $416.78 (Total Line Payment) at 100% = $416.78 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0202U at $416.78 (Fee Schedule) = $416.78 (Total Line Payment) at 100% = $416.78 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,123.50,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $123.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,109.20,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $109.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,92.30,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $92.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,94.90,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $94.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,63.18,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $63.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,110.50,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HUMANA,HUMANA CHOICE CARE HMO,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.53 from Fee Schedule 005543_170 for Rev 300 Proc 0202U * Qty 1 = $708.53 at 100% = $708.53 (Limited to $130.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HUMANA,HUMANA CHOICE CARE PPO,110.50,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,HUMANA,HUMANA NATIIONAL POS HMO,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.53 from Fee Schedule 005543_170 for Rev 300 Proc 0202U * Qty 1 = $708.53 at 100% = $708.53 (Limited to $130.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,94.90,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $94.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,130.00,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0202U at $416.78 (Fee Schedule) = $416.78 (Total Line Payment) at 100% = $416.78 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0202U at $416.78 (Fee Schedule) = $416.78 (Total Line Payment) at 100% = $416.78 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,137.80,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0202U at $416.78 (Fee Schedule) = $416.78 (Total Line Payment) at 100% = $416.78 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges)... $130.00 at 106% = $137.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.00,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,109.20,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $109.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,292.50,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,97.50,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $97.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,119.60,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $119.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA360,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,82.98,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $82.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,131.30,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,93.60,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,TRIOLOGY,TRILOGY MEDICAID,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0202U at $416.78 (Fee Schedule) = $416.78 (Total Line Payment) at 106% = $441.79 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 300 Proc 0202U * Qty 1 = $500.14 at 100% = $500.14 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 300 Proc 0202U * Qty 1 = $500.14 at 100% = $500.14 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,130.00,,,,,,,63.1800,292.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 300 Proc 0202U * Qty 1 = $500.14 at 100% = $500.14 (Service Line reduced to $130.00, claim capped at $130.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,UNITY HEALTH PLAN,UNITY HOSPICE,130.00,,,,,,,63.1800,292.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,93.60,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,80.60,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $80.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,93.60,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,93.60,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2,0202U,CPT,300,RC,30002068,CDM,,,,both,,,130.0000,85.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,78.00,,,,,,,63.1800,292.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.00 in Billed Charges for Rev 300 Proc 0202U = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,AETNA,AETNA HSHS,33.59,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $33.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,AETNA,AETNA MEDICARE,17.27,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,AETNA,ALL COMMERCIAL AETNA,52.00,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,ANTHEM,ANTEHM MEDICAID,1.65,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0281U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,17.27,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,ANTHEM,ANTHEM POS/HMO,52.00,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.45 from Fee Schedule WII28_25 for Rev 300 Proc 0281U Mod TC * Qty 1 = $60.45 at 100% = $60.45 (Limited to $52.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,ANTHEM,ANTHEM PPO,52.00,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.45 from Fee Schedule WII28_25 for Rev 300 Proc 0281U Mod TC * Qty 1 = $60.45 at 100% = $60.45 (Limited to $52.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,52.00,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,CENPATICO,ALL MEDICAID CENPATICO,52.00,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,44.20,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $44.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,CIGNA,ALL COMMERCIAL CIGNA,36.40,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $36.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,COFINITY,COFINITY,52.00,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1.65,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0281U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1.65,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0281U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,49.40,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $49.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,43.68,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $43.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,36.92,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $36.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,37.96,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,25.27,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $25.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,44.20,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $44.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HUMANA,HUMANA CHOICE CARE HMO,29.36,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.36 from Fee Schedule 005543_170 for Rev 300 Proc 0281U * Qty 1 = $29.36 at 100% = $29.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HUMANA,HUMANA CHOICE CARE PPO,44.20,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $44.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,17.27,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,HUMANA,HUMANA NATIIONAL POS HMO,29.36,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.36 from Fee Schedule 005543_170 for Rev 300 Proc 0281U * Qty 1 = $29.36 at 100% = $29.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,37.96,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,52.00,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1.65,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0281U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.27,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1.65,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0281U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,1.75,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0281U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 100% = $1.65... $1.65 at 106% = $1.75 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,17.27,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.00,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,43.68,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $43.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,38.86,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,39.00,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,47.84,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $47.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,22.45,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,22.45,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,PREVEA HEALTH NETWORK,PREVEA360,22.45,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,22.45,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,33.19,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $33.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.44,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,37.44,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $37.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,TRIOLOGY,TRILOGY MEDICAID,1.74,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00406 Proc 0281U at $125.60 (Base Rate) * 0.0131 (Relative Weight) = $1.65 (Total Line Payment) at 106% = $1.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.72,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.72 from Fee Schedule UHC_98227C for Rev 300 Proc 0281U * Qty 1 = $20.72 at 100% = $20.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,20.72,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.72 from Fee Schedule UHC_98227C for Rev 300 Proc 0281U * Qty 1 = $20.72 at 100% = $20.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,17.27,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,20.72,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.72 from Fee Schedule UHC_98227C for Rev 300 Proc 0281U * Qty 1 = $20.72 at 100% = $20.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,UNITY HEALTH PLAN,UNITY HOSPICE,17.27,,,,,,,1.6500,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,37.44,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $37.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.24,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $32.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,37.44,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $37.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,37.44,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $37.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEM VW DS VW PROPEPTIDE ELISA AG LEVEL,0281U,CPT,300,RC,30002078,CDM,,,,both,,,52.0000,34.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.20,,,,,,,1.6500,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.00 in Billed Charges for Rev 300 Proc 0281U = $31.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,AETNA,AETNA HSHS,755.82,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $755.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,AETNA,AETNA MEDICARE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,AETNA,ALL COMMERCIAL AETNA,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,ANTHEM,ANTEHM MEDICAID,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81414 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,ANTHEM,ANTHEM POS/HMO,1170.00,,,,,,,467.9200,1316.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,047.15 from Fee Schedule WII28_25 for Rev 300 Proc 81414 Mod TC * Qty 1 = $2,047.15 at 100% = $2,047.15 (Limited to $1,170.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,ANTHEM,ANTHEM PPO,1170.00,,,,,,,467.9200,1316.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,047.15 from Fee Schedule WII28_25 for Rev 300 Proc 81414 Mod TC * Qty 1 = $2,047.15 at 100% = $2,047.15 (Limited to $1,170.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,CENPATICO,ALL MEDICAID CENPATICO,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,994.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $994.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,CIGNA,ALL COMMERCIAL CIGNA,819.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,COFINITY,COFINITY,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81414 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81414 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1111.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $1,111.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,982.80,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $982.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,830.70,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $830.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,854.10,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $854.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,568.62,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $568.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,994.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $994.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HUMANA,HUMANA CHOICE CARE HMO,994.33,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $994.33 from Fee Schedule 005543_170 for Rev 300 Proc 81414 * Qty 1 = $994.33 at 100% = $994.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HUMANA,HUMANA CHOICE CARE PPO,994.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $994.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,HUMANA,HUMANA NATIIONAL POS HMO,994.33,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $994.33 from Fee Schedule 005543_170 for Rev 300 Proc 81414 * Qty 1 = $994.33 at 100% = $994.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,854.10,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $854.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1170.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $1,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81414 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,467.92,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81414 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,496.00,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81414 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 100% = $467.92... $467.92 at 106% = $496.00 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,585.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,982.80,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $982.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,1316.03,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,877.50,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $877.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1076.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $1,076.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,760.37,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,760.37,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,PREVEA HEALTH NETWORK,PREVEA360,760.37,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,760.37,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,746.81,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $746.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,590.75,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,842.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $842.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,TRIOLOGY,TRILOGY MEDICAID,496.00,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81414 at $467.92 (Fee Schedule) = $467.92 (Total Line Payment) at 106% = $496.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,701.88,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 300 Proc 81414 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,701.88,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 300 Proc 81414 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,701.88,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 300 Proc 81414 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,UNITY HEALTH PLAN,UNITY HOSPICE,584.90,,,,,,,467.9200,1316.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,842.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $842.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,725.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $725.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,842.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $842.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,842.40,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $842.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES,81414,CPT,300,RC,30002080,CDM,,,,both,,,1170.0000,772.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,702.00,,,,,,,467.9200,1316.0300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,170.00 in Billed Charges for Rev 300 Proc 81414 = $702.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,AETNA,AETNA HSHS,82.04,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $82.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,AETNA,AETNA MEDICARE,62.14,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,AETNA,ALL COMMERCIAL AETNA,127.00,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTEHM MEDICAID,63.40,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,62.14,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTHEM POS/HMO,127.00,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $217.49 from Fee Schedule WII28_25 for Rev 301 Proc 80307 Mod TC * Qty 1 = $217.49 at 100% = $217.49 (Limited to $127.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTHEM PPO,127.00,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $217.49 from Fee Schedule WII28_25 for Rev 301 Proc 80307 Mod TC * Qty 1 = $217.49 at 100% = $217.49 (Limited to $127.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,127.00,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,CENPATICO,ALL MEDICAID CENPATICO,127.00,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,107.95,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,CIGNA,ALL COMMERCIAL CIGNA,88.90,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $88.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,COFINITY,COFINITY,127.00,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,63.40,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,63.40,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,120.65,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $120.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,106.68,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $106.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,90.17,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $90.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,92.71,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $92.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,61.72,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $61.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,107.95,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA CHOICE CARE HMO,105.64,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $105.64 from Fee Schedule 005543_170 for Rev 301 Proc 80307 * Qty 1 = $105.64 at 100% = $105.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA CHOICE CARE PPO,107.95,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,62.14,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA NATIIONAL POS HMO,105.64,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $105.64 from Fee Schedule 005543_170 for Rev 301 Proc 80307 * Qty 1 = $105.64 at 100% = $105.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,92.71,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $92.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,127.00,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,63.40,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,62.14,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,63.40,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,67.20,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 100% = $63.40... $63.40 at 106% = $67.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,62.14,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,63.50,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $63.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,106.68,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $106.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,139.82,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,95.25,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $95.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,116.84,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $116.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,80.78,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,80.78,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA360,80.78,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,80.78,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,81.06,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $81.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,62.76,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,91.44,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,TRIOLOGY,TRILOGY MEDICAID,67.20,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc 80307 at $63.40 (Fee Schedule) = $63.40 (Total Line Payment) at 106% = $67.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,74.57,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,74.57,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,62.14,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,74.57,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $74.57 from Fee Schedule UHC_98227C for Rev 301 Proc 80307 * Qty 1 = $74.57 at 100% = $74.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,UNITY HEALTH PLAN,UNITY HOSPICE,62.14,,,,,,,61.7200,139.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,91.44,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,78.74,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $78.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,91.44,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,91.44,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHET/METHAMPHET CONFIRM MEC,80307,CPT,301,RC,30100062,CDM,,,,both,,,127.0000,83.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,76.20,,,,,,,61.7200,139.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $127.00 in Billed Charges for Rev 301 Proc 80307 = $76.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,AETNA,AETNA HSHS,7.75,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,AETNA,AETNA MEDICARE,8.46,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,AETNA,ALL COMMERCIAL AETNA,12.00,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,ANTHEM,ANTEHM MEDICAID,8.74,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.46,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,ANTHEM,ANTHEM POS/HMO,12.00,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). $29.61 from Fee Schedule WII28_25 for Rev 301 Proc 80048 Mod TC * Qty 1 = $29.61 at 100% = $29.61 (Limited to $12.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,ANTHEM,ANTHEM PPO,12.00,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). $29.61 from Fee Schedule WII28_25 for Rev 301 Proc 80048 Mod TC * Qty 1 = $29.61 at 100% = $29.61 (Limited to $12.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.00,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,CENPATICO,ALL MEDICAID CENPATICO,12.00,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.20,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $10.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,CIGNA,ALL COMMERCIAL CIGNA,8.40,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $8.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,COFINITY,COFINITY,12.00,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.74,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.74,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.40,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $11.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,10.08,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $10.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.52,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $8.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.76,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $8.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,5.83,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $5.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.20,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $10.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HUMANA,HUMANA CHOICE CARE HMO,12.00,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule 005543_170 for Rev 301 Proc 80048 * Qty 1 = $14.38 at 100% = $14.38 (Limited to $12.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HUMANA,HUMANA CHOICE CARE PPO,10.20,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $10.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,8.46,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,HUMANA,HUMANA NATIIONAL POS HMO,12.00,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule 005543_170 for Rev 301 Proc 80048 * Qty 1 = $14.38 at 100% = $14.38 (Limited to $12.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.76,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $8.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.00,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.74,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.46,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.74,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,9.26,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74... $8.74 at 106% = $9.26 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,8.46,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.00,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.08,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $10.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,19.04,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.00,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.04,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $11.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.00,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.00,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,PREVEA HEALTH NETWORK,PREVEA360,11.00,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.00,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.66,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $7.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.54,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.64,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $8.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,TRIOLOGY,TRILOGY MEDICAID,9.26,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 106% = $9.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.15,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). $10.15 from Fee Schedule UHC_98227C for Rev 301 Proc 80048 * Qty 1 = $10.15 at 100% = $10.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,10.15,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). $10.15 from Fee Schedule UHC_98227C for Rev 301 Proc 80048 * Qty 1 = $10.15 at 100% = $10.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.46,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,10.15,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). $10.15 from Fee Schedule UHC_98227C for Rev 301 Proc 80048 * Qty 1 = $10.15 at 100% = $10.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,UNITY HEALTH PLAN,UNITY HOSPICE,8.46,,,,,,,5.8300,19.0400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.64,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $8.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.44,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.64,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $8.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.64,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $8.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURGICAL VET PANEL,80048,CPT,301,RC,30100099,CDM,,,,both,,,12.0000,7.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.20,,,,,,,5.8300,19.0400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.00 in Billed Charges for Rev 301 Proc 80048 = $7.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,AETNA,AETNA HSHS,83.98,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $83.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,AETNA,AETNA MEDICARE,8.46,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,AETNA,ALL COMMERCIAL AETNA,130.00,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,ANTHEM,ANTEHM MEDICAID,8.74,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.46,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,ANTHEM,ANTHEM POS/HMO,29.61,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.61 from Fee Schedule WII28_25 for Rev 301 Proc 80048 Mod TC * Qty 1 = $29.61 at 100% = $29.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,ANTHEM,ANTHEM PPO,29.61,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.61 from Fee Schedule WII28_25 for Rev 301 Proc 80048 Mod TC * Qty 1 = $29.61 at 100% = $29.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,130.00,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,CENPATICO,ALL MEDICAID CENPATICO,130.00,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,110.50,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,CIGNA,ALL COMMERCIAL CIGNA,91.00,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $91.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,COFINITY,COFINITY,130.00,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.74,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.74,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,123.50,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $123.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,109.20,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $109.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,92.30,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $92.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,94.90,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $94.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,63.18,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $63.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,110.50,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HUMANA,HUMANA CHOICE CARE HMO,14.38,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule 005543_170 for Rev 301 Proc 80048 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HUMANA,HUMANA CHOICE CARE PPO,110.50,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,8.46,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,HUMANA,HUMANA NATIIONAL POS HMO,14.38,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule 005543_170 for Rev 301 Proc 80048 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,94.90,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $94.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,130.00,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.74,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.46,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.74,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,9.26,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 100% = $8.74... $8.74 at 106% = $9.26 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,8.46,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.00,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,109.20,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $109.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,19.04,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,97.50,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $97.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,119.60,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $119.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.00,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.00,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA360,11.00,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.00,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,82.98,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $82.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.54,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,93.60,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,TRIOLOGY,TRILOGY MEDICAID,9.26,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80048 at $8.74 (Fee Schedule) = $8.74 (Total Line Payment) at 106% = $9.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.15,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.15 from Fee Schedule UHC_98227C for Rev 301 Proc 80048 * Qty 1 = $10.15 at 100% = $10.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,10.15,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.15 from Fee Schedule UHC_98227C for Rev 301 Proc 80048 * Qty 1 = $10.15 at 100% = $10.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.46,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,10.15,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.15 from Fee Schedule UHC_98227C for Rev 301 Proc 80048 * Qty 1 = $10.15 at 100% = $10.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,UNITY HEALTH PLAN,UNITY HOSPICE,8.46,,,,,,,8.4600,130.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,93.60,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,80.60,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $80.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,93.60,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,93.60,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BASIC METABOLIC PANEL,80048,CPT,301,RC,30100101,CDM,,,,both,,,130.0000,85.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,78.00,,,,,,,8.4600,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.00 in Billed Charges for Rev 301 Proc 80048 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,AETNA,AETNA HSHS,47.80,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $47.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,AETNA,AETNA MEDICARE,7.01,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,AETNA,ALL COMMERCIAL AETNA,74.00,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,ANTHEM,ANTEHM MEDICAID,7.24,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80051 at $7.24 (Fee Schedule) = $7.24 (Total Line Payment) at 100% = $7.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.01,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,ANTHEM,ANTHEM POS/HMO,24.54,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.54 from Fee Schedule WII28_25 for Rev 301 Proc 80051 Mod TC * Qty 1 = $24.54 at 100% = $24.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,ANTHEM,ANTHEM PPO,24.54,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.54 from Fee Schedule WII28_25 for Rev 301 Proc 80051 Mod TC * Qty 1 = $24.54 at 100% = $24.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,74.00,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,CENPATICO,ALL MEDICAID CENPATICO,74.00,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,62.90,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $62.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,CIGNA,ALL COMMERCIAL CIGNA,51.80,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $51.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,COFINITY,COFINITY,74.00,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,7.24,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80051 at $7.24 (Fee Schedule) = $7.24 (Total Line Payment) at 100% = $7.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,7.24,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80051 at $7.24 (Fee Schedule) = $7.24 (Total Line Payment) at 100% = $7.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,70.30,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $70.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,62.16,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $62.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.54,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $52.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.02,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $54.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,35.96,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $35.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,62.90,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $62.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HUMANA,HUMANA CHOICE CARE HMO,11.92,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.92 from Fee Schedule 005543_170 for Rev 301 Proc 80051 * Qty 1 = $11.92 at 100% = $11.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HUMANA,HUMANA CHOICE CARE PPO,62.90,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $62.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,7.01,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,HUMANA,HUMANA NATIIONAL POS HMO,11.92,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.92 from Fee Schedule 005543_170 for Rev 301 Proc 80051 * Qty 1 = $11.92 at 100% = $11.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.02,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $54.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,74.00,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,7.24,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80051 at $7.24 (Fee Schedule) = $7.24 (Total Line Payment) at 100% = $7.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.01,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,7.24,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80051 at $7.24 (Fee Schedule) = $7.24 (Total Line Payment) at 100% = $7.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,7.67,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80051 at $7.24 (Fee Schedule) = $7.24 (Total Line Payment) at 100% = $7.24... $7.24 at 106% = $7.67 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,7.01,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.00,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $37.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,62.16,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $62.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,15.77,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.50,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $55.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,68.08,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $68.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9.11,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9.11,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,PREVEA HEALTH NETWORK,PREVEA360,9.11,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9.11,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.23,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $47.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.08,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.28,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $53.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,TRIOLOGY,TRILOGY MEDICAID,7.67,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80051 at $7.24 (Fee Schedule) = $7.24 (Total Line Payment) at 106% = $7.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.41,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.41 from Fee Schedule UHC_98227C for Rev 301 Proc 80051 * Qty 1 = $8.41 at 100% = $8.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,8.41,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.41 from Fee Schedule UHC_98227C for Rev 301 Proc 80051 * Qty 1 = $8.41 at 100% = $8.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.01,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,8.41,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.41 from Fee Schedule UHC_98227C for Rev 301 Proc 80051 * Qty 1 = $8.41 at 100% = $8.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,UNITY HEALTH PLAN,UNITY HOSPICE,7.01,,,,,,,7.0100,74.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.28,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $53.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.88,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $45.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.28,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $53.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.28,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $53.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ELECTROLYTE PANEL,80051,CPT,301,RC,30100103,CDM,,,,both,,,74.0000,48.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.40,,,,,,,7.0100,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.00 in Billed Charges for Rev 301 Proc 80051 = $44.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,AETNA,AETNA HSHS,251.29,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $251.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,AETNA,AETNA MEDICARE,47.81,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,AETNA,ALL COMMERCIAL AETNA,389.00,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,ANTHEM,ANTEHM MEDICAID,18.84,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80055 at $18.84 (Fee Schedule) = $18.84 (Total Line Payment) at 100% = $18.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,47.81,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,ANTHEM,ANTHEM POS/HMO,167.34,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $167.34 from Fee Schedule WII28_25 for Rev 301 Proc 80055 Mod TC * Qty 1 = $167.34 at 100% = $167.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,ANTHEM,ANTHEM PPO,167.34,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $167.34 from Fee Schedule WII28_25 for Rev 301 Proc 80055 Mod TC * Qty 1 = $167.34 at 100% = $167.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,389.00,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,CENPATICO,ALL MEDICAID CENPATICO,389.00,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,330.65,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $330.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,CIGNA,ALL COMMERCIAL CIGNA,272.30,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $272.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,COFINITY,COFINITY,389.00,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,18.84,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80055 at $18.84 (Fee Schedule) = $18.84 (Total Line Payment) at 100% = $18.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,18.84,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80055 at $18.84 (Fee Schedule) = $18.84 (Total Line Payment) at 100% = $18.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,369.55,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $369.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,326.76,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $326.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,276.19,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $276.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,283.97,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $283.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,189.05,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $189.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,330.65,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $330.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HUMANA,HUMANA CHOICE CARE HMO,81.28,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $81.28 from Fee Schedule 005543_170 for Rev 301 Proc 80055 * Qty 1 = $81.28 at 100% = $81.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HUMANA,HUMANA CHOICE CARE PPO,330.65,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $330.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,47.81,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,HUMANA,HUMANA NATIIONAL POS HMO,81.28,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $81.28 from Fee Schedule 005543_170 for Rev 301 Proc 80055 * Qty 1 = $81.28 at 100% = $81.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,283.97,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $283.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,389.00,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,18.84,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80055 at $18.84 (Fee Schedule) = $18.84 (Total Line Payment) at 100% = $18.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,47.81,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,18.84,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80055 at $18.84 (Fee Schedule) = $18.84 (Total Line Payment) at 100% = $18.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,19.97,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80055 at $18.84 (Fee Schedule) = $18.84 (Total Line Payment) at 100% = $18.84... $18.84 at 106% = $19.97 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,47.81,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,194.50,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $194.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,326.76,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $326.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,107.57,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,291.75,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $291.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,357.88,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $357.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,62.15,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,62.15,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,PREVEA HEALTH NETWORK,PREVEA360,62.15,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,62.15,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,248.30,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $248.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,48.29,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,280.08,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $280.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,TRIOLOGY,TRILOGY MEDICAID,19.97,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80055 at $18.84 (Fee Schedule) = $18.84 (Total Line Payment) at 106% = $19.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,57.37,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.37 from Fee Schedule UHC_98227C for Rev 301 Proc 80055 * Qty 1 = $57.37 at 100% = $57.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,57.37,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.37 from Fee Schedule UHC_98227C for Rev 301 Proc 80055 * Qty 1 = $57.37 at 100% = $57.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,47.81,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,57.37,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.37 from Fee Schedule UHC_98227C for Rev 301 Proc 80055 * Qty 1 = $57.37 at 100% = $57.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,UNITY HEALTH PLAN,UNITY HOSPICE,47.81,,,,,,,18.8400,389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,280.08,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $280.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,241.18,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $241.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,280.08,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $280.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,280.08,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $280.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PRENATAL PANEL,80055,CPT,301,RC,30100106,CDM,,,,both,,,389.0000,256.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,233.40,,,,,,,18.8400,389.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $389.00 in Billed Charges for Rev 301 Proc 80055 = $233.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,AETNA,AETNA HSHS,87.21,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $87.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,AETNA,AETNA MEDICARE,13.39,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,AETNA,ALL COMMERCIAL AETNA,135.00,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,ANTHEM,ANTEHM MEDICAID,13.84,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80061 at $13.84 (Fee Schedule) = $13.84 (Total Line Payment) at 100% = $13.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.39,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,ANTHEM,ANTHEM POS/HMO,46.87,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.87 from Fee Schedule WII28_25 for Rev 301 Proc 80061 Mod TC * Qty 1 = $46.87 at 100% = $46.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,ANTHEM,ANTHEM PPO,46.87,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.87 from Fee Schedule WII28_25 for Rev 301 Proc 80061 Mod TC * Qty 1 = $46.87 at 100% = $46.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,135.00,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,CENPATICO,ALL MEDICAID CENPATICO,135.00,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,114.75,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $114.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,CIGNA,ALL COMMERCIAL CIGNA,94.50,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $94.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,COFINITY,COFINITY,135.00,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.84,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80061 at $13.84 (Fee Schedule) = $13.84 (Total Line Payment) at 100% = $13.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.84,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80061 at $13.84 (Fee Schedule) = $13.84 (Total Line Payment) at 100% = $13.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,128.25,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $128.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,113.40,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $113.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,95.85,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $95.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,98.55,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $98.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,65.61,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $65.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,114.75,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $114.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HUMANA,HUMANA CHOICE CARE HMO,22.76,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.76 from Fee Schedule 005543_170 for Rev 301 Proc 80061 * Qty 1 = $22.76 at 100% = $22.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HUMANA,HUMANA CHOICE CARE PPO,114.75,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $114.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,13.39,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,HUMANA,HUMANA NATIIONAL POS HMO,22.76,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.76 from Fee Schedule 005543_170 for Rev 301 Proc 80061 * Qty 1 = $22.76 at 100% = $22.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,98.55,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $98.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,135.00,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.84,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80061 at $13.84 (Fee Schedule) = $13.84 (Total Line Payment) at 100% = $13.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.39,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.84,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80061 at $13.84 (Fee Schedule) = $13.84 (Total Line Payment) at 100% = $13.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,14.67,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80061 at $13.84 (Fee Schedule) = $13.84 (Total Line Payment) at 100% = $13.84... $13.84 at 106% = $14.67 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,13.39,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,67.50,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,113.40,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $113.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,30.13,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,101.25,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $101.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,124.20,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $124.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.41,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.41,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,PREVEA HEALTH NETWORK,PREVEA360,17.41,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.41,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,86.17,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $86.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.52,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,97.20,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,TRIOLOGY,TRILOGY MEDICAID,14.67,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80061 at $13.84 (Fee Schedule) = $13.84 (Total Line Payment) at 106% = $14.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.07,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.07 from Fee Schedule UHC_98227C for Rev 301 Proc 80061 * Qty 1 = $16.07 at 100% = $16.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,16.07,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.07 from Fee Schedule UHC_98227C for Rev 301 Proc 80061 * Qty 1 = $16.07 at 100% = $16.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.39,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,16.07,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.07 from Fee Schedule UHC_98227C for Rev 301 Proc 80061 * Qty 1 = $16.07 at 100% = $16.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,UNITY HEALTH PLAN,UNITY HOSPICE,13.39,,,,,,,13.3900,135.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,97.20,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,83.70,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $83.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,97.20,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,97.20,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $97.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIPID PANEL,80061,CPT,301,RC,30100107,CDM,,,,both,,,135.0000,89.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,81.00,,,,,,,13.3900,135.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $135.00 in Billed Charges for Rev 301 Proc 80061 = $81.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,AETNA,AETNA HSHS,815.90,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $815.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,AETNA,AETNA MEDICARE,416.78,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,AETNA,ALL COMMERCIAL AETNA,1263.00,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,ANTHEM,ANTEHM MEDICAID,430.66,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87507 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,416.78,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,ANTHEM,ANTHEM POS/HMO,1263.00,,,,,,,416.7800,1263.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,458.73 from Fee Schedule WII28_25 for Rev 306 Proc 87507 Mod TC * Qty 1 = $1,458.73 at 100% = $1,458.73 (Limited to $1,263.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,ANTHEM,ANTHEM PPO,1263.00,,,,,,,416.7800,1263.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,458.73 from Fee Schedule WII28_25 for Rev 306 Proc 87507 Mod TC * Qty 1 = $1,458.73 at 100% = $1,458.73 (Limited to $1,263.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1263.00,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,CENPATICO,ALL MEDICAID CENPATICO,1263.00,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1073.55,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,073.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,CIGNA,ALL COMMERCIAL CIGNA,884.10,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $884.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,COFINITY,COFINITY,1263.00,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,430.66,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87507 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,430.66,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87507 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1199.85,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,199.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,1060.92,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,060.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,896.73,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $896.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,921.99,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $921.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,613.82,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $613.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1073.55,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,073.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HUMANA,HUMANA CHOICE CARE HMO,708.53,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.53 from Fee Schedule 005543_170 for Rev 306 Proc 87507 * Qty 1 = $708.53 at 100% = $708.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HUMANA,HUMANA CHOICE CARE PPO,1073.55,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,073.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HUMANA,HUMANA MEDICARE ADVANTAGE,416.78,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,HUMANA,HUMANA NATIIONAL POS HMO,708.53,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.53 from Fee Schedule 005543_170 for Rev 306 Proc 87507 * Qty 1 = $708.53 at 100% = $708.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,921.99,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $921.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1263.00,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,430.66,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87507 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,416.78,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,430.66,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87507 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,MOLINA HEALTHCARE,MOLINA MEDICAID,456.50,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87507 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 100% = $430.66... $430.66 at 106% = $456.50 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,MOLINA HEALTHCARE,MOLINA MEDICARE,416.78,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,631.50,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $631.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1060.92,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,060.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,NAPHCARE,ALL COMMERICAL NAPHCARE,937.76,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,947.25,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $947.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1161.96,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $1,161.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,541.81,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,541.81,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,PREVEA HEALTH NETWORK,PREVEA360,541.81,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,541.81,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,806.17,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $806.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,420.95,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,909.36,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $909.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,TRIOLOGY,TRILOGY MEDICAID,456.50,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87507 at $430.66 (Fee Schedule) = $430.66 (Total Line Payment) at 106% = $456.50. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,500.14,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87507 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,500.14,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87507 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,416.78,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,500.14,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87507 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,UNITY HEALTH PLAN,UNITY HOSPICE,416.78,,,,,,,416.7800,1263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,909.36,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $909.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,783.06,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $783.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,909.36,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $909.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,909.36,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $909.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IF AG DNA/RNA PROBE TQ 12-25 TARGETS,87507,CPT,306,RC,30600336,CDM,,,,both,,,1263.0000,833.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,757.80,,,,,,,416.7800,1263.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,263.00 in Billed Charges for Rev 306 Proc 87507 = $757.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,AETNA,AETNA HSHS,1648.59,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,648.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,AETNA,AETNA MEDICARE,416.78,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,AETNA,ALL COMMERCIAL AETNA,2552.00,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,552.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,ANTHEM,ANTEHM MEDICAID,333.42,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87483 at $333.42 (Fee Schedule) = $333.42 (Total Line Payment) at 100% = $333.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,416.78,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,ANTHEM,ANTHEM POS/HMO,1458.73,,,,,,,333.4200,2552.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,458.73 from Fee Schedule WII28_25 for Rev 306 Proc 87483 Mod TC * Qty 1 = $1,458.73 at 100% = $1,458.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,ANTHEM,ANTHEM PPO,1458.73,,,,,,,333.4200,2552.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,458.73 from Fee Schedule WII28_25 for Rev 306 Proc 87483 Mod TC * Qty 1 = $1,458.73 at 100% = $1,458.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2552.00,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,552.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,CENPATICO,ALL MEDICAID CENPATICO,2552.00,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,552.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2169.20,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,169.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,CIGNA,ALL COMMERCIAL CIGNA,1786.40,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,786.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,COFINITY,COFINITY,2552.00,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,552.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,333.42,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87483 at $333.42 (Fee Schedule) = $333.42 (Total Line Payment) at 100% = $333.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,333.42,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87483 at $333.42 (Fee Schedule) = $333.42 (Total Line Payment) at 100% = $333.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2424.40,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,424.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,2143.68,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,143.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1811.92,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,811.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1862.96,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,862.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,1240.27,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,240.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2169.20,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,169.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HUMANA,HUMANA CHOICE CARE HMO,708.53,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.53 from Fee Schedule 005543_170 for Rev 306 Proc 87483 * Qty 1 = $708.53 at 100% = $708.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HUMANA,HUMANA CHOICE CARE PPO,2169.20,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,169.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,416.78,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,HUMANA,HUMANA NATIIONAL POS HMO,708.53,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.53 from Fee Schedule 005543_170 for Rev 306 Proc 87483 * Qty 1 = $708.53 at 100% = $708.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1862.96,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,862.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2552.00,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,552.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,333.42,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87483 at $333.42 (Fee Schedule) = $333.42 (Total Line Payment) at 100% = $333.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,416.78,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,333.42,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87483 at $333.42 (Fee Schedule) = $333.42 (Total Line Payment) at 100% = $333.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,353.43,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87483 at $333.42 (Fee Schedule) = $333.42 (Total Line Payment) at 100% = $333.42... $333.42 at 106% = $353.43 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,416.78,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1276.00,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,276.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2143.68,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,143.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,937.76,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1914.00,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,914.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2347.84,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $2,347.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,541.81,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,541.81,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,PREVEA HEALTH NETWORK,PREVEA360,541.81,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,541.81,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1628.94,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,628.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,420.95,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1837.44,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,837.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,TRIOLOGY,TRILOGY MEDICAID,353.43,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87483 at $333.42 (Fee Schedule) = $333.42 (Total Line Payment) at 106% = $353.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,500.14,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87483 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,500.14,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87483 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,416.78,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,500.14,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.14 from Fee Schedule UHC_98227C for Rev 306 Proc 87483 * Qty 1 = $500.14 at 100% = $500.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,UNITY HEALTH PLAN,UNITY HOSPICE,416.78,,,,,,,333.4200,2552.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1837.44,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,837.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1582.24,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,582.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1837.44,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,837.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1837.44,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,837.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INFECT AMP CNS DNA/RNA 14 TARGETS,87483,CPT,306,RC,30600348,CDM,,,,both,,,2552.0000,1684.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1531.20,,,,,,,333.4200,2552.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,552.00 in Billed Charges for Rev 306 Proc 87483 = $1,531.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,AETNA,AETNA HSHS,159.56,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $159.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,AETNA,AETNA MEDICARE,20.46,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,AETNA,ALL COMMERCIAL AETNA,247.00,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $247.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,ANTHEM,ANTEHM MEDICAID,12.68,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87103 at $12.68 (Fee Schedule) = $12.68 (Total Line Payment) at 100% = $12.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,20.46,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,ANTHEM,ANTHEM POS/HMO,71.61,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $71.61 from Fee Schedule WII28_25 for Rev 306 Proc 87103 Mod TC * Qty 1 = $71.61 at 100% = $71.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,ANTHEM,ANTHEM PPO,71.61,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $71.61 from Fee Schedule WII28_25 for Rev 306 Proc 87103 Mod TC * Qty 1 = $71.61 at 100% = $71.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,247.00,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $247.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,CENPATICO,ALL MEDICAID CENPATICO,247.00,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $247.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,209.95,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $209.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,CIGNA,ALL COMMERCIAL CIGNA,172.90,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $172.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,COFINITY,COFINITY,247.00,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $247.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.68,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87103 at $12.68 (Fee Schedule) = $12.68 (Total Line Payment) at 100% = $12.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.68,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87103 at $12.68 (Fee Schedule) = $12.68 (Total Line Payment) at 100% = $12.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,234.65,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $234.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,207.48,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $207.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,175.37,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $175.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,180.31,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $180.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,120.04,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $120.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,209.95,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $209.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HUMANA,HUMANA CHOICE CARE HMO,34.78,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.78 from Fee Schedule 005543_170 for Rev 306 Proc 87103 * Qty 1 = $34.78 at 100% = $34.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HUMANA,HUMANA CHOICE CARE PPO,209.95,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $209.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,20.46,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,HUMANA,HUMANA NATIIONAL POS HMO,34.78,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.78 from Fee Schedule 005543_170 for Rev 306 Proc 87103 * Qty 1 = $34.78 at 100% = $34.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,180.31,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $180.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,247.00,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $247.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.68,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87103 at $12.68 (Fee Schedule) = $12.68 (Total Line Payment) at 100% = $12.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,20.46,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.68,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87103 at $12.68 (Fee Schedule) = $12.68 (Total Line Payment) at 100% = $12.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,13.44,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87103 at $12.68 (Fee Schedule) = $12.68 (Total Line Payment) at 100% = $12.68... $12.68 at 106% = $13.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,20.46,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,123.50,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $123.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,207.48,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $207.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,46.04,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,185.25,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $185.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,227.24,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $227.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,26.60,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,26.60,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,PREVEA HEALTH NETWORK,PREVEA360,26.60,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,26.60,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,157.66,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $157.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,20.66,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,177.84,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $177.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,TRIOLOGY,TRILOGY MEDICAID,13.44,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87103 at $12.68 (Fee Schedule) = $12.68 (Total Line Payment) at 106% = $13.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,24.55,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.55 from Fee Schedule UHC_98227C for Rev 306 Proc 87103 * Qty 1 = $24.55 at 100% = $24.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,24.55,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.55 from Fee Schedule UHC_98227C for Rev 306 Proc 87103 * Qty 1 = $24.55 at 100% = $24.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,20.46,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,24.55,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.55 from Fee Schedule UHC_98227C for Rev 306 Proc 87103 * Qty 1 = $24.55 at 100% = $24.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,UNITY HEALTH PLAN,UNITY HOSPICE,20.46,,,,,,,12.6800,247.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,177.84,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $177.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,153.14,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $153.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,177.84,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $177.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,177.84,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $177.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE FUNGUS BLOOD,87103,CPT,306,RC,30600363,CDM,,,,both,,,247.0000,163.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,148.20,,,,,,,12.6800,247.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $247.00 in Billed Charges for Rev 306 Proc 87103 = $148.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,AETNA,AETNA HSHS,343.67,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $343.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,AETNA,ALL COMMERCIAL AETNA,532.00,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87471 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87471 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87471 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,532.00,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,CENPATICO,ALL MEDICAID CENPATICO,532.00,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,452.20,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,CIGNA,ALL COMMERCIAL CIGNA,372.40,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $372.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,COFINITY,COFINITY,532.00,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87471 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87471 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,505.40,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $505.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,446.88,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,377.72,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $377.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,388.36,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,258.55,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $258.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,452.20,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87471 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE PPO,452.20,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87471 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,388.36,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,532.00,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87471 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87471 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87471 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,266.00,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $266.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,446.88,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,399.00,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $399.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,489.44,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $489.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,339.58,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $339.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,383.04,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87471 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87471 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87471 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87471 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,383.04,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,329.84,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $329.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,383.04,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,383.04,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INF AGT BARTONELLA HENSELAE,87471,CPT,306,RC,30600436,CDM,,,,both,,,532.0000,351.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,319.20,,,,,,,35.0900,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 306 Proc 87471 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,AETNA,AETNA HSHS,48.45,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $48.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,AETNA,AETNA MEDICARE,5.57,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,AETNA,ALL COMMERCIAL AETNA,75.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTEHM MEDICAID,5.76,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87140 at $5.76 (Fee Schedule) = $5.76 (Total Line Payment) at 100% = $5.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5.57,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM POS/HMO,19.50,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.50 from Fee Schedule WII28_25 for Rev 306 Proc 87140 Mod TC * Qty 1 = $19.50 at 100% = $19.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM PPO,19.50,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.50 from Fee Schedule WII28_25 for Rev 306 Proc 87140 Mod TC * Qty 1 = $19.50 at 100% = $19.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,75.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,CENPATICO,ALL MEDICAID CENPATICO,75.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,63.75,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,CIGNA,ALL COMMERCIAL CIGNA,52.50,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $52.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,COFINITY,COFINITY,75.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.76,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87140 at $5.76 (Fee Schedule) = $5.76 (Total Line Payment) at 100% = $5.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.76,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87140 at $5.76 (Fee Schedule) = $5.76 (Total Line Payment) at 100% = $5.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,71.25,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,63.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,53.25,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $53.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.75,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,36.45,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $36.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,63.75,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA CHOICE CARE HMO,9.47,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.47 from Fee Schedule 005543_170 for Rev 306 Proc 87140 * Qty 1 = $9.47 at 100% = $9.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA CHOICE CARE PPO,63.75,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,5.57,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA NATIIONAL POS HMO,9.47,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.47 from Fee Schedule 005543_170 for Rev 306 Proc 87140 * Qty 1 = $9.47 at 100% = $9.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.75,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,75.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.76,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87140 at $5.76 (Fee Schedule) = $5.76 (Total Line Payment) at 100% = $5.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5.57,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.76,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87140 at $5.76 (Fee Schedule) = $5.76 (Total Line Payment) at 100% = $5.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,6.11,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87140 at $5.76 (Fee Schedule) = $5.76 (Total Line Payment) at 100% = $5.76... $5.76 at 106% = $6.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,5.57,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.50,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $37.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,63.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,12.53,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,56.25,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $56.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,69.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.24,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.24,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA360,7.24,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.24,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.87,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $47.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5.63,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,54.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,TRIOLOGY,TRILOGY MEDICAID,6.11,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87140 at $5.76 (Fee Schedule) = $5.76 (Total Line Payment) at 106% = $6.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.68,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.68 from Fee Schedule UHC_98227C for Rev 306 Proc 87140 * Qty 1 = $6.68 at 100% = $6.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,6.68,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.68 from Fee Schedule UHC_98227C for Rev 306 Proc 87140 * Qty 1 = $6.68 at 100% = $6.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5.57,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,6.68,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.68 from Fee Schedule UHC_98227C for Rev 306 Proc 87140 * Qty 1 = $6.68 at 100% = $6.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,UNITY HEALTH PLAN,UNITY HOSPICE,5.57,,,,,,,5.5700,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,54.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,46.50,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $46.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,54.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,54.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE TYPE IMMUNOFLUORESC,87140,CPT,306,RC,30600501,CDM,,,,both,,,75.0000,49.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,45.00,,,,,,,5.5700,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $75.00 in Billed Charges for Rev 306 Proc 87140 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,10.32,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,10.66,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87040 at $10.66 (Fee Schedule) = $10.66 (Total Line Payment) at 100% = $10.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,10.32,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,36.12,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.12 from Fee Schedule WII28_25 for Rev 306 Proc 87040 Mod TC * Qty 1 = $36.12 at 100% = $36.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,36.12,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.12 from Fee Schedule WII28_25 for Rev 306 Proc 87040 Mod TC * Qty 1 = $36.12 at 100% = $36.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.66,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87040 at $10.66 (Fee Schedule) = $10.66 (Total Line Payment) at 100% = $10.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.66,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87040 at $10.66 (Fee Schedule) = $10.66 (Total Line Payment) at 100% = $10.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,17.54,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.54 from Fee Schedule 005543_170 for Rev 306 Proc 87040 * Qty 1 = $17.54 at 100% = $17.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,10.32,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,17.54,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.54 from Fee Schedule 005543_170 for Rev 306 Proc 87040 * Qty 1 = $17.54 at 100% = $17.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.66,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87040 at $10.66 (Fee Schedule) = $10.66 (Total Line Payment) at 100% = $10.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.32,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.66,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87040 at $10.66 (Fee Schedule) = $10.66 (Total Line Payment) at 100% = $10.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,11.30,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87040 at $10.66 (Fee Schedule) = $10.66 (Total Line Payment) at 100% = $10.66... $10.66 at 106% = $11.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,10.32,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,23.22,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.42,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.42,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,13.42,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.42,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,10.42,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,11.30,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87040 at $10.66 (Fee Schedule) = $10.66 (Total Line Payment) at 106% = $11.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.38,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87040 * Qty 1 = $12.38 at 100% = $12.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,12.38,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87040 * Qty 1 = $12.38 at 100% = $12.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,10.32,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,12.38,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87040 * Qty 1 = $12.38 at 100% = $12.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,10.32,,,,,,,10.3200,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BACTERIA BLOOD CULTURE T1,87040,CPT,306,RC,30600516,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,10.3200,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 306 Proc 87040 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA HSHS,58.14,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $58.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,AETNA,ALL COMMERCIAL AETNA,90.00,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM POS/HMO,90.00,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87150 Mod TC * Qty 1 = $122.82 at 100% = $122.82 (Limited to $90.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM PPO,90.00,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87150 Mod TC * Qty 1 = $122.82 at 100% = $122.82 (Limited to $90.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,90.00,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,CENPATICO,ALL MEDICAID CENPATICO,90.00,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,76.50,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,CIGNA,ALL COMMERCIAL CIGNA,63.00,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,COFINITY,COFINITY,90.00,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,85.50,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,75.60,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.90,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $63.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,65.70,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,43.74,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $43.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,76.50,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87150 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE PPO,76.50,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87150 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,65.70,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,90.00,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.00,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,75.60,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,67.50,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,82.80,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,57.45,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $57.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,64.80,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87150 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87150 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87150 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,64.80,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.80,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,64.80,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,64.80,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTURE TYPING ID AMP PROBE TECH,87150,CPT,306,RC,30600594,CDM,,,,both,,,90.0000,59.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,54.00,,,,,,,35.0900,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $90.00 in Billed Charges for Rev 306 Proc 87150 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,AETNA,AETNA HSHS,348.84,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $348.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,AETNA,AETNA MEDICARE,8.65,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,AETNA,ALL COMMERCIAL AETNA,540.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,ANTHEM,ANTEHM MEDICAID,8.94,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87186 at $8.94 (Fee Schedule) = $8.94 (Total Line Payment) at 100% = $8.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.65,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,ANTHEM,ANTHEM POS/HMO,30.28,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.28 from Fee Schedule WII28_25 for Rev 306 Proc 87186 Mod TC * Qty 1 = $30.28 at 100% = $30.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,ANTHEM,ANTHEM PPO,30.28,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.28 from Fee Schedule WII28_25 for Rev 306 Proc 87186 Mod TC * Qty 1 = $30.28 at 100% = $30.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,540.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,CENPATICO,ALL MEDICAID CENPATICO,540.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,459.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $459.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,CIGNA,ALL COMMERCIAL CIGNA,378.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $378.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,COFINITY,COFINITY,540.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.94,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87186 at $8.94 (Fee Schedule) = $8.94 (Total Line Payment) at 100% = $8.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.94,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87186 at $8.94 (Fee Schedule) = $8.94 (Total Line Payment) at 100% = $8.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,513.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $513.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,453.60,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $453.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,383.40,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $383.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,394.20,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $394.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,262.44,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $262.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,459.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $459.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HUMANA,HUMANA CHOICE CARE HMO,14.71,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.71 from Fee Schedule 005543_170 for Rev 306 Proc 87186 * Qty 1 = $14.71 at 100% = $14.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HUMANA,HUMANA CHOICE CARE PPO,459.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $459.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,8.65,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,HUMANA,HUMANA NATIIONAL POS HMO,14.71,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.71 from Fee Schedule 005543_170 for Rev 306 Proc 87186 * Qty 1 = $14.71 at 100% = $14.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,394.20,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $394.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,540.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.94,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87186 at $8.94 (Fee Schedule) = $8.94 (Total Line Payment) at 100% = $8.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.65,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.94,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87186 at $8.94 (Fee Schedule) = $8.94 (Total Line Payment) at 100% = $8.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,9.48,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87186 at $8.94 (Fee Schedule) = $8.94 (Total Line Payment) at 100% = $8.94... $8.94 at 106% = $9.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,8.65,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,270.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,453.60,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $453.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,19.46,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,405.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $405.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,496.80,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $496.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.25,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.25,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,PREVEA HEALTH NETWORK,PREVEA360,11.25,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.25,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,344.68,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $344.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.74,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,388.80,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $388.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,TRIOLOGY,TRILOGY MEDICAID,9.48,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87186 at $8.94 (Fee Schedule) = $8.94 (Total Line Payment) at 106% = $9.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.38,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87186 * Qty 1 = $10.38 at 100% = $10.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,10.38,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87186 * Qty 1 = $10.38 at 100% = $10.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.65,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,10.38,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87186 * Qty 1 = $10.38 at 100% = $10.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,UNITY HEALTH PLAN,UNITY HOSPICE,8.65,,,,,,,8.6500,540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,388.80,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $388.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,334.80,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $334.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,388.80,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $388.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,388.80,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $388.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SENSITIVITY MIC FUNGUS,87186,CPT,306,RC,30600597,CDM,,,,both,,,540.0000,356.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,324.00,,,,,,,8.6500,540.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $540.00 in Billed Charges for Rev 306 Proc 87186 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,AETNA,AETNA HSHS,116.93,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $116.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,AETNA,AETNA MEDICARE,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,AETNA,ALL COMMERCIAL AETNA,181.00,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $181.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,ANTHEM,ANTEHM MEDICAID,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,ANTHEM,ANTHEM POS/HMO,179.59,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $179.59 from Fee Schedule WII28_25 for Rev 306 Proc 87635 Mod TC * Qty 1 = $179.59 at 100% = $179.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,ANTHEM,ANTHEM PPO,179.59,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $179.59 from Fee Schedule WII28_25 for Rev 306 Proc 87635 Mod TC * Qty 1 = $179.59 at 100% = $179.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,181.00,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $181.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,CENPATICO,ALL MEDICAID CENPATICO,181.00,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $181.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,153.85,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $153.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,CIGNA,ALL COMMERCIAL CIGNA,126.70,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $126.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,COFINITY,COFINITY,181.00,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $181.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,171.95,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $171.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,152.04,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $152.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,128.51,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $128.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,132.13,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $132.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,87.97,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $87.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,153.85,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $153.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HUMANA,HUMANA CHOICE CARE HMO,87.23,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $87.23 from Fee Schedule 005543_170 for Rev 306 Proc 87635 * Qty 1 = $87.23 at 100% = $87.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HUMANA,HUMANA CHOICE CARE PPO,153.85,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $153.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,HUMANA,HUMANA NATIIONAL POS HMO,87.23,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $87.23 from Fee Schedule 005543_170 for Rev 306 Proc 87635 * Qty 1 = $87.23 at 100% = $87.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,132.13,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $132.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,181.00,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $181.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,54.39,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31... $51.31 at 106% = $54.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,90.50,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $90.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,152.04,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $152.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,115.45,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,135.75,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $135.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,166.52,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $166.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,66.70,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,66.70,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,PREVEA HEALTH NETWORK,PREVEA360,66.70,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,66.70,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,115.53,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $115.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.82,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,130.32,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $130.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,TRIOLOGY,TRILOGY MEDICAID,54.39,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 106% = $54.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,61.57,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87635 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,61.57,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87635 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,61.57,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87635 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,UNITY HEALTH PLAN,UNITY HOSPICE,51.31,,,,,,,51.3100,181.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,130.32,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $130.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,112.22,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $112.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,130.32,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $130.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,130.32,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $130.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600624,CDM,,,,both,,,181.0000,119.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,108.60,,,,,,,51.3100,181.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $181.00 in Billed Charges for Rev 306 Proc 87635 = $108.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,AETNA,AETNA HSHS,355.30,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $355.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,AETNA,AETNA MEDICARE,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,AETNA,ALL COMMERCIAL AETNA,550.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $550.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,ANTHEM,ANTEHM MEDICAID,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87637 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,ANTHEM,ANTHEM POS/HMO,499.21,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $499.21 from Fee Schedule WII28_25 for Rev 306 Proc 87637 Mod TC * Qty 1 = $499.21 at 100% = $499.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,ANTHEM,ANTHEM PPO,499.21,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $499.21 from Fee Schedule WII28_25 for Rev 306 Proc 87637 Mod TC * Qty 1 = $499.21 at 100% = $499.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,550.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $550.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,CENPATICO,ALL MEDICAID CENPATICO,550.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $550.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,467.50,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $467.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,CIGNA,ALL COMMERCIAL CIGNA,385.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $385.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,COFINITY,COFINITY,550.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $550.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87637 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87637 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,522.50,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $522.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,462.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $462.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,390.50,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $390.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,401.50,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $401.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,267.30,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,467.50,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $467.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HUMANA,HUMANA CHOICE CARE HMO,242.47,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.47 from Fee Schedule 005543_170 for Rev 306 Proc 87637 * Qty 1 = $242.47 at 100% = $242.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HUMANA,HUMANA CHOICE CARE PPO,467.50,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $467.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,HUMANA,HUMANA NATIIONAL POS HMO,242.47,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.47 from Fee Schedule 005543_170 for Rev 306 Proc 87637 * Qty 1 = $242.47 at 100% = $242.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,401.50,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $401.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,550.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $550.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87637 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87637 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,151.19,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87637 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63... $142.63 at 106% = $151.19 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,275.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $275.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,462.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $462.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,320.92,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,412.50,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $412.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,506.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $506.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,185.42,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,185.42,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,PREVEA HEALTH NETWORK,PREVEA360,185.42,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,185.42,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,351.07,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $351.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,144.06,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,396.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,TRIOLOGY,TRILOGY MEDICAID,151.19,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87637 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 106% = $151.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,171.16,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 306 Proc 87637 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,171.16,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 306 Proc 87637 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,171.16,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 306 Proc 87637 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,UNITY HEALTH PLAN,UNITY HOSPICE,142.63,,,,,,,142.6300,550.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,396.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,341.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $341.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,396.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,396.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC 4PLEX COVID/RSV/FLU PCR,87637,CPT,306,RC,30600635,CDM,,,,both,,,550.0000,363.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,330.00,,,,,,,142.6300,550.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $550.00 in Billed Charges for Rev 306 Proc 87637 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,AETNA,AETNA HSHS,85.27,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $85.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,AETNA,AETNA MEDICARE,51.31,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,AETNA,ALL COMMERCIAL AETNA,132.00,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,ANTHEM,ANTEHM MEDICAID,15.93,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87593 at $125.60 (Base Rate) * 0.1268 (Relative Weight) = $15.93 (Total Line Payment) at 100% = $15.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,51.31,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,ANTHEM,ANTHEM POS/HMO,132.00,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.75 from Fee Schedule WII28_25 for Rev 306 Proc 87593 Mod TC * Qty 1 = $173.75 at 100% = $173.75 (Limited to $132.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,ANTHEM,ANTHEM PPO,132.00,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.75 from Fee Schedule WII28_25 for Rev 306 Proc 87593 Mod TC * Qty 1 = $173.75 at 100% = $173.75 (Limited to $132.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,132.00,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,CENPATICO,ALL MEDICAID CENPATICO,132.00,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,112.20,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $112.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,CIGNA,ALL COMMERCIAL CIGNA,92.40,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $92.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,COFINITY,COFINITY,132.00,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.93,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87593 at $125.60 (Base Rate) * 0.1268 (Relative Weight) = $15.93 (Total Line Payment) at 100% = $15.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.93,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87593 at $125.60 (Base Rate) * 0.1268 (Relative Weight) = $15.93 (Total Line Payment) at 100% = $15.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,125.40,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,110.88,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $110.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,93.72,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $93.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,96.36,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $96.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,64.15,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $64.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,112.20,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $112.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HUMANA,HUMANA CHOICE CARE HMO,87.23,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $87.23 from Fee Schedule 005543_170 for Rev 306 Proc 87593 * Qty 1 = $87.23 at 100% = $87.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HUMANA,HUMANA CHOICE CARE PPO,112.20,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $112.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,51.31,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,HUMANA,HUMANA NATIIONAL POS HMO,87.23,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $87.23 from Fee Schedule 005543_170 for Rev 306 Proc 87593 * Qty 1 = $87.23 at 100% = $87.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,96.36,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $96.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,132.00,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.93,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87593 at $125.60 (Base Rate) * 0.1268 (Relative Weight) = $15.93 (Total Line Payment) at 100% = $15.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,51.31,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.93,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87593 at $125.60 (Base Rate) * 0.1268 (Relative Weight) = $15.93 (Total Line Payment) at 100% = $15.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,16.89,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87593 at $125.60 (Base Rate) * 0.1268 (Relative Weight) = $15.93 (Total Line Payment) at 100% = $15.93... $15.93 at 106% = $16.89 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,51.31,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,66.00,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,110.88,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $110.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,115.45,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,99.00,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,121.44,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $121.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,66.70,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,66.70,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,PREVEA HEALTH NETWORK,PREVEA360,66.70,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,66.70,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,84.26,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $84.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.82,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,95.04,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $95.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,TRIOLOGY,TRILOGY MEDICAID,16.88,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87593 at $125.60 (Base Rate) * 0.1268 (Relative Weight) = $15.93 (Total Line Payment) at 106% = $16.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,61.40,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87593 * Qty 1 = $61.40 at 100% = $61.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,61.40,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87593 * Qty 1 = $61.40 at 100% = $61.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,51.31,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,61.40,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87593 * Qty 1 = $61.40 at 100% = $61.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,UNITY HEALTH PLAN,UNITY HOSPICE,51.31,,,,,,,15.9300,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,95.04,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $95.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,81.84,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $81.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,95.04,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $95.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,95.04,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $95.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP ORTHOPOXVIRUS/MONKEYPOX DNA,87593,CPT,306,RC,30600663,CDM,,,,both,,,132.0000,87.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,79.20,,,,,,,15.9300,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $132.00 in Billed Charges for Rev 306 Proc 87593 = $79.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,AETNA,AETNA HSHS,310.08,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $310.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,AETNA,ALL COMMERCIAL AETNA,480.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87449 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87449 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,480.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,CENPATICO,ALL MEDICAID CENPATICO,480.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,408.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,CIGNA,ALL COMMERCIAL CIGNA,336.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,COFINITY,COFINITY,480.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,456.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $456.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,403.20,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,340.80,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $340.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,350.40,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $350.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,233.28,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $233.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,408.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87449 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA CHOICE CARE PPO,408.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87449 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,350.40,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $350.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,480.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,240.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,403.20,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,360.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,441.60,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $441.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,306.38,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $306.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,345.60,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87449 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87449 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87449 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87449 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,345.60,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,297.60,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,345.60,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,345.60,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL MLT AG INF (FUNGITELL),87449,CPT,306,RC,30600666,CDM,,,,both,,,480.0000,316.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,288.00,,,,,,,11.9800,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $480.00 in Billed Charges for Rev 306 Proc 87449 = $288.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,AETNA,AETNA HSHS,97.55,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $97.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,AETNA,ALL COMMERCIAL AETNA,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTEHM MEDICAID,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87469 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87469 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87469 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,CENPATICO,ALL MEDICAID CENPATICO,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,128.35,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,CIGNA,ALL COMMERCIAL CIGNA,105.70,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $105.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,COFINITY,COFINITY,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87469 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87469 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,143.45,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $143.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,126.84,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $126.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,107.21,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $107.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,110.23,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $110.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,73.39,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $73.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,128.35,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87469 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA CHOICE CARE PPO,128.35,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87469 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,110.23,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $110.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87469 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87469 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,37.20,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87469 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09... $35.09 at 106% = $37.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.50,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $75.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.84,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $126.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,113.25,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $113.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.92,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $138.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,96.38,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $96.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.72,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,TRIOLOGY,TRILOGY MEDICAID,37.20,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87469 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 106% = $37.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87469 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87469 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87469 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.72,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.62,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $93.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.72,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.72,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BABESIA MICROTI AMP PRB,87469,CPT,306,RC,30600668,CDM,,,,both,,,151.0000,99.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.60,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $151.00 in Billed Charges for Rev 306 Proc 87469 = $90.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,AETNA,AETNA HSHS,97.55,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $97.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,AETNA,ALL COMMERCIAL AETNA,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTEHM MEDICAID,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87478 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87478 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87478 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,CENPATICO,ALL MEDICAID CENPATICO,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,128.35,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,CIGNA,ALL COMMERCIAL CIGNA,105.70,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $105.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,COFINITY,COFINITY,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87478 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87478 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,143.45,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $143.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,126.84,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $126.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,107.21,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $107.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,110.23,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $110.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,73.39,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $73.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,128.35,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87478 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA CHOICE CARE PPO,128.35,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87478 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,110.23,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $110.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,151.00,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87478 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87478 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,37.20,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87478 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09... $35.09 at 106% = $37.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.50,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $75.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.84,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $126.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,113.25,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $113.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.92,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $138.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,96.38,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $96.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.72,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,TRIOLOGY,TRILOGY MEDICAID,37.20,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87478 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 106% = $37.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87478 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87478 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87478 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.72,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.62,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $93.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.72,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.72,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BORRELIA MIYAMOTOI AMP PRB,87478,CPT,306,RC,30600669,CDM,,,,both,,,151.0000,99.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.60,,,,,,,35.0900,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $151.00 in Billed Charges for Rev 306 Proc 87478 = $90.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87484 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87484 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87484 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87484 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87484 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87484 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87484 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87484 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87484 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,37.20,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87484 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09... $35.09 at 106% = $37.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,37.20,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87484 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 106% = $37.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87484 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87484 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87484 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,306,RC,30600670,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87484 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,AETNA,AETNA HSHS,473.52,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $473.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,AETNA,AETNA MEDICARE,218.06,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,AETNA,ALL COMMERCIAL AETNA,733.00,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $733.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,ANTHEM,ANTEHM MEDICAID,12.05,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,218.06,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,ANTHEM,ANTHEM POS/HMO,733.00,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $763.21 from Fee Schedule WII28_25 for Rev 306 Proc 87154 Mod TC * Qty 1 = $763.21 at 100% = $763.21 (Limited to $733.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,ANTHEM,ANTHEM PPO,733.00,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $763.21 from Fee Schedule WII28_25 for Rev 306 Proc 87154 Mod TC * Qty 1 = $763.21 at 100% = $763.21 (Limited to $733.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,733.00,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $733.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,CENPATICO,ALL MEDICAID CENPATICO,733.00,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $733.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,623.05,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $623.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,CIGNA,ALL COMMERCIAL CIGNA,513.10,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $513.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,COFINITY,COFINITY,733.00,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $733.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.05,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.05,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,696.35,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $696.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,615.72,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $615.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,520.43,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $520.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,535.09,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $535.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,356.24,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $356.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,623.05,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $623.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HUMANA,HUMANA CHOICE CARE HMO,370.70,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $370.70 from Fee Schedule 005543_170 for Rev 306 Proc 87154 * Qty 1 = $370.70 at 100% = $370.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HUMANA,HUMANA CHOICE CARE PPO,623.05,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $623.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,218.06,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,HUMANA,HUMANA NATIIONAL POS HMO,370.70,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $370.70 from Fee Schedule 005543_170 for Rev 306 Proc 87154 * Qty 1 = $370.70 at 100% = $370.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,535.09,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $535.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,733.00,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $733.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.05,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,218.06,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.05,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,12.77,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05... $12.05 at 106% = $12.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,218.06,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,366.50,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $366.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,615.72,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $615.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,490.64,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,549.75,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $549.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,674.36,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $674.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,283.48,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,283.48,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,PREVEA HEALTH NETWORK,PREVEA360,283.48,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,283.48,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,467.87,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $467.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,220.24,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,527.76,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $527.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,TRIOLOGY,TRILOGY MEDICAID,12.77,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 106% = $12.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,261.67,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $261.67 from Fee Schedule UHC_98227C for Rev 306 Proc 87154 * Qty 1 = $261.67 at 100% = $261.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,261.67,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $261.67 from Fee Schedule UHC_98227C for Rev 306 Proc 87154 * Qty 1 = $261.67 at 100% = $261.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,218.06,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,261.67,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $261.67 from Fee Schedule UHC_98227C for Rev 306 Proc 87154 * Qty 1 = $261.67 at 100% = $261.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,UNITY HEALTH PLAN,UNITY HOSPICE,218.06,,,,,,,12.0500,733.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,527.76,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $527.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,454.46,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $454.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,527.76,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $527.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,527.76,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $527.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600681,CDM,,,,both,,,733.0000,483.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,439.80,,,,,,,12.0500,733.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $733.00 in Billed Charges for Rev 306 Proc 87154 = $439.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,AETNA,AETNA HSHS,140.18,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $140.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,AETNA,AETNA MEDICARE,130.35,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,AETNA,ALL COMMERCIAL AETNA,217.00,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,ANTHEM,ANTEHM MEDICAID,134.69,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87900 at $134.69 (Fee Schedule) = $134.69 (Total Line Payment) at 100% = $134.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,130.35,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,ANTHEM,ANTHEM POS/HMO,217.00,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $456.23 from Fee Schedule WII28_25 for Rev 306 Proc 87900 Mod TC * Qty 1 = $456.23 at 100% = $456.23 (Limited to $217.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,ANTHEM,ANTHEM PPO,217.00,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $456.23 from Fee Schedule WII28_25 for Rev 306 Proc 87900 Mod TC * Qty 1 = $456.23 at 100% = $456.23 (Limited to $217.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,217.00,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,CENPATICO,ALL MEDICAID CENPATICO,217.00,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,184.45,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $184.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,CIGNA,ALL COMMERCIAL CIGNA,151.90,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $151.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,COFINITY,COFINITY,217.00,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,134.69,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87900 at $134.69 (Fee Schedule) = $134.69 (Total Line Payment) at 100% = $134.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,134.69,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87900 at $134.69 (Fee Schedule) = $134.69 (Total Line Payment) at 100% = $134.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,206.15,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $206.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,182.28,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $182.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,154.07,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $154.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,158.41,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $158.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,105.46,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $105.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,184.45,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $184.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HUMANA,HUMANA CHOICE CARE HMO,217.00,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $221.60 from Fee Schedule 005543_170 for Rev 306 Proc 87900 * Qty 1 = $221.60 at 100% = $221.60 (Limited to $217.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HUMANA,HUMANA CHOICE CARE PPO,184.45,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $184.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,130.35,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,HUMANA,HUMANA NATIIONAL POS HMO,217.00,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $221.60 from Fee Schedule 005543_170 for Rev 306 Proc 87900 * Qty 1 = $221.60 at 100% = $221.60 (Limited to $217.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,158.41,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $158.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,217.00,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,134.69,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87900 at $134.69 (Fee Schedule) = $134.69 (Total Line Payment) at 100% = $134.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,130.35,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,134.69,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87900 at $134.69 (Fee Schedule) = $134.69 (Total Line Payment) at 100% = $134.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,142.77,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87900 at $134.69 (Fee Schedule) = $134.69 (Total Line Payment) at 100% = $134.69... $134.69 at 106% = $142.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,130.35,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,108.50,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $108.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,182.28,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $182.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,293.29,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,162.75,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $162.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,199.64,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $199.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,169.46,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,169.46,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,PREVEA HEALTH NETWORK,PREVEA360,169.46,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,169.46,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,138.51,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $138.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,131.65,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,156.24,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $156.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,TRIOLOGY,TRILOGY MEDICAID,142.77,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87900 at $134.69 (Fee Schedule) = $134.69 (Total Line Payment) at 106% = $142.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,156.42,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $156.42 from Fee Schedule UHC_98227C for Rev 306 Proc 87900 * Qty 1 = $156.42 at 100% = $156.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,156.42,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $156.42 from Fee Schedule UHC_98227C for Rev 306 Proc 87900 * Qty 1 = $156.42 at 100% = $156.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,130.35,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,156.42,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $156.42 from Fee Schedule UHC_98227C for Rev 306 Proc 87900 * Qty 1 = $156.42 at 100% = $156.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,UNITY HEALTH PLAN,UNITY HOSPICE,130.35,,,,,,,105.4600,293.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,156.24,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $156.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,134.54,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $134.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,156.24,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $156.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,156.24,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $156.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENOTYPE INFCT AGT DRG SUS,87900,CPT,306,RC,30600691,CDM,,,,both,,,217.0000,143.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,130.20,,,,,,,105.4600,293.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $217.00 in Billed Charges for Rev 306 Proc 87900 = $130.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,AETNA,AETNA HSHS,84.63,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $84.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,AETNA,AETNA MEDICARE,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,AETNA,ALL COMMERCIAL AETNA,131.00,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $131.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,ANTHEM,ANTEHM MEDICAID,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87901 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,ANTHEM,ANTHEM POS/HMO,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $901.08 from Fee Schedule WII28_25 for Rev 306 Proc 87901 Mod TC * Qty 1 = $901.08 at 100% = $901.08 (Limited to $131.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,ANTHEM,ANTHEM PPO,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $901.08 from Fee Schedule WII28_25 for Rev 306 Proc 87901 Mod TC * Qty 1 = $901.08 at 100% = $901.08 (Limited to $131.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,131.00,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $131.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,CENPATICO,ALL MEDICAID CENPATICO,131.00,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $131.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,111.35,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $111.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,CIGNA,ALL COMMERCIAL CIGNA,91.70,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $91.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,COFINITY,COFINITY,131.00,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $131.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87901 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87901 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,124.45,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $124.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,110.04,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $110.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,93.01,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $93.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,95.63,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $95.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,63.67,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $63.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,111.35,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $111.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HUMANA,HUMANA CHOICE CARE HMO,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $437.67 from Fee Schedule 005543_170 for Rev 306 Proc 87901 * Qty 1 = $437.67 at 100% = $437.67 (Limited to $131.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HUMANA,HUMANA CHOICE CARE PPO,111.35,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $111.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,HUMANA,HUMANA NATIIONAL POS HMO,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $437.67 from Fee Schedule 005543_170 for Rev 306 Proc 87901 * Qty 1 = $437.67 at 100% = $437.67 (Limited to $131.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,95.63,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $95.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,131.00,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $131.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87901 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87901 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,138.86,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87901 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges)... $131.00 at 106% = $138.86 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.50,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $65.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,110.04,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $110.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,294.75,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,98.25,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $98.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,120.52,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $120.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,PREVEA HEALTH NETWORK,PREVEA360,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,83.62,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $83.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,132.31,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,94.32,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,TRIOLOGY,TRILOGY MEDICAID,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87901 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 106% = $281.98 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $308.94 from Fee Schedule UHC_98227C for Rev 306 Proc 87901 * Qty 1 = $308.94 at 100% = $308.94 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $308.94 from Fee Schedule UHC_98227C for Rev 306 Proc 87901 * Qty 1 = $308.94 at 100% = $308.94 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,131.00,,,,,,,63.6700,294.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $308.94 from Fee Schedule UHC_98227C for Rev 306 Proc 87901 * Qty 1 = $308.94 at 100% = $308.94 (Service Line reduced to $131.00, claim capped at $131.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,UNITY HEALTH PLAN,UNITY HOSPICE,131.00,,,,,,,63.6700,294.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,94.32,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,81.22,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $81.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,94.32,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,94.32,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOTYPE HIV 1,87901,CPT,306,RC,30600692,CDM,,,,both,,,131.0000,86.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,78.60,,,,,,,63.6700,294.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $131.00 in Billed Charges for Rev 306 Proc 87901 = $78.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,AETNA,AETNA HSHS,193.80,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,AETNA,AETNA MEDICARE,76.77,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,AETNA,ALL COMMERCIAL AETNA,300.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,76.77,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM POS/HMO,204.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 306 Proc 87564 $300.00 in Billed Charges at 68% = $204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM PPO,204.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 306 Proc 87564 $300.00 in Billed Charges at 68% = $204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,300.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,CENPATICO,ALL MEDICAID CENPATICO,300.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,255.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,CIGNA,ALL COMMERCIAL CIGNA,210.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,COFINITY,COFINITY,300.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,285.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $285.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,252.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,213.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $213.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,219.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,145.80,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $145.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,255.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA CHOICE CARE PPO,255.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,76.77,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,219.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,300.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,76.77,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,76.77,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,150.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,252.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,172.73,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,225.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,276.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $276.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,99.80,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,99.80,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA360,99.80,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,99.80,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,191.49,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $191.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,77.54,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,216.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,92.12,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $92.12 from Fee Schedule UHC_98227C for Rev 306 Proc 87564 * Qty 1 = $92.12 at 100% = $92.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,92.12,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $92.12 from Fee Schedule UHC_98227C for Rev 306 Proc 87564 * Qty 1 = $92.12 at 100% = $92.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,76.77,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,92.12,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $92.12 from Fee Schedule UHC_98227C for Rev 306 Proc 87564 * Qty 1 = $92.12 at 100% = $92.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,UNITY HEALTH PLAN,UNITY HOSPICE,76.77,,,,,,,76.7700,300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,216.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,186.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,216.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,216.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MTB RIFAMPIN RESISTANCE AMP PRB TQ,87564,CPT,306,RC,30600721,CDM,,,,both,,,300.0000,198.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,180.00,,,,,,,76.7700,300.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $300.00 in Billed Charges for Rev 306 Proc 87564 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,AETNA,AETNA HSHS,72.35,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $72.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,AETNA,AETNA MEDICARE,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,AETNA,ALL COMMERCIAL AETNA,112.00,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,ANTHEM,ANTEHM MEDICAID,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87426 at $35.33 (Fee Schedule) = $35.33 (Total Line Payment) at 100% = $35.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,ANTHEM,ANTHEM POS/HMO,112.00,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $123.66 from Fee Schedule WII28_25 for Rev 306 Proc 87426 Mod TC * Qty 1 = $123.66 at 100% = $123.66 (Limited to $112.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,ANTHEM,ANTHEM PPO,112.00,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $123.66 from Fee Schedule WII28_25 for Rev 306 Proc 87426 Mod TC * Qty 1 = $123.66 at 100% = $123.66 (Limited to $112.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,112.00,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,CENPATICO,ALL MEDICAID CENPATICO,112.00,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,95.20,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,CIGNA,ALL COMMERCIAL CIGNA,78.40,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $78.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,COFINITY,COFINITY,112.00,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87426 at $35.33 (Fee Schedule) = $35.33 (Total Line Payment) at 100% = $35.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87426 at $35.33 (Fee Schedule) = $35.33 (Total Line Payment) at 100% = $35.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,106.40,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $106.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,94.08,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $94.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,79.52,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $79.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,81.76,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $81.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,54.43,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $54.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,95.20,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HUMANA,HUMANA CHOICE CARE HMO,60.06,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.06 from Fee Schedule 005543_170 for Rev 306 Proc 87426 * Qty 1 = $60.06 at 100% = $60.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HUMANA,HUMANA CHOICE CARE PPO,95.20,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,HUMANA,HUMANA NATIIONAL POS HMO,60.06,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.06 from Fee Schedule 005543_170 for Rev 306 Proc 87426 * Qty 1 = $60.06 at 100% = $60.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,81.76,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $81.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,112.00,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $112.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87426 at $35.33 (Fee Schedule) = $35.33 (Total Line Payment) at 100% = $35.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87426 at $35.33 (Fee Schedule) = $35.33 (Total Line Payment) at 100% = $35.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,37.45,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87426 at $35.33 (Fee Schedule) = $35.33 (Total Line Payment) at 100% = $35.33... $35.33 at 106% = $37.45 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,56.00,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $56.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,94.08,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $94.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,79.49,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,84.00,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,103.04,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $103.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.93,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.93,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,PREVEA HEALTH NETWORK,PREVEA360,45.93,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.93,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,71.49,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $71.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.68,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,80.64,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,TRIOLOGY,TRILOGY MEDICAID,37.45,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87426 at $35.33 (Fee Schedule) = $35.33 (Total Line Payment) at 106% = $37.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.40,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87426 * Qty 1 = $42.40 at 100% = $42.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,42.40,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87426 * Qty 1 = $42.40 at 100% = $42.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,42.40,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87426 * Qty 1 = $42.40 at 100% = $42.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,UNITY HEALTH PLAN,UNITY HOSPICE,35.33,,,,,,,35.3300,112.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,80.64,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,69.44,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $69.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,80.64,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,80.64,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS COVID ANTIGEN TEST,87426,CPT,306,RC,30682023,CDM,,,,both,,,112.0000,73.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,67.20,,,,,,,35.3300,112.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.00 in Billed Charges for Rev 306 Proc 87426 = $67.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,AETNA,AETNA HSHS,37.47,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $37.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,AETNA,AETNA MEDICARE,3.17,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,AETNA,ALL COMMERCIAL AETNA,58.00,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $58.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,ANTHEM,ANTEHM MEDICAID,3.28,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81001 at $3.28 (Fee Schedule) = $3.28 (Total Line Payment) at 100% = $3.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.17,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,ANTHEM,ANTHEM POS/HMO,11.10,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.10 from Fee Schedule WII28_25 for Rev 307 Proc 81001 Mod TC * Qty 1 = $11.10 at 100% = $11.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,ANTHEM,ANTHEM PPO,11.10,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.10 from Fee Schedule WII28_25 for Rev 307 Proc 81001 Mod TC * Qty 1 = $11.10 at 100% = $11.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,58.00,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $58.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,CENPATICO,ALL MEDICAID CENPATICO,58.00,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $58.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,49.30,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $49.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,CIGNA,ALL COMMERCIAL CIGNA,40.60,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $40.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,COFINITY,COFINITY,58.00,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $58.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,3.28,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81001 at $3.28 (Fee Schedule) = $3.28 (Total Line Payment) at 100% = $3.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,3.28,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81001 at $3.28 (Fee Schedule) = $3.28 (Total Line Payment) at 100% = $3.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,55.10,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $55.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,48.72,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $48.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,41.18,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $41.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,42.34,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $42.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,28.19,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $28.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,49.30,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $49.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HUMANA,HUMANA CHOICE CARE HMO,5.39,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.39 from Fee Schedule 005543_170 for Rev 307 Proc 81001 * Qty 1 = $5.39 at 100% = $5.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HUMANA,HUMANA CHOICE CARE PPO,49.30,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $49.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,3.17,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.39,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.39 from Fee Schedule 005543_170 for Rev 307 Proc 81001 * Qty 1 = $5.39 at 100% = $5.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,42.34,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $42.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,58.00,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $58.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,3.28,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81001 at $3.28 (Fee Schedule) = $3.28 (Total Line Payment) at 100% = $3.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.17,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,3.28,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81001 at $3.28 (Fee Schedule) = $3.28 (Total Line Payment) at 100% = $3.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,3.48,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81001 at $3.28 (Fee Schedule) = $3.28 (Total Line Payment) at 100% = $3.28... $3.28 at 106% = $3.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,3.17,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,29.00,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $29.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,48.72,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $48.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,7.13,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,43.50,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $43.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,53.36,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $53.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.12,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.12,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,PREVEA HEALTH NETWORK,PREVEA360,4.12,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.12,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,37.02,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $37.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.20,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,41.76,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $41.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,TRIOLOGY,TRILOGY MEDICAID,3.48,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81001 at $3.28 (Fee Schedule) = $3.28 (Total Line Payment) at 106% = $3.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.80,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.80 from Fee Schedule UHC_98227C for Rev 307 Proc 81001 * Qty 1 = $3.80 at 100% = $3.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,3.80,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.80 from Fee Schedule UHC_98227C for Rev 307 Proc 81001 * Qty 1 = $3.80 at 100% = $3.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.17,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,3.80,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.80 from Fee Schedule UHC_98227C for Rev 307 Proc 81001 * Qty 1 = $3.80 at 100% = $3.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,UNITY HEALTH PLAN,UNITY HOSPICE,3.17,,,,,,,3.1700,58.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,41.76,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $41.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,35.96,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $35.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,41.76,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $41.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,41.76,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $41.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/MICRO,81001,CPT,307,RC,30700101,CDM,,,,both,,,58.0000,38.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,34.80,,,,,,,3.1700,58.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $58.00 in Billed Charges for Rev 307 Proc 81001 = $34.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,AETNA,AETNA HSHS,22.61,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $22.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,AETNA,AETNA MEDICARE,2.25,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,AETNA,ALL COMMERCIAL AETNA,35.00,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,ANTHEM,ANTEHM MEDICAID,2.32,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.25,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,ANTHEM,ANTHEM POS/HMO,7.88,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,ANTHEM,ANTHEM PPO,7.88,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,35.00,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,CENPATICO,ALL MEDICAID CENPATICO,35.00,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,29.75,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $29.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,CIGNA,ALL COMMERCIAL CIGNA,24.50,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,COFINITY,COFINITY,35.00,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2.32,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2.32,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,33.25,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $33.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,29.40,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,24.85,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $24.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,25.55,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $25.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,17.01,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $17.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,29.75,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $29.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HUMANA,HUMANA CHOICE CARE HMO,3.83,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HUMANA,HUMANA CHOICE CARE PPO,29.75,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $29.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,2.25,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,HUMANA,HUMANA NATIIONAL POS HMO,3.83,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,25.55,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $25.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,35.00,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2.32,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.25,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2.32,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,2.46,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32... $2.32 at 106% = $2.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,2.25,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,17.50,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $17.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,29.40,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,5.06,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,26.25,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,32.20,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $32.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.93,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.93,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,PREVEA HEALTH NETWORK,PREVEA360,2.93,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.93,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,22.34,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $22.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.27,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,25.20,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $25.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,TRIOLOGY,TRILOGY MEDICAID,2.46,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 106% = $2.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.70,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,2.70,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.25,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,2.70,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,UNITY HEALTH PLAN,UNITY HOSPICE,2.25,,,,,,,2.2500,35.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,25.20,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $25.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,21.70,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $21.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,25.20,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $25.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,25.20,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $25.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS DIP STICK,81003,CPT,307,RC,30700102,CDM,,,QW,both,,,35.0000,23.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,21.00,,,,,,,2.2500,35.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,AETNA,AETNA HSHS,27.13,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,AETNA,AETNA MEDICARE,2.25,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,AETNA,ALL COMMERCIAL AETNA,42.00,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,ANTHEM,ANTEHM MEDICAID,2.32,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.25,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,ANTHEM,ANTHEM POS/HMO,7.88,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,ANTHEM,ANTHEM PPO,7.88,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,42.00,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,CENPATICO,ALL MEDICAID CENPATICO,42.00,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,35.70,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,CIGNA,ALL COMMERCIAL CIGNA,29.40,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,COFINITY,COFINITY,42.00,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2.32,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2.32,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,39.90,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,35.28,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.82,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $29.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,30.66,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $30.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,20.41,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $20.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,35.70,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HUMANA,HUMANA CHOICE CARE HMO,3.83,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HUMANA,HUMANA CHOICE CARE PPO,35.70,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,2.25,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,HUMANA,HUMANA NATIIONAL POS HMO,3.83,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,30.66,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $30.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,42.00,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2.32,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.25,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2.32,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,2.46,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32... $2.32 at 106% = $2.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,2.25,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,21.00,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $21.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,35.28,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,5.06,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,31.50,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $31.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,38.64,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.93,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.93,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,PREVEA HEALTH NETWORK,PREVEA360,2.93,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.93,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.81,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.27,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,30.24,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $30.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,TRIOLOGY,TRILOGY MEDICAID,2.46,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 106% = $2.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.70,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,2.70,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.25,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,2.70,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,UNITY HEALTH PLAN,UNITY HOSPICE,2.25,,,,,,,2.2500,42.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,30.24,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $30.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,26.04,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,30.24,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $30.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,30.24,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $30.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINALYSIS AUTO W/O MICRO,81003,CPT,307,RC,30700104,CDM,,,QW,both,,,42.0000,27.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,25.20,,,,,,,2.2500,42.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $42.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $25.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,AETNA,AETNA HSHS,21.32,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $21.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,AETNA,AETNA MEDICARE,2.25,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,AETNA,ALL COMMERCIAL AETNA,33.00,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,ANTHEM,ANTEHM MEDICAID,2.32,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.25,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,ANTHEM,ANTHEM POS/HMO,7.88,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,ANTHEM,ANTHEM PPO,7.88,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,33.00,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,CENPATICO,ALL MEDICAID CENPATICO,33.00,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,28.05,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,CIGNA,ALL COMMERCIAL CIGNA,23.10,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $23.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,COFINITY,COFINITY,33.00,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2.32,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2.32,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,31.35,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $31.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,27.72,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,23.43,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $23.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,24.09,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $24.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,16.04,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $16.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,28.05,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HUMANA,HUMANA CHOICE CARE HMO,3.83,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HUMANA,HUMANA CHOICE CARE PPO,28.05,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,2.25,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,HUMANA,HUMANA NATIIONAL POS HMO,3.83,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,24.09,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $24.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,33.00,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2.32,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.25,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2.32,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,2.46,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32... $2.32 at 106% = $2.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,2.25,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.50,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $16.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,27.72,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,5.06,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,24.75,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,30.36,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $30.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.93,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.93,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,PREVEA HEALTH NETWORK,PREVEA360,2.93,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.93,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,21.06,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $21.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.27,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,23.76,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,TRIOLOGY,TRILOGY MEDICAID,2.46,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 106% = $2.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.70,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,2.70,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.25,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,2.70,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,UNITY HEALTH PLAN,UNITY HOSPICE,2.25,,,,,,,2.2500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,23.76,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,20.46,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $20.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,23.76,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,23.76,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE ONE TEST ONLY,81003,CPT,307,RC,30700105,CDM,,,QW,both,,,33.0000,21.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,19.80,,,,,,,2.2500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $19.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,AETNA,AETNA HSHS,34.88,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $34.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,AETNA,AETNA MEDICARE,2.25,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,AETNA,ALL COMMERCIAL AETNA,54.00,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,ANTHEM,ANTEHM MEDICAID,2.32,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.25,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,ANTHEM,ANTHEM POS/HMO,7.88,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,ANTHEM,ANTHEM PPO,7.88,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,54.00,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,CENPATICO,ALL MEDICAID CENPATICO,54.00,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,45.90,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $45.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,CIGNA,ALL COMMERCIAL CIGNA,37.80,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $37.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,COFINITY,COFINITY,54.00,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2.32,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2.32,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,51.30,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $51.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,45.36,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $45.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,38.34,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,39.42,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $39.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,26.24,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,45.90,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $45.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HUMANA,HUMANA CHOICE CARE HMO,3.83,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HUMANA,HUMANA CHOICE CARE PPO,45.90,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $45.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,2.25,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,HUMANA,HUMANA NATIIONAL POS HMO,3.83,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,39.42,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $39.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,54.00,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2.32,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.25,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2.32,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,2.46,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32... $2.32 at 106% = $2.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,2.25,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27.00,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,45.36,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $45.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,5.06,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,40.50,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $40.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,49.68,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.93,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.93,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,PREVEA HEALTH NETWORK,PREVEA360,2.93,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.93,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,34.47,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $34.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.27,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,38.88,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,TRIOLOGY,TRILOGY MEDICAID,2.46,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 106% = $2.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.70,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,2.70,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.25,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,2.70,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,UNITY HEALTH PLAN,UNITY HOSPICE,2.25,,,,,,,2.2500,54.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,38.88,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,33.48,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $33.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,38.88,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,38.88,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700106,CDM,,,QW,both,,,54.0000,35.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,32.40,,,,,,,2.2500,54.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $54.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $32.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,AETNA,AETNA HSHS,24.55,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $24.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,AETNA,AETNA MEDICARE,2.25,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,AETNA,ALL COMMERCIAL AETNA,38.00,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,ANTHEM,ANTEHM MEDICAID,2.32,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.25,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,ANTHEM,ANTHEM POS/HMO,7.88,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,ANTHEM,ANTHEM PPO,7.88,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,38.00,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,CENPATICO,ALL MEDICAID CENPATICO,38.00,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,32.30,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,CIGNA,ALL COMMERCIAL CIGNA,26.60,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,COFINITY,COFINITY,38.00,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2.32,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2.32,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,36.10,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $36.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,31.92,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $31.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,26.98,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,27.74,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,18.47,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,32.30,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HUMANA,HUMANA CHOICE CARE HMO,3.83,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HUMANA,HUMANA CHOICE CARE PPO,32.30,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HUMANA,HUMANA MEDICARE ADVANTAGE,2.25,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,HUMANA,HUMANA NATIIONAL POS HMO,3.83,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,27.74,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,38.00,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2.32,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.25,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2.32,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,2.46,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32... $2.32 at 106% = $2.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,MOLINA HEALTHCARE,MOLINA MEDICARE,2.25,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.00,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $19.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,31.92,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $31.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,NAPHCARE,ALL COMMERICAL NAPHCARE,5.06,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,28.50,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $28.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,34.96,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $34.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.93,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.93,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA360,2.93,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.93,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,24.26,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $24.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.27,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,27.36,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,TRIOLOGY,TRILOGY MEDICAID,2.46,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 106% = $2.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.70,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,2.70,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.25,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,2.70,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,UNITY HEALTH PLAN,UNITY HOSPICE,2.25,,,,,,,2.2500,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,27.36,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,23.56,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $23.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,27.36,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,27.36,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700108,CDM,,,QW,both,,,38.0000,25.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,22.80,,,,,,,2.2500,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,AETNA,AETNA HSHS,62.02,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $62.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,AETNA,AETNA MEDICARE,2.17,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,AETNA,ALL COMMERCIAL AETNA,96.00,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,ANTHEM,ANTEHM MEDICAID,2.24,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.17,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,ANTHEM,ANTHEM POS/HMO,7.60,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.60 from Fee Schedule WII28_25 for Rev 307 Proc 81005 Mod TC * Qty 1 = $7.60 at 100% = $7.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,ANTHEM,ANTHEM PPO,7.60,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.60 from Fee Schedule WII28_25 for Rev 307 Proc 81005 Mod TC * Qty 1 = $7.60 at 100% = $7.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,96.00,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,CENPATICO,ALL MEDICAID CENPATICO,96.00,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,81.60,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,CIGNA,ALL COMMERCIAL CIGNA,67.20,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $67.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,COFINITY,COFINITY,96.00,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2.24,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2.24,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,91.20,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $91.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,80.64,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,68.16,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $68.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,70.08,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $70.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,46.66,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $46.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,81.60,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HUMANA,HUMANA CHOICE CARE HMO,3.69,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.69 from Fee Schedule 005543_170 for Rev 307 Proc 81005 * Qty 1 = $3.69 at 100% = $3.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HUMANA,HUMANA CHOICE CARE PPO,81.60,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,2.17,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,HUMANA,HUMANA NATIIONAL POS HMO,3.69,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.69 from Fee Schedule 005543_170 for Rev 307 Proc 81005 * Qty 1 = $3.69 at 100% = $3.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,70.08,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $70.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,96.00,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2.24,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.17,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2.24,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,2.37,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24... $2.24 at 106% = $2.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,2.17,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,48.00,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $48.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,80.64,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $80.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,4.88,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,72.00,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,88.32,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $88.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.82,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.82,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,PREVEA HEALTH NETWORK,PREVEA360,2.82,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.82,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,61.28,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $61.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.19,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,69.12,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $69.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,TRIOLOGY,TRILOGY MEDICAID,2.37,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 106% = $2.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.60,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.60 from Fee Schedule UHC_98227C for Rev 307 Proc 81005 * Qty 1 = $2.60 at 100% = $2.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,2.60,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.60 from Fee Schedule UHC_98227C for Rev 307 Proc 81005 * Qty 1 = $2.60 at 100% = $2.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.17,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,2.60,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.60 from Fee Schedule UHC_98227C for Rev 307 Proc 81005 * Qty 1 = $2.60 at 100% = $2.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,UNITY HEALTH PLAN,UNITY HOSPICE,2.17,,,,,,,2.1700,96.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,69.12,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $69.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,59.52,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $59.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,69.12,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $69.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,69.12,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $69.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REDUCING SUBSTANCES,81005,CPT,307,RC,30700113,CDM,,,,both,,,96.0000,63.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,57.60,,,,,,,2.1700,96.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $96.00 in Billed Charges for Rev 307 Proc 81005 = $57.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA HSHS,58.14,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $58.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA MEDICARE,8.61,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,AETNA,ALL COMMERCIAL AETNA,90.00,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTEHM MEDICAID,8.90,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81025 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.61,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM POS/HMO,30.14,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.14 from Fee Schedule WII28_25 for Rev 307 Proc 81025 Mod TC * Qty 1 = $30.14 at 100% = $30.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM PPO,30.14,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.14 from Fee Schedule WII28_25 for Rev 307 Proc 81025 Mod TC * Qty 1 = $30.14 at 100% = $30.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,90.00,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,CENPATICO,ALL MEDICAID CENPATICO,90.00,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,76.50,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,CIGNA,ALL COMMERCIAL CIGNA,63.00,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,COFINITY,COFINITY,90.00,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.90,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81025 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.90,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81025 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,85.50,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,75.60,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.90,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $63.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,65.70,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,43.74,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $43.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,76.50,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE HMO,14.64,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.64 from Fee Schedule 005543_170 for Rev 307 Proc 81025 * Qty 1 = $14.64 at 100% = $14.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE PPO,76.50,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,8.61,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA NATIIONAL POS HMO,14.64,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.64 from Fee Schedule 005543_170 for Rev 307 Proc 81025 * Qty 1 = $14.64 at 100% = $14.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,65.70,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,90.00,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.90,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81025 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.61,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.90,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81025 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,9.43,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81025 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 100% = $8.90... $8.90 at 106% = $9.43 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,8.61,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.00,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,75.60,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,19.37,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,67.50,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,82.80,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.19,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.19,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360,11.19,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.19,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,57.45,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $57.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.70,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,64.80,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,TRILOGY MEDICAID,9.43,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81025 at $8.90 (Fee Schedule) = $8.90 (Total Line Payment) at 106% = $9.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.33,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.33 from Fee Schedule UHC_98227C for Rev 307 Proc 81025 * Qty 1 = $10.33 at 100% = $10.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,10.33,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.33 from Fee Schedule UHC_98227C for Rev 307 Proc 81025 * Qty 1 = $10.33 at 100% = $10.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.61,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,10.33,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.33 from Fee Schedule UHC_98227C for Rev 307 Proc 81025 * Qty 1 = $10.33 at 100% = $10.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,UNITY HEALTH PLAN,UNITY HOSPICE,8.61,,,,,,,8.6100,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,64.80,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.80,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,64.80,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,64.80,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URINE PREGNANCY TEST,81025,CPT,307,RC,30700116,CDM,,,,both,,,90.0000,59.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,54.00,,,,,,,8.6100,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $90.00 in Billed Charges for Rev 307 Proc 81025 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,AETNA,AETNA HSHS,21.96,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $21.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,AETNA,AETNA MEDICARE,3.64,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,AETNA,ALL COMMERCIAL AETNA,34.00,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $34.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,ANTHEM,ANTEHM MEDICAID,3.76,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81050 at $3.76 (Fee Schedule) = $3.76 (Total Line Payment) at 100% = $3.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.64,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,ANTHEM,ANTHEM POS/HMO,12.74,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.74 from Fee Schedule WII28_25 for Rev 307 Proc 81050 Mod TC * Qty 1 = $12.74 at 100% = $12.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,ANTHEM,ANTHEM PPO,12.74,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.74 from Fee Schedule WII28_25 for Rev 307 Proc 81050 Mod TC * Qty 1 = $12.74 at 100% = $12.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,34.00,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $34.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,CENPATICO,ALL MEDICAID CENPATICO,34.00,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $34.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,28.90,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $28.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,CIGNA,ALL COMMERCIAL CIGNA,23.80,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $23.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,COFINITY,COFINITY,34.00,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $34.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,3.76,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81050 at $3.76 (Fee Schedule) = $3.76 (Total Line Payment) at 100% = $3.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,3.76,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81050 at $3.76 (Fee Schedule) = $3.76 (Total Line Payment) at 100% = $3.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,32.30,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,28.56,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $28.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,24.14,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $24.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,24.82,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $24.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,16.52,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $16.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,28.90,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $28.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HUMANA,HUMANA CHOICE CARE HMO,6.19,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.19 from Fee Schedule 005543_170 for Rev 307 Proc 81050 * Qty 1 = $6.19 at 100% = $6.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HUMANA,HUMANA CHOICE CARE PPO,28.90,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $28.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,3.64,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,HUMANA,HUMANA NATIIONAL POS HMO,6.19,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.19 from Fee Schedule 005543_170 for Rev 307 Proc 81050 * Qty 1 = $6.19 at 100% = $6.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,24.82,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $24.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,34.00,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $34.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,3.76,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81050 at $3.76 (Fee Schedule) = $3.76 (Total Line Payment) at 100% = $3.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.64,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,3.76,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81050 at $3.76 (Fee Schedule) = $3.76 (Total Line Payment) at 100% = $3.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,3.99,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81050 at $3.76 (Fee Schedule) = $3.76 (Total Line Payment) at 100% = $3.76... $3.76 at 106% = $3.99 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,3.64,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,17.00,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $17.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,28.56,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $28.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,8.19,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,25.50,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $25.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,31.28,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.73,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.73,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,PREVEA HEALTH NETWORK,PREVEA360,4.73,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.73,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,21.70,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $21.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.68,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,24.48,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $24.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,TRIOLOGY,TRILOGY MEDICAID,3.99,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81050 at $3.76 (Fee Schedule) = $3.76 (Total Line Payment) at 106% = $3.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.37,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.37 from Fee Schedule UHC_98227C for Rev 307 Proc 81050 * Qty 1 = $4.37 at 100% = $4.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,4.37,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.37 from Fee Schedule UHC_98227C for Rev 307 Proc 81050 * Qty 1 = $4.37 at 100% = $4.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.64,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,4.37,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.37 from Fee Schedule UHC_98227C for Rev 307 Proc 81050 * Qty 1 = $4.37 at 100% = $4.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,UNITY HEALTH PLAN,UNITY HOSPICE,3.64,,,,,,,3.6400,34.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,24.48,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $24.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,21.08,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $21.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,24.48,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $24.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,24.48,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $24.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VOLUME MEASUREMENT URINE,81050,CPT,307,RC,30700117,CDM,,,,both,,,34.0000,22.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,20.40,,,,,,,3.6400,34.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $34.00 in Billed Charges for Rev 307 Proc 81050 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,AETNA,AETNA HSHS,10.34,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.00 in Billed Charges for Rev 309 = $10.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,AETNA,ALL COMMERCIAL AETNA,16.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.00 in Billed Charges for Rev 309 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,ANTHEM,ANTHEM POS/HMO,10.88,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 309 $16.00 in Billed Charges at 68% = $10.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,ANTHEM,ANTHEM PPO,10.88,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 309 $16.00 in Billed Charges at 68% = $10.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.00 in Billed Charges for Rev 309 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,CENPATICO,ALL MEDICAID CENPATICO,16.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.00 in Billed Charges for Rev 309 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.60,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.00 in Billed Charges for Rev 309 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,CIGNA,ALL COMMERCIAL CIGNA,11.20,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.00 in Billed Charges for Rev 309 = $11.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,COFINITY,COFINITY,16.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.00 in Billed Charges for Rev 309 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.20,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.00 in Billed Charges for Rev 309 = $15.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,13.44,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.00 in Billed Charges for Rev 309 = $13.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.36,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.00 in Billed Charges for Rev 309 = $11.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.68,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.00 in Billed Charges for Rev 309 = $11.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,7.78,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.00 in Billed Charges for Rev 309 = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.60,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.00 in Billed Charges for Rev 309 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,HUMANA,HUMANA CHOICE CARE PPO,13.60,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.00 in Billed Charges for Rev 309 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.68,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.00 in Billed Charges for Rev 309 = $11.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.00 in Billed Charges for Rev 309 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.00 in Billed Charges for Rev 309 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.44,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.00 in Billed Charges for Rev 309 = $13.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.00 in Billed Charges for Rev 309 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,14.72,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.00 in Billed Charges for Rev 309 = $14.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9.60,,,,,,,7.7800,16.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9.60,,,,,,,7.7800,16.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,PREVEA HEALTH NETWORK,PREVEA360,9.60,,,,,,,7.7800,16.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9.60,,,,,,,7.7800,16.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.21,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.00 in Billed Charges for Rev 309 = $10.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.52,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.00 in Billed Charges for Rev 309 = $11.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 309 $16.00 in Billed Charges at 50% = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,8.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 309 $16.00 in Billed Charges at 50% = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,8.00,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 309 $16.00 in Billed Charges at 50% = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.52,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.00 in Billed Charges for Rev 309 = $11.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.92,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.00 in Billed Charges for Rev 309 = $9.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.52,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.00 in Billed Charges for Rev 309 = $11.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.52,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.00 in Billed Charges for Rev 309 = $11.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SLIDE PROCESSING FEE,309,RC,30900001,CDM,,,,,,both,,,16.0000,10.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.60,,,,,,,7.7800,16.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.00 in Billed Charges for Rev 309 = $9.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,AETNA,AETNA HSHS,65.25,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $65.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,AETNA,AETNA MEDICARE,9.84,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,AETNA,ALL COMMERCIAL AETNA,101.00,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,ANTHEM,ANTEHM MEDICAID,10.17,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89300 at $10.17 (Fee Schedule) = $10.17 (Total Line Payment) at 100% = $10.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,9.84,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,ANTHEM,ANTHEM POS/HMO,34.44,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.44 from Fee Schedule WII28_25 for Rev 309 Proc 89300 Mod TC * Qty 1 = $34.44 at 100% = $34.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,ANTHEM,ANTHEM PPO,34.44,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.44 from Fee Schedule WII28_25 for Rev 309 Proc 89300 Mod TC * Qty 1 = $34.44 at 100% = $34.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,101.00,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,CENPATICO,ALL MEDICAID CENPATICO,101.00,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,85.85,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,CIGNA,ALL COMMERCIAL CIGNA,70.70,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $70.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,COFINITY,COFINITY,101.00,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.17,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89300 at $10.17 (Fee Schedule) = $10.17 (Total Line Payment) at 100% = $10.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.17,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89300 at $10.17 (Fee Schedule) = $10.17 (Total Line Payment) at 100% = $10.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,95.95,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $95.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,84.84,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $84.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,71.71,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $71.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,73.73,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $73.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,49.09,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $49.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,85.85,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HUMANA,HUMANA CHOICE CARE HMO,16.73,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.73 from Fee Schedule 005543_170 for Rev 309 Proc 89300 * Qty 1 = $16.73 at 100% = $16.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HUMANA,HUMANA CHOICE CARE PPO,85.85,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,9.84,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,HUMANA,HUMANA NATIIONAL POS HMO,16.73,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.73 from Fee Schedule 005543_170 for Rev 309 Proc 89300 * Qty 1 = $16.73 at 100% = $16.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,73.73,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $73.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,101.00,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.17,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89300 at $10.17 (Fee Schedule) = $10.17 (Total Line Payment) at 100% = $10.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,9.84,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.17,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89300 at $10.17 (Fee Schedule) = $10.17 (Total Line Payment) at 100% = $10.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,10.78,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89300 at $10.17 (Fee Schedule) = $10.17 (Total Line Payment) at 100% = $10.17... $10.17 at 106% = $10.78 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,9.84,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,50.50,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $50.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,84.84,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $84.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,22.14,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,75.75,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $75.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,92.92,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $92.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.79,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.79,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,PREVEA HEALTH NETWORK,PREVEA360,12.79,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.79,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,64.47,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $64.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,9.94,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,72.72,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,TRIOLOGY,TRILOGY MEDICAID,10.78,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00390 Proc 89300 at $10.17 (Fee Schedule) = $10.17 (Total Line Payment) at 106% = $10.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.81,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.81 from Fee Schedule UHC_98227C for Rev 309 Proc 89300 * Qty 1 = $11.81 at 100% = $11.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,11.81,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.81 from Fee Schedule UHC_98227C for Rev 309 Proc 89300 * Qty 1 = $11.81 at 100% = $11.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,9.84,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,11.81,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.81 from Fee Schedule UHC_98227C for Rev 309 Proc 89300 * Qty 1 = $11.81 at 100% = $11.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,UNITY HEALTH PLAN,UNITY HOSPICE,9.84,,,,,,,9.8400,101.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,72.72,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,62.62,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $62.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,72.72,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,72.72,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC POST VASECTOMY SEMEN ANALYSIS,89300,CPT,309,RC,30900002,CDM,,,,both,,,101.0000,66.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,60.60,,,,,,,9.8400,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.00 in Billed Charges for Rev 309 Proc 89300 = $60.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA HSHS,126.62,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $126.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA MEDICARE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,AETNA,ALL COMMERCIAL AETNA,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTEHM MEDICAID,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM POS/HMO,68.46,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.46 from Fee Schedule WII28_25 for Rev 309 Proc 87254 Mod TC * Qty 1 = $68.46 at 100% = $68.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM PPO,68.46,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.46 from Fee Schedule WII28_25 for Rev 309 Proc 87254 Mod TC * Qty 1 = $68.46 at 100% = $68.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,CENPATICO,ALL MEDICAID CENPATICO,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,166.60,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,CIGNA,ALL COMMERCIAL CIGNA,137.20,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $137.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,COFINITY,COFINITY,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,186.20,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $186.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,164.64,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.16,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $139.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.08,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,95.26,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $95.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,166.60,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE HMO,33.25,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $33.25 from Fee Schedule 005543_170 for Rev 309 Proc 87254 * Qty 1 = $33.25 at 100% = $33.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE PPO,166.60,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA NATIIONAL POS HMO,33.25,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $33.25 from Fee Schedule 005543_170 for Rev 309 Proc 87254 * Qty 1 = $33.25 at 100% = $33.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.08,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,7.48,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06... $7.06 at 106% = $7.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,164.64,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,44.01,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,180.32,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $180.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,25.43,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,25.43,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360,25.43,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,25.43,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.11,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $125.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,19.76,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.12,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,TRILOGY MEDICAID,7.48,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 106% = $7.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,23.47,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.47 from Fee Schedule UHC_98227C for Rev 309 Proc 87254 * Qty 1 = $23.47 at 100% = $23.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,23.47,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.47 from Fee Schedule UHC_98227C for Rev 309 Proc 87254 * Qty 1 = $23.47 at 100% = $23.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,23.47,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.47 from Fee Schedule UHC_98227C for Rev 309 Proc 87254 * Qty 1 = $23.47 at 100% = $23.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,UNITY HEALTH PLAN,UNITY HOSPICE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.12,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,121.52,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $121.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.12,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.12,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VIRUS ISOL SHELL ID,87254,CPT,309,RC,30900199,CDM,,,,both,,,196.0000,129.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,117.60,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $196.00 in Billed Charges for Rev 309 Proc 87254 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,AETNA,AETNA HSHS,15.50,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.00 in Billed Charges for Rev 310 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,AETNA,ALL COMMERCIAL AETNA,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 310 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,ANTHEM,ANTHEM POS/HMO,16.32,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $24.00 in Billed Charges at 68% = $16.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,ANTHEM,ANTHEM PPO,16.32,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $24.00 in Billed Charges at 68% = $16.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 310 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,CENPATICO,ALL MEDICAID CENPATICO,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 310 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.40,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 310 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,CIGNA,ALL COMMERCIAL CIGNA,16.80,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.00 in Billed Charges for Rev 310 = $16.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,COFINITY,COFINITY,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 310 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,22.80,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.00 in Billed Charges for Rev 310 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,20.16,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.00 in Billed Charges for Rev 310 = $20.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.04,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.00 in Billed Charges for Rev 310 = $17.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.52,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.00 in Billed Charges for Rev 310 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,11.66,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.00 in Billed Charges for Rev 310 = $11.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.40,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 310 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,HUMANA,HUMANA CHOICE CARE PPO,20.40,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.00 in Billed Charges for Rev 310 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.52,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.00 in Billed Charges for Rev 310 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.00 in Billed Charges for Rev 310 = $24.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.00 in Billed Charges for Rev 310 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.16,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.00 in Billed Charges for Rev 310 = $20.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.00 in Billed Charges for Rev 310 = $18.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.08,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.00 in Billed Charges for Rev 310 = $22.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.40,,,,,,,11.6600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.40,,,,,,,11.6600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA360,14.40,,,,,,,11.6600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.40,,,,,,,11.6600,24.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.32,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.00 in Billed Charges for Rev 310 = $15.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.28,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 310 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $24.00 in Billed Charges at 50% = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,12.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $24.00 in Billed Charges at 50% = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,12.00,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $24.00 in Billed Charges at 50% = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.28,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 310 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.88,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.00 in Billed Charges for Rev 310 = $14.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.28,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 310 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.28,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.00 in Billed Charges for Rev 310 = $17.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-CLINICS,310,RC,31000001,CDM,,,,,,outpatient,,,24.0000,15.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.40,,,,,,,11.6600,24.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.00 in Billed Charges for Rev 310 = $14.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,AETNA,AETNA HSHS,202.84,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $314.00 in Billed Charges for Rev 310 = $202.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,AETNA,ALL COMMERCIAL AETNA,314.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $314.00 in Billed Charges for Rev 310 = $314.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,ANTHEM,ANTHEM POS/HMO,213.52,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $314.00 in Billed Charges at 68% = $213.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,ANTHEM,ANTHEM PPO,213.52,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $314.00 in Billed Charges at 68% = $213.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,314.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $314.00 in Billed Charges for Rev 310 = $314.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,CENPATICO,ALL MEDICAID CENPATICO,314.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $314.00 in Billed Charges for Rev 310 = $314.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,266.90,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $314.00 in Billed Charges for Rev 310 = $266.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,CIGNA,ALL COMMERCIAL CIGNA,219.80,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $314.00 in Billed Charges for Rev 310 = $219.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,COFINITY,COFINITY,314.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $314.00 in Billed Charges for Rev 310 = $314.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,298.30,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $314.00 in Billed Charges for Rev 310 = $298.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,263.76,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $314.00 in Billed Charges for Rev 310 = $263.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,222.94,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $314.00 in Billed Charges for Rev 310 = $222.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,229.22,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $314.00 in Billed Charges for Rev 310 = $229.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,152.60,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $314.00 in Billed Charges for Rev 310 = $152.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,266.90,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $314.00 in Billed Charges for Rev 310 = $266.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,HUMANA,HUMANA CHOICE CARE PPO,266.90,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $314.00 in Billed Charges for Rev 310 = $266.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,229.22,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $314.00 in Billed Charges for Rev 310 = $229.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,314.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $314.00 in Billed Charges for Rev 310 = $314.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,157.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $314.00 in Billed Charges for Rev 310 = $157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,263.76,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $314.00 in Billed Charges for Rev 310 = $263.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,235.50,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $314.00 in Billed Charges for Rev 310 = $235.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,288.88,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $314.00 in Billed Charges for Rev 310 = $288.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,188.40,,,,,,,152.6000,314.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,188.40,,,,,,,152.6000,314.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,PREVEA HEALTH NETWORK,PREVEA360,188.40,,,,,,,152.6000,314.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,188.40,,,,,,,152.6000,314.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,200.43,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $314.00 in Billed Charges for Rev 310 = $200.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,226.08,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $314.00 in Billed Charges for Rev 310 = $226.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,157.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $314.00 in Billed Charges at 50% = $157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,157.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $314.00 in Billed Charges at 50% = $157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,157.00,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $314.00 in Billed Charges at 50% = $157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,226.08,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $314.00 in Billed Charges for Rev 310 = $226.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,194.68,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $314.00 in Billed Charges for Rev 310 = $194.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,226.08,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $314.00 in Billed Charges for Rev 310 = $226.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,226.08,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $314.00 in Billed Charges for Rev 310 = $226.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MORGUE USE,310,RC,31000003,CDM,,,,,,both,,,314.0000,207.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,188.40,,,,,,,152.6000,314.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $314.00 in Billed Charges for Rev 310 = $188.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,AETNA,AETNA HSHS,44.57,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $44.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,AETNA,ALL COMMERCIAL AETNA,69.00,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,ANTHEM,ANTEHM MEDICAID,14.77,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00305 Proc 88341 at $125.60 (Base Rate) * 0.1176 (Relative Weight) = $14.77 (Total Line Payment) at 100% = $14.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,ANTHEM,ANTHEM POS/HMO,69.00,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $203.09 from Fee Schedule WII28_25 for Rev 310 Proc 88341 Mod TC * Qty 1 = $203.09 at 100% = $203.09 (Limited to $69.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,ANTHEM,ANTHEM PPO,69.00,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $203.09 from Fee Schedule WII28_25 for Rev 310 Proc 88341 Mod TC * Qty 1 = $203.09 at 100% = $203.09 (Limited to $69.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,69.00,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,CENPATICO,ALL MEDICAID CENPATICO,69.00,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.65,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $58.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,CIGNA,ALL COMMERCIAL CIGNA,48.30,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $48.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,COFINITY,COFINITY,69.00,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.77,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00305 Proc 88341 at $125.60 (Base Rate) * 0.1176 (Relative Weight) = $14.77 (Total Line Payment) at 100% = $14.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.77,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00305 Proc 88341 at $125.60 (Base Rate) * 0.1176 (Relative Weight) = $14.77 (Total Line Payment) at 100% = $14.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.55,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $65.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,57.96,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $57.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.99,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $48.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.37,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $50.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,33.53,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $33.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.65,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $58.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,HUMANA,HUMANA CHOICE CARE HMO,69.00,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $148.31 from Fee Schedule 005543_170 for Rev 310 Proc 88341 * Qty 1 = $148.31 at 100% = $148.31 (Limited to $69.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,HUMANA,HUMANA CHOICE CARE PPO,58.65,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $58.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,HUMANA,HUMANA NATIIONAL POS HMO,69.00,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $148.31 from Fee Schedule 005543_170 for Rev 310 Proc 88341 * Qty 1 = $148.31 at 100% = $148.31 (Limited to $69.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.37,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $50.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,69.00,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.77,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00305 Proc 88341 at $125.60 (Base Rate) * 0.1176 (Relative Weight) = $14.77 (Total Line Payment) at 100% = $14.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.77,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00305 Proc 88341 at $125.60 (Base Rate) * 0.1176 (Relative Weight) = $14.77 (Total Line Payment) at 100% = $14.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,MOLINA HEALTHCARE,MOLINA MEDICAID,15.66,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00305 Proc 88341 at $125.60 (Base Rate) * 0.1176 (Relative Weight) = $14.77 (Total Line Payment) at 100% = $14.77... $14.77 at 106% = $15.66 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.50,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $34.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.96,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $57.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.75,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $51.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.48,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $63.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,41.40,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,41.40,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,PREVEA HEALTH NETWORK,PREVEA360,41.40,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,41.40,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44.04,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $44.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.68,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,TRIOLOGY,TRILOGY MEDICAID,15.66,,,,,,,14.7700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00305 Proc 88341 at $125.60 (Base Rate) * 0.1176 (Relative Weight) = $14.77 (Total Line Payment) at 106% = $15.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,69.00,,,,,,,14.7700,69.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $71.16 from Fee Schedule UHC_98227C for Rev 310 Proc 88341 * Qty 1 = $71.16 at 100% = $71.16 (Service Line reduced to $69.00, claim capped at $69.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,69.00,,,,,,,14.7700,69.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $71.16 from Fee Schedule UHC_98227C for Rev 310 Proc 88341 * Qty 1 = $71.16 at 100% = $71.16 (Service Line reduced to $69.00, claim capped at $69.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,69.00,,,,,,,14.7700,69.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $71.16 from Fee Schedule UHC_98227C for Rev 310 Proc 88341 * Qty 1 = $71.16 at 100% = $71.16 (Service Line reduced to $69.00, claim capped at $69.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.68,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.78,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $42.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.68,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.68,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QL,88341,CPT,310,RC,31000008,CDM,,,,both,,,69.0000,45.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.40,,,,,,,14.7700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $69.00 in Billed Charges for Rev 310 Proc 88341 = $41.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,AETNA,AETNA HSHS,402.46,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $402.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,AETNA,AETNA MEDICARE,165.49,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,AETNA,ALL COMMERCIAL AETNA,623.00,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $623.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,ANTHEM,ANTEHM MEDICAID,60.31,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00306 Proc 88360 at $125.60 (Base Rate) * 0.4802 (Relative Weight) = $60.31 (Total Line Payment) at 100% = $60.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,165.49,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,ANTHEM,ANTHEM POS/HMO,266.20,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $266.20 from Fee Schedule WII28_25 for Rev 310 Proc 88360 Mod TC * Qty 1 = $266.20 at 100% = $266.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,ANTHEM,ANTHEM PPO,266.20,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $266.20 from Fee Schedule WII28_25 for Rev 310 Proc 88360 Mod TC * Qty 1 = $266.20 at 100% = $266.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,623.00,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $623.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,CENPATICO,ALL MEDICAID CENPATICO,623.00,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $623.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,529.55,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $529.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,CIGNA,ALL COMMERCIAL CIGNA,436.10,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $436.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,COFINITY,COFINITY,623.00,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $623.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,60.31,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00306 Proc 88360 at $125.60 (Base Rate) * 0.4802 (Relative Weight) = $60.31 (Total Line Payment) at 100% = $60.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,60.31,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00306 Proc 88360 at $125.60 (Base Rate) * 0.4802 (Relative Weight) = $60.31 (Total Line Payment) at 100% = $60.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,591.85,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $591.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,523.32,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $523.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,442.33,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $442.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,454.79,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $454.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,302.78,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $302.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,529.55,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $529.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HUMANA,HUMANA CHOICE CARE HMO,196.86,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.86 from Fee Schedule 005543_170 for Rev 310 Proc 88360 * Qty 1 = $196.86 at 100% = $196.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HUMANA,HUMANA CHOICE CARE PPO,529.55,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $529.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,165.49,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,HUMANA,HUMANA NATIIONAL POS HMO,196.86,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.86 from Fee Schedule 005543_170 for Rev 310 Proc 88360 * Qty 1 = $196.86 at 100% = $196.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,454.79,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $454.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,623.00,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $623.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,60.31,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00306 Proc 88360 at $125.60 (Base Rate) * 0.4802 (Relative Weight) = $60.31 (Total Line Payment) at 100% = $60.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,165.49,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,60.31,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00306 Proc 88360 at $125.60 (Base Rate) * 0.4802 (Relative Weight) = $60.31 (Total Line Payment) at 100% = $60.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,63.93,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00306 Proc 88360 at $125.60 (Base Rate) * 0.4802 (Relative Weight) = $60.31 (Total Line Payment) at 100% = $60.31... $60.31 at 106% = $63.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,165.49,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,311.50,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $311.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,523.32,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $523.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,372.34,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,467.25,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $467.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,573.16,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $573.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,373.80,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,373.80,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,PREVEA HEALTH NETWORK,PREVEA360,373.80,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,373.80,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,397.66,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $397.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,167.14,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,448.56,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $448.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,TRIOLOGY,TRILOGY MEDICAID,63.93,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00306 Proc 88360 at $125.60 (Base Rate) * 0.4802 (Relative Weight) = $60.31 (Total Line Payment) at 106% = $63.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,188.70,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 310 Proc 88360 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,188.70,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 310 Proc 88360 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,165.49,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,188.70,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 310 Proc 88360 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,UNITY HEALTH PLAN,UNITY HOSPICE,165.49,,,,,,,60.3100,623.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,448.56,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $448.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,386.26,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $386.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,448.56,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $448.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,448.56,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $448.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY IMMUNOPEROXIDASE QN,88360,CPT,310,RC,31000009,CDM,,,,both,,,623.0000,411.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,373.80,,,,,,,60.3100,623.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $623.00 in Billed Charges for Rev 310 Proc 88360 = $373.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,AETNA,AETNA HSHS,467.06,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $467.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,AETNA,AETNA MEDICARE,163.96,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,AETNA,ALL COMMERCIAL AETNA,723.00,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $723.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,ANTHEM,ANTEHM MEDICAID,169.42,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,163.96,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,ANTHEM,ANTHEM POS/HMO,573.86,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $573.86 from Fee Schedule WII28_25 for Rev 310 Proc 81206 Mod TC * Qty 1 = $573.86 at 100% = $573.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,ANTHEM,ANTHEM PPO,573.86,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $573.86 from Fee Schedule WII28_25 for Rev 310 Proc 81206 Mod TC * Qty 1 = $573.86 at 100% = $573.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,723.00,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $723.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,CENPATICO,ALL MEDICAID CENPATICO,723.00,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $723.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,614.55,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $614.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,CIGNA,ALL COMMERCIAL CIGNA,506.10,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $506.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,COFINITY,COFINITY,723.00,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $723.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,169.42,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,169.42,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,686.85,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $686.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,607.32,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $607.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,513.33,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $513.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,527.79,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $527.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,351.38,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $351.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,614.55,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $614.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HUMANA,HUMANA CHOICE CARE HMO,278.73,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $278.73 from Fee Schedule 005543_170 for Rev 310 Proc 81206 * Qty 1 = $278.73 at 100% = $278.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HUMANA,HUMANA CHOICE CARE PPO,614.55,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $614.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,163.96,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,HUMANA,HUMANA NATIIONAL POS HMO,278.73,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $278.73 from Fee Schedule 005543_170 for Rev 310 Proc 81206 * Qty 1 = $278.73 at 100% = $278.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,527.79,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $527.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,723.00,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $723.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,169.42,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,163.96,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,169.42,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,179.59,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42... $169.42 at 106% = $179.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,163.96,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,361.50,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $361.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,607.32,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $607.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,368.91,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,542.25,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $542.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,665.16,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $665.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,213.15,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,213.15,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,PREVEA HEALTH NETWORK,PREVEA360,213.15,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,213.15,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,461.49,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $461.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,165.60,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,520.56,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $520.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,TRIOLOGY,TRILOGY MEDICAID,179.59,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 106% = $179.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,196.75,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81206 * Qty 1 = $196.75 at 100% = $196.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,196.75,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81206 * Qty 1 = $196.75 at 100% = $196.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,163.96,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,196.75,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81206 * Qty 1 = $196.75 at 100% = $196.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,UNITY HEALTH PLAN,UNITY HOSPICE,163.96,,,,,,,163.9600,723.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,520.56,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $520.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,448.26,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $448.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,520.56,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $520.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,520.56,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $520.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP QUEST,81206,CPT,310,RC,31000011,CDM,,,,both,,,723.0000,477.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,433.80,,,,,,,163.9600,723.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $723.00 in Billed Charges for Rev 310 Proc 81206 = $433.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,65.69,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,53.70,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81240 at $53.70 (Fee Schedule) = $53.70 (Total Line Payment) at 100% = $53.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,65.69,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,229.92,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $229.92 from Fee Schedule WII28_25 for Rev 310 Proc 81240 Mod TC * Qty 1 = $229.92 at 100% = $229.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,229.92,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $229.92 from Fee Schedule WII28_25 for Rev 310 Proc 81240 Mod TC * Qty 1 = $229.92 at 100% = $229.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,53.70,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81240 at $53.70 (Fee Schedule) = $53.70 (Total Line Payment) at 100% = $53.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,53.70,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81240 at $53.70 (Fee Schedule) = $53.70 (Total Line Payment) at 100% = $53.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,111.67,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.67 from Fee Schedule 005543_170 for Rev 310 Proc 81240 * Qty 1 = $111.67 at 100% = $111.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,65.69,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,111.67,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.67 from Fee Schedule 005543_170 for Rev 310 Proc 81240 * Qty 1 = $111.67 at 100% = $111.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,53.70,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81240 at $53.70 (Fee Schedule) = $53.70 (Total Line Payment) at 100% = $53.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,65.69,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,53.70,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81240 at $53.70 (Fee Schedule) = $53.70 (Total Line Payment) at 100% = $53.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,56.92,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81240 at $53.70 (Fee Schedule) = $53.70 (Total Line Payment) at 100% = $53.70... $53.70 at 106% = $56.92 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,65.69,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,147.80,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,85.40,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,85.40,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,85.40,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,85.40,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,66.35,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,56.92,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81240 at $53.70 (Fee Schedule) = $53.70 (Total Line Payment) at 106% = $56.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,78.83,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.83 from Fee Schedule UHC_98227C for Rev 310 Proc 81240 * Qty 1 = $78.83 at 100% = $78.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,78.83,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.83 from Fee Schedule UHC_98227C for Rev 310 Proc 81240 * Qty 1 = $78.83 at 100% = $78.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,65.69,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,78.83,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.83 from Fee Schedule UHC_98227C for Rev 310 Proc 81240 * Qty 1 = $78.83 at 100% = $78.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,65.69,,,,,,,53.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F2 GENE ANAL 20210G A VAR,81240,CPT,310,RC,31000015,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,53.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 310 Proc 81240 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,57.04,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,54.46,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81243 at $54.46 (Fee Schedule) = $54.46 (Total Line Payment) at 100% = $54.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,57.04,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,199.64,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $199.64 from Fee Schedule WII28_25 for Rev 310 Proc 81243 Mod TC * Qty 1 = $199.64 at 100% = $199.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,199.64,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $199.64 from Fee Schedule WII28_25 for Rev 310 Proc 81243 Mod TC * Qty 1 = $199.64 at 100% = $199.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,54.46,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81243 at $54.46 (Fee Schedule) = $54.46 (Total Line Payment) at 100% = $54.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,54.46,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81243 at $54.46 (Fee Schedule) = $54.46 (Total Line Payment) at 100% = $54.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,96.97,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $96.97 from Fee Schedule 005543_170 for Rev 310 Proc 81243 * Qty 1 = $96.97 at 100% = $96.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,57.04,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,96.97,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $96.97 from Fee Schedule 005543_170 for Rev 310 Proc 81243 * Qty 1 = $96.97 at 100% = $96.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,54.46,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81243 at $54.46 (Fee Schedule) = $54.46 (Total Line Payment) at 100% = $54.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,57.04,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,54.46,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81243 at $54.46 (Fee Schedule) = $54.46 (Total Line Payment) at 100% = $54.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,57.73,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81243 at $54.46 (Fee Schedule) = $54.46 (Total Line Payment) at 100% = $54.46... $54.46 at 106% = $57.73 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,57.04,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,128.34,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,74.15,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,74.15,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,74.15,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,74.15,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,57.61,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,57.73,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81243 at $54.46 (Fee Schedule) = $54.46 (Total Line Payment) at 106% = $57.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,68.45,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.45 from Fee Schedule UHC_98227C for Rev 310 Proc 81243 * Qty 1 = $68.45 at 100% = $68.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,68.45,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.45 from Fee Schedule UHC_98227C for Rev 310 Proc 81243 * Qty 1 = $68.45 at 100% = $68.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,57.04,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,68.45,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.45 from Fee Schedule UHC_98227C for Rev 310 Proc 81243 * Qty 1 = $68.45 at 100% = $68.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,57.04,,,,,,,54.4600,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FMR1 GENE CHARACTERZTN,81243,CPT,310,RC,31000017,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,54.4600,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 310 Proc 81243 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,AETNA,AETNA HSHS,1057.50,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,057.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,AETNA,AETNA MEDICARE,348.56,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,AETNA,ALL COMMERCIAL AETNA,1637.00,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,637.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,ANTHEM,ANTEHM MEDICAID,316.03,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,348.56,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,ANTHEM,ANTHEM POS/HMO,1219.96,,,,,,,316.0300,1637.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,219.96 from Fee Schedule WII28_25 for Rev 310 Proc 81301 Mod TC * Qty 1 = $1,219.96 at 100% = $1,219.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,ANTHEM,ANTHEM PPO,1219.96,,,,,,,316.0300,1637.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,219.96 from Fee Schedule WII28_25 for Rev 310 Proc 81301 Mod TC * Qty 1 = $1,219.96 at 100% = $1,219.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1637.00,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,637.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,CENPATICO,ALL MEDICAID CENPATICO,1637.00,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,637.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1391.45,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,391.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,CIGNA,ALL COMMERCIAL CIGNA,1145.90,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,145.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,COFINITY,COFINITY,1637.00,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,637.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,316.03,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,316.03,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1555.15,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,555.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,1375.08,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,375.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1162.27,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,162.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1195.01,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,195.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,795.58,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $795.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1391.45,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,391.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HUMANA,HUMANA CHOICE CARE HMO,592.55,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $592.55 from Fee Schedule 005543_170 for Rev 310 Proc 81301 * Qty 1 = $592.55 at 100% = $592.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HUMANA,HUMANA CHOICE CARE PPO,1391.45,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,391.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HUMANA,HUMANA MEDICARE ADVANTAGE,348.56,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,HUMANA,HUMANA NATIIONAL POS HMO,592.55,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $592.55 from Fee Schedule 005543_170 for Rev 310 Proc 81301 * Qty 1 = $592.55 at 100% = $592.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1195.01,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,195.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1637.00,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,637.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,316.03,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,348.56,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,316.03,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,MOLINA HEALTHCARE,MOLINA MEDICAID,334.99,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03... $316.03 at 106% = $334.99 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,MOLINA HEALTHCARE,MOLINA MEDICARE,348.56,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,818.50,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $818.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1375.08,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,375.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,NAPHCARE,ALL COMMERICAL NAPHCARE,784.26,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1227.75,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,227.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1506.04,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,506.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,453.13,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,453.13,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,PREVEA HEALTH NETWORK,PREVEA360,453.13,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,453.13,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1044.90,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,044.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,352.05,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1178.64,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,178.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,TRIOLOGY,TRILOGY MEDICAID,334.99,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 106% = $334.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,418.27,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $418.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81301 * Qty 1 = $418.27 at 100% = $418.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,418.27,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $418.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81301 * Qty 1 = $418.27 at 100% = $418.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,348.56,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,418.27,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $418.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81301 * Qty 1 = $418.27 at 100% = $418.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,UNITY HEALTH PLAN,UNITY HOSPICE,348.56,,,,,,,316.0300,1637.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1178.64,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,178.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1014.94,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,014.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1178.64,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,178.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1178.64,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $1,178.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MSI MICROSAT INSTAB,81301,CPT,310,RC,31000023,CDM,,,,both,,,1637.0000,1080.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,982.20,,,,,,,316.0300,1637.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,637.00 in Billed Charges for Rev 310 Proc 81301 = $982.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,AETNA,AETNA HSHS,506.46,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $506.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,AETNA,AETNA MEDICARE,348.56,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,AETNA,ALL COMMERCIAL AETNA,784.00,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,ANTHEM,ANTEHM MEDICAID,316.03,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,348.56,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,ANTHEM,ANTHEM POS/HMO,784.00,,,,,,,316.0300,784.2600,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,219.96 from Fee Schedule WII28_25 for Rev 310 Proc 81301 Mod TC * Qty 1 = $1,219.96 at 100% = $1,219.96 (Limited to $784.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,ANTHEM,ANTHEM PPO,784.00,,,,,,,316.0300,784.2600,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,219.96 from Fee Schedule WII28_25 for Rev 310 Proc 81301 Mod TC * Qty 1 = $1,219.96 at 100% = $1,219.96 (Limited to $784.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,784.00,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,CENPATICO,ALL MEDICAID CENPATICO,784.00,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,666.40,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $666.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,CIGNA,ALL COMMERCIAL CIGNA,548.80,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $548.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,COFINITY,COFINITY,784.00,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,316.03,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,316.03,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,744.80,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $744.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,658.56,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $658.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,556.64,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $556.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,572.32,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $572.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,381.02,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $381.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,666.40,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $666.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HUMANA,HUMANA CHOICE CARE HMO,592.55,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $592.55 from Fee Schedule 005543_170 for Rev 310 Proc 81301 * Qty 1 = $592.55 at 100% = $592.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HUMANA,HUMANA CHOICE CARE PPO,666.40,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $666.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,348.56,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,HUMANA,HUMANA NATIIONAL POS HMO,592.55,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $592.55 from Fee Schedule 005543_170 for Rev 310 Proc 81301 * Qty 1 = $592.55 at 100% = $592.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,572.32,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $572.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,784.00,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,316.03,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,348.56,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,316.03,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,334.99,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 100% = $316.03... $316.03 at 106% = $334.99 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,348.56,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,392.00,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,658.56,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $658.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,784.26,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,588.00,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,721.28,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $721.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,453.13,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,453.13,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,PREVEA HEALTH NETWORK,PREVEA360,453.13,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,453.13,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,500.43,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $500.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,352.05,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,564.48,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $564.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,TRIOLOGY,TRILOGY MEDICAID,334.99,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81301 at $316.03 (Fee Schedule) = $316.03 (Total Line Payment) at 106% = $334.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,418.27,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $418.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81301 * Qty 1 = $418.27 at 100% = $418.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,418.27,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $418.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81301 * Qty 1 = $418.27 at 100% = $418.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,348.56,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,418.27,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $418.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81301 * Qty 1 = $418.27 at 100% = $418.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,UNITY HEALTH PLAN,UNITY HOSPICE,348.56,,,,,,,316.0300,784.2600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,564.48,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $564.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,486.08,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $486.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,564.48,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $564.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,564.48,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $564.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HNCP MICROSATL INSTABLTY,81301,CPT,310,RC,31000025,CDM,,,,both,,,784.0000,517.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,470.40,,,,,,,316.0300,784.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $784.00 in Billed Charges for Rev 310 Proc 81301 = $470.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,AETNA,AETNA HSHS,843.68,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $843.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,AETNA,AETNA MEDICARE,207.31,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,AETNA,ALL COMMERCIAL AETNA,1306.00,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,ANTHEM,ANTEHM MEDICAID,214.21,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,207.31,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,ANTHEM,ANTHEM POS/HMO,725.59,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $725.59 from Fee Schedule WII28_25 for Rev 310 Proc 81315 Mod TC * Qty 1 = $725.59 at 100% = $725.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,ANTHEM,ANTHEM PPO,725.59,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $725.59 from Fee Schedule WII28_25 for Rev 310 Proc 81315 Mod TC * Qty 1 = $725.59 at 100% = $725.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1306.00,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,CENPATICO,ALL MEDICAID CENPATICO,1306.00,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1110.10,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,110.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,CIGNA,ALL COMMERCIAL CIGNA,914.20,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $914.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,COFINITY,COFINITY,1306.00,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,214.21,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,214.21,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1240.70,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,240.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,1097.04,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,097.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,927.26,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $927.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,953.38,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $953.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,634.72,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $634.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1110.10,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,110.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HUMANA,HUMANA CHOICE CARE HMO,352.43,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $352.43 from Fee Schedule 005543_170 for Rev 310 Proc 81315 * Qty 1 = $352.43 at 100% = $352.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HUMANA,HUMANA CHOICE CARE PPO,1110.10,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,110.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,207.31,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,HUMANA,HUMANA NATIIONAL POS HMO,352.43,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $352.43 from Fee Schedule 005543_170 for Rev 310 Proc 81315 * Qty 1 = $352.43 at 100% = $352.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,953.38,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $953.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1306.00,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,214.21,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,207.31,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,214.21,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,227.06,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21... $214.21 at 106% = $227.06 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,207.31,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,653.00,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $653.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1097.04,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,097.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,466.45,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,979.50,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $979.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1201.52,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $1,201.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,269.50,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,269.50,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,PREVEA HEALTH NETWORK,PREVEA360,269.50,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,269.50,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,833.62,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $833.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,209.38,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,940.32,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $940.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,TRIOLOGY,TRILOGY MEDICAID,227.06,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 106% = $227.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,248.77,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81315 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,248.77,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81315 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,207.31,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,248.77,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81315 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,UNITY HEALTH PLAN,UNITY HOSPICE,207.31,,,,,,,207.3100,1306.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,940.32,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $940.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,809.72,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $809.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,940.32,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $940.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,940.32,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $940.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PML/RARAL COM BRKPNTS,81315,CPT,310,RC,31000026,CDM,,,,both,,,1306.0000,861.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,783.60,,,,,,,207.3100,1306.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,306.00 in Billed Charges for Rev 310 Proc 81315 = $783.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,AETNA,AETNA HSHS,616.28,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $616.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,AETNA,AETNA MEDICARE,109.13,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,AETNA,ALL COMMERCIAL AETNA,954.00,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,ANTHEM,ANTEHM MEDICAID,112.76,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81383 at $112.76 (Fee Schedule) = $112.76 (Total Line Payment) at 100% = $112.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,109.13,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,ANTHEM,ANTHEM POS/HMO,381.96,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $381.96 from Fee Schedule WII28_25 for Rev 310 Proc 81383 Mod TC * Qty 1 = $381.96 at 100% = $381.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,ANTHEM,ANTHEM PPO,381.96,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $381.96 from Fee Schedule WII28_25 for Rev 310 Proc 81383 Mod TC * Qty 1 = $381.96 at 100% = $381.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,954.00,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,CENPATICO,ALL MEDICAID CENPATICO,954.00,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,810.90,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,CIGNA,ALL COMMERCIAL CIGNA,667.80,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $667.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,COFINITY,COFINITY,954.00,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,112.76,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81383 at $112.76 (Fee Schedule) = $112.76 (Total Line Payment) at 100% = $112.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,112.76,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81383 at $112.76 (Fee Schedule) = $112.76 (Total Line Payment) at 100% = $112.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,906.30,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $906.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,801.36,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $801.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,677.34,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $677.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,696.42,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $696.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,463.64,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $463.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,810.90,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HUMANA,HUMANA CHOICE CARE HMO,185.52,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $185.52 from Fee Schedule 005543_170 for Rev 310 Proc 81383 * Qty 1 = $185.52 at 100% = $185.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HUMANA,HUMANA CHOICE CARE PPO,810.90,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,109.13,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,HUMANA,HUMANA NATIIONAL POS HMO,185.52,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $185.52 from Fee Schedule 005543_170 for Rev 310 Proc 81383 * Qty 1 = $185.52 at 100% = $185.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,696.42,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $696.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,954.00,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,112.76,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81383 at $112.76 (Fee Schedule) = $112.76 (Total Line Payment) at 100% = $112.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,109.13,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,112.76,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81383 at $112.76 (Fee Schedule) = $112.76 (Total Line Payment) at 100% = $112.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,119.53,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81383 at $112.76 (Fee Schedule) = $112.76 (Total Line Payment) at 100% = $112.76... $112.76 at 106% = $119.53 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,109.13,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,477.00,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $477.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,801.36,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $801.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,245.54,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,715.50,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $715.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,877.68,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $877.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,141.87,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,141.87,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,PREVEA HEALTH NETWORK,PREVEA360,141.87,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,141.87,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,608.94,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $608.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,110.22,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,686.88,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $686.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,TRIOLOGY,TRILOGY MEDICAID,119.53,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81383 at $112.76 (Fee Schedule) = $112.76 (Total Line Payment) at 106% = $119.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,130.96,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $130.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81383 * Qty 1 = $130.96 at 100% = $130.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,130.96,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $130.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81383 * Qty 1 = $130.96 at 100% = $130.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,109.13,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,130.96,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $130.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81383 * Qty 1 = $130.96 at 100% = $130.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,UNITY HEALTH PLAN,UNITY HOSPICE,109.13,,,,,,,109.1300,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,686.88,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $686.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,591.48,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $591.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,686.88,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $686.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,686.88,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $686.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA II TYPING ALLELE HR,81383,CPT,310,RC,31000029,CDM,,,,both,,,954.0000,629.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,572.40,,,,,,,109.1300,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $954.00 in Billed Charges for Rev 310 Proc 81383 = $572.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA HSHS,484.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $484.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA MEDICARE,91.66,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,AETNA,ALL COMMERCIAL AETNA,750.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTEHM MEDICAID,94.71,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,91.66,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM POS/HMO,320.81,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $320.81 from Fee Schedule WII28_25 for Rev 310 Proc 81270 Mod TC * Qty 1 = $320.81 at 100% = $320.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM PPO,320.81,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $320.81 from Fee Schedule WII28_25 for Rev 310 Proc 81270 Mod TC * Qty 1 = $320.81 at 100% = $320.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,750.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,CENPATICO,ALL MEDICAID CENPATICO,750.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,637.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,CIGNA,ALL COMMERCIAL CIGNA,525.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $525.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,COFINITY,COFINITY,750.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,94.71,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,94.71,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,712.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $712.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,630.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,532.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $532.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,547.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,364.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $364.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,637.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE HMO,155.82,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $155.82 from Fee Schedule 005543_170 for Rev 310 Proc 81270 * Qty 1 = $155.82 at 100% = $155.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE PPO,637.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,91.66,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA NATIIONAL POS HMO,155.82,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $155.82 from Fee Schedule 005543_170 for Rev 310 Proc 81270 * Qty 1 = $155.82 at 100% = $155.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,547.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,750.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,94.71,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,91.66,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,94.71,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,100.39,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71... $94.71 at 106% = $100.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,91.66,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,375.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,630.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,206.24,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,562.50,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $562.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,690.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,119.16,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,119.16,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360,119.16,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,119.16,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.73,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $478.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,92.58,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,540.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,TRILOGY MEDICAID,100.39,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 106% = $100.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,109.99,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,109.99,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,91.66,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,109.99,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,UNITY HEALTH PLAN,UNITY HOSPICE,91.66,,,,,,,91.6600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,540.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,465.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,540.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,540.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE,81270,CPT,310,RC,31000033,CDM,,,,both,,,750.0000,495.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,450.00,,,,,,,91.6600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $750.00 in Billed Charges for Rev 310 Proc 81270 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,AETNA,AETNA HSHS,360.47,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $360.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,AETNA,AETNA MEDICARE,73.37,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,AETNA,ALL COMMERCIAL AETNA,558.00,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,ANTHEM,ANTEHM MEDICAID,66.70,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,73.37,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,ANTHEM,ANTHEM POS/HMO,256.80,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $256.80 from Fee Schedule WII28_25 for Rev 310 Proc 81241 Mod TC * Qty 1 = $256.80 at 100% = $256.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,ANTHEM,ANTHEM PPO,256.80,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $256.80 from Fee Schedule WII28_25 for Rev 310 Proc 81241 Mod TC * Qty 1 = $256.80 at 100% = $256.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,558.00,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,CENPATICO,ALL MEDICAID CENPATICO,558.00,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,474.30,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $474.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,CIGNA,ALL COMMERCIAL CIGNA,390.60,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $390.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,COFINITY,COFINITY,558.00,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,66.70,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,66.70,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,530.10,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $530.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,468.72,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $468.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,396.18,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $396.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,407.34,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $407.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,271.19,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $271.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,474.30,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $474.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HUMANA,HUMANA CHOICE CARE HMO,124.73,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $124.73 from Fee Schedule 005543_170 for Rev 310 Proc 81241 * Qty 1 = $124.73 at 100% = $124.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HUMANA,HUMANA CHOICE CARE PPO,474.30,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $474.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,73.37,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,HUMANA,HUMANA NATIIONAL POS HMO,124.73,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $124.73 from Fee Schedule 005543_170 for Rev 310 Proc 81241 * Qty 1 = $124.73 at 100% = $124.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,407.34,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $407.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,558.00,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,66.70,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,73.37,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,66.70,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,70.70,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70... $66.70 at 106% = $70.70 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,73.37,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,279.00,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $279.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,468.72,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $468.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,165.08,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,418.50,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $418.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,513.36,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $513.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,95.38,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,95.38,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,PREVEA HEALTH NETWORK,PREVEA360,95.38,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,95.38,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,356.17,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $356.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,74.10,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,401.76,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $401.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,TRIOLOGY,TRILOGY MEDICAID,70.70,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 106% = $70.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,88.04,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,88.04,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,73.37,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,88.04,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,UNITY HEALTH PLAN,UNITY HOSPICE,73.37,,,,,,,66.7000,558.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,401.76,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $401.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,345.96,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $345.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,401.76,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $401.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,401.76,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $401.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FACTOR V GENE ANALYSIS (HR2),81241,CPT,310,RC,31000050,CDM,,,,both,,,558.0000,368.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,334.80,,,,,,,66.7000,558.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $558.00 in Billed Charges for Rev 310 Proc 81241 = $334.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,AETNA,AETNA HSHS,708.66,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $708.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,AETNA,AETNA MEDICARE,556.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,AETNA,ALL COMMERCIAL AETNA,1097.00,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $1,097.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,ANTHEM,ANTEHM MEDICAID,210.00,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,556.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,ANTHEM,ANTHEM POS/HMO,1097.00,,,,,,,210.0000,1252.3500,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,948.10 from Fee Schedule WII28_25 for Rev 310 Proc 81220 Mod TC * Qty 1 = $1,948.10 at 100% = $1,948.10 (Limited to $1,097.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,ANTHEM,ANTHEM PPO,1097.00,,,,,,,210.0000,1252.3500,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,948.10 from Fee Schedule WII28_25 for Rev 310 Proc 81220 Mod TC * Qty 1 = $1,948.10 at 100% = $1,948.10 (Limited to $1,097.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1097.00,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $1,097.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,CENPATICO,ALL MEDICAID CENPATICO,1097.00,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $1,097.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,932.45,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $932.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,CIGNA,ALL COMMERCIAL CIGNA,767.90,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $767.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,COFINITY,COFINITY,1097.00,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $1,097.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,210.00,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,210.00,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1042.15,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $1,042.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,921.48,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $921.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,778.87,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $778.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,800.81,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $800.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,533.14,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $533.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,932.45,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $932.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HUMANA,HUMANA CHOICE CARE HMO,946.22,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $946.22 from Fee Schedule 005543_170 for Rev 310 Proc 81220 * Qty 1 = $946.22 at 100% = $946.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HUMANA,HUMANA CHOICE CARE PPO,932.45,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $932.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,556.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,HUMANA,HUMANA NATIIONAL POS HMO,946.22,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $946.22 from Fee Schedule 005543_170 for Rev 310 Proc 81220 * Qty 1 = $946.22 at 100% = $946.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,800.81,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $800.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1097.00,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $1,097.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,210.00,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,556.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,210.00,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,222.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00... $210.00 at 106% = $222.60 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,556.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,548.50,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $548.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,921.48,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $921.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,1252.35,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,822.75,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $822.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1009.24,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $1,009.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,723.58,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,723.58,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,PREVEA HEALTH NETWORK,PREVEA360,723.58,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,723.58,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,700.22,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $700.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,562.17,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,789.84,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $789.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,TRIOLOGY,TRILOGY MEDICAID,222.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 106% = $222.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,667.92,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $667.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81220 * Qty 1 = $667.92 at 100% = $667.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,667.92,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $667.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81220 * Qty 1 = $667.92 at 100% = $667.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,556.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,667.92,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $667.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81220 * Qty 1 = $667.92 at 100% = $667.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,UNITY HEALTH PLAN,UNITY HOSPICE,556.60,,,,,,,210.0000,1252.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,789.84,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $789.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,680.14,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $680.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,789.84,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $789.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,789.84,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $789.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE ANALYSIS,81220,CPT,310,RC,31000051,CDM,,,,both,,,1097.0000,724.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,658.20,,,,,,,210.0000,1252.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,097.00 in Billed Charges for Rev 310 Proc 81220 = $658.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,AETNA,AETNA HSHS,426.36,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $426.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,AETNA,AETNA MEDICARE,197.99,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,AETNA,ALL COMMERCIAL AETNA,660.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,ANTHEM,ANTEHM MEDICAID,204.58,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,197.99,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,ANTHEM,ANTHEM POS/HMO,660.00,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $692.97 from Fee Schedule WII28_25 for Rev 310 Proc 81261 Mod TC * Qty 1 = $692.97 at 100% = $692.97 (Limited to $660.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,ANTHEM,ANTHEM PPO,660.00,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $692.97 from Fee Schedule WII28_25 for Rev 310 Proc 81261 Mod TC * Qty 1 = $692.97 at 100% = $692.97 (Limited to $660.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,660.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,CENPATICO,ALL MEDICAID CENPATICO,660.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,561.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,CIGNA,ALL COMMERCIAL CIGNA,462.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $462.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,COFINITY,COFINITY,660.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,204.58,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,204.58,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,627.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,554.40,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $554.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,468.60,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $468.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,481.80,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $481.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,320.76,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $320.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,561.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HUMANA,HUMANA CHOICE CARE HMO,336.58,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $336.58 from Fee Schedule 005543_170 for Rev 310 Proc 81261 * Qty 1 = $336.58 at 100% = $336.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HUMANA,HUMANA CHOICE CARE PPO,561.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,197.99,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,HUMANA,HUMANA NATIIONAL POS HMO,336.58,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $336.58 from Fee Schedule 005543_170 for Rev 310 Proc 81261 * Qty 1 = $336.58 at 100% = $336.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,481.80,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $481.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,660.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,204.58,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,197.99,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,204.58,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,216.85,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58... $204.58 at 106% = $216.85 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,197.99,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,330.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,554.40,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $554.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,445.48,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,495.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $495.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,607.20,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $607.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,257.39,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,257.39,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,PREVEA HEALTH NETWORK,PREVEA360,257.39,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,257.39,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,421.28,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $421.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,199.97,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,475.20,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $475.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,TRIOLOGY,TRILOGY MEDICAID,216.85,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 106% = $216.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,237.59,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,237.59,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,197.99,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,237.59,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,UNITY HEALTH PLAN,UNITY HOSPICE,197.99,,,,,,,197.9900,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,475.20,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $475.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,409.20,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $409.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,475.20,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $475.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,475.20,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $475.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPLIFIED METH IG GRA,81261,CPT,310,RC,31000054,CDM,,,,both,,,660.0000,435.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,396.00,,,,,,,197.9900,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $660.00 in Billed Charges for Rev 310 Proc 81261 = $396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,AETNA,AETNA HSHS,426.36,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $426.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,AETNA,AETNA MEDICARE,172.73,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,AETNA,ALL COMMERCIAL AETNA,660.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,ANTHEM,ANTEHM MEDICAID,162.98,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,172.73,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,ANTHEM,ANTHEM POS/HMO,604.56,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $604.56 from Fee Schedule WII28_25 for Rev 310 Proc 81264 Mod TC * Qty 1 = $604.56 at 100% = $604.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,ANTHEM,ANTHEM PPO,604.56,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $604.56 from Fee Schedule WII28_25 for Rev 310 Proc 81264 Mod TC * Qty 1 = $604.56 at 100% = $604.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,660.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,CENPATICO,ALL MEDICAID CENPATICO,660.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,561.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,CIGNA,ALL COMMERCIAL CIGNA,462.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $462.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,COFINITY,COFINITY,660.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,162.98,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,162.98,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,627.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $627.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,554.40,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $554.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,468.60,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $468.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,481.80,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $481.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,320.76,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $320.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,561.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HUMANA,HUMANA CHOICE CARE HMO,293.64,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $293.64 from Fee Schedule 005543_170 for Rev 310 Proc 81264 * Qty 1 = $293.64 at 100% = $293.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HUMANA,HUMANA CHOICE CARE PPO,561.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,172.73,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,HUMANA,HUMANA NATIIONAL POS HMO,293.64,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $293.64 from Fee Schedule 005543_170 for Rev 310 Proc 81264 * Qty 1 = $293.64 at 100% = $293.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,481.80,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $481.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,660.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,162.98,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,172.73,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,162.98,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,172.76,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98... $162.98 at 106% = $172.76 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,172.73,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,330.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,554.40,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $554.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,388.64,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,495.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $495.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,607.20,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $607.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,224.55,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,224.55,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,PREVEA HEALTH NETWORK,PREVEA360,224.55,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,224.55,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,421.28,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $421.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,174.46,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,475.20,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $475.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,TRIOLOGY,TRILOGY MEDICAID,172.76,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 106% = $172.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,207.28,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81264 * Qty 1 = $207.28 at 100% = $207.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,207.28,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81264 * Qty 1 = $207.28 at 100% = $207.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,172.73,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,207.28,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81264 * Qty 1 = $207.28 at 100% = $207.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,UNITY HEALTH PLAN,UNITY HOSPICE,172.73,,,,,,,162.9800,660.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,475.20,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $475.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,409.20,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $409.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,475.20,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $475.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,475.20,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $475.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EVAL CLONAL POP IG GRA,81264,CPT,310,RC,31000055,CDM,,,,both,,,660.0000,435.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,396.00,,,,,,,162.9800,660.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $660.00 in Billed Charges for Rev 310 Proc 81264 = $396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,AETNA,AETNA HSHS,322.35,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $322.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,AETNA,AETNA MEDICARE,73.37,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,AETNA,ALL COMMERCIAL AETNA,499.00,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $499.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,ANTHEM,ANTEHM MEDICAID,66.70,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,73.37,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,ANTHEM,ANTHEM POS/HMO,256.80,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $256.80 from Fee Schedule WII28_25 for Rev 310 Proc 81241 Mod TC * Qty 1 = $256.80 at 100% = $256.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,ANTHEM,ANTHEM PPO,256.80,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $256.80 from Fee Schedule WII28_25 for Rev 310 Proc 81241 Mod TC * Qty 1 = $256.80 at 100% = $256.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,499.00,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $499.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,CENPATICO,ALL MEDICAID CENPATICO,499.00,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $499.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,424.15,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $424.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,CIGNA,ALL COMMERCIAL CIGNA,349.30,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $349.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,COFINITY,COFINITY,499.00,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $499.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,66.70,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,66.70,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,474.05,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $474.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,419.16,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $419.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,354.29,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $354.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,364.27,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $364.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,242.51,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $242.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,424.15,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $424.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HUMANA,HUMANA CHOICE CARE HMO,124.73,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $124.73 from Fee Schedule 005543_170 for Rev 310 Proc 81241 * Qty 1 = $124.73 at 100% = $124.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HUMANA,HUMANA CHOICE CARE PPO,424.15,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $424.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HUMANA,HUMANA MEDICARE ADVANTAGE,73.37,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,HUMANA,HUMANA NATIIONAL POS HMO,124.73,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $124.73 from Fee Schedule 005543_170 for Rev 310 Proc 81241 * Qty 1 = $124.73 at 100% = $124.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,364.27,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $364.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,499.00,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $499.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,66.70,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,73.37,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,66.70,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,MOLINA HEALTHCARE,MOLINA MEDICAID,70.70,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70... $66.70 at 106% = $70.70 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,MOLINA HEALTHCARE,MOLINA MEDICARE,73.37,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,249.50,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $249.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,419.16,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $419.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,NAPHCARE,ALL COMMERICAL NAPHCARE,165.08,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,374.25,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $374.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,459.08,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $459.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,95.38,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,95.38,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,PREVEA HEALTH NETWORK,PREVEA360,95.38,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,95.38,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,318.51,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $318.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,74.10,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,359.28,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $359.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,TRIOLOGY,TRILOGY MEDICAID,70.70,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 106% = $70.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,88.04,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,88.04,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,73.37,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,88.04,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,UNITY HEALTH PLAN,UNITY HOSPICE,73.37,,,,,,,66.7000,499.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,359.28,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $359.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,309.38,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $309.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,359.28,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $359.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,359.28,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $359.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000060,CDM,,,,both,,,499.0000,329.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,299.40,,,,,,,66.7000,499.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $499.00 in Billed Charges for Rev 310 Proc 81241 = $299.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,AETNA,AETNA HSHS,290.70,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $290.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,AETNA,AETNA MEDICARE,144.84,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,AETNA,ALL COMMERCIAL AETNA,450.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,ANTHEM,ANTEHM MEDICAID,149.66,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,144.84,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,ANTHEM,ANTHEM POS/HMO,450.00,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $506.94 from Fee Schedule WII28_25 for Rev 310 Proc 81207 Mod TC * Qty 1 = $506.94 at 100% = $506.94 (Limited to $450.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,ANTHEM,ANTHEM PPO,450.00,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $506.94 from Fee Schedule WII28_25 for Rev 310 Proc 81207 Mod TC * Qty 1 = $506.94 at 100% = $506.94 (Limited to $450.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,450.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,CENPATICO,ALL MEDICAID CENPATICO,450.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,382.50,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $382.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,CIGNA,ALL COMMERCIAL CIGNA,315.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,COFINITY,COFINITY,450.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,149.66,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,149.66,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,427.50,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $427.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,378.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $378.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,319.50,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $319.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,328.50,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $328.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,218.70,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $218.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,382.50,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $382.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HUMANA,HUMANA CHOICE CARE HMO,246.23,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $246.23 from Fee Schedule 005543_170 for Rev 310 Proc 81207 * Qty 1 = $246.23 at 100% = $246.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HUMANA,HUMANA CHOICE CARE PPO,382.50,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $382.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,144.84,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,HUMANA,HUMANA NATIIONAL POS HMO,246.23,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $246.23 from Fee Schedule 005543_170 for Rev 310 Proc 81207 * Qty 1 = $246.23 at 100% = $246.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,328.50,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $328.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,450.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,149.66,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,144.84,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,149.66,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,158.64,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66... $149.66 at 106% = $158.64 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,144.84,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,225.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,378.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $378.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,325.89,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,337.50,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $337.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,414.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,188.29,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,188.29,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,PREVEA HEALTH NETWORK,PREVEA360,188.29,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,188.29,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,287.24,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $287.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,146.29,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,324.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,TRIOLOGY,TRILOGY MEDICAID,158.64,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 106% = $158.64. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,173.81,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.81 from Fee Schedule UHC_98227C for Rev 310 Proc 81207 * Qty 1 = $173.81 at 100% = $173.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,173.81,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.81 from Fee Schedule UHC_98227C for Rev 310 Proc 81207 * Qty 1 = $173.81 at 100% = $173.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,144.84,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,173.81,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.81 from Fee Schedule UHC_98227C for Rev 310 Proc 81207 * Qty 1 = $173.81 at 100% = $173.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,UNITY HEALTH PLAN,UNITY HOSPICE,144.84,,,,,,,144.8400,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,324.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,279.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $279.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,324.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,324.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MINOR BP QUEST,81207,CPT,310,RC,31000073,CDM,,,,both,,,450.0000,297.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,270.00,,,,,,,144.8400,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $450.00 in Billed Charges for Rev 310 Proc 81207 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,AETNA,AETNA HSHS,1164.09,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,164.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,AETNA,AETNA MEDICARE,324.58,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,AETNA,ALL COMMERCIAL AETNA,1802.00,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,ANTHEM,ANTEHM MEDICAID,264.01,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81235 at $264.01 (Fee Schedule) = $264.01 (Total Line Payment) at 100% = $264.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,324.58,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,ANTHEM,ANTHEM POS/HMO,1136.03,,,,,,,264.0100,1802.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,136.03 from Fee Schedule WII28_25 for Rev 310 Proc 81235 Mod TC * Qty 1 = $1,136.03 at 100% = $1,136.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,ANTHEM,ANTHEM PPO,1136.03,,,,,,,264.0100,1802.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,136.03 from Fee Schedule WII28_25 for Rev 310 Proc 81235 Mod TC * Qty 1 = $1,136.03 at 100% = $1,136.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1802.00,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,CENPATICO,ALL MEDICAID CENPATICO,1802.00,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1531.70,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,531.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,CIGNA,ALL COMMERCIAL CIGNA,1261.40,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,261.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,COFINITY,COFINITY,1802.00,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,264.01,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81235 at $264.01 (Fee Schedule) = $264.01 (Total Line Payment) at 100% = $264.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,264.01,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81235 at $264.01 (Fee Schedule) = $264.01 (Total Line Payment) at 100% = $264.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1711.90,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,711.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,1513.68,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,513.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1279.42,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,279.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1315.46,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,315.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,875.77,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $875.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1531.70,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,531.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,HUMANA CHOICE CARE HMO,551.79,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $551.79 from Fee Schedule 005543_170 for Rev 310 Proc 81235 * Qty 1 = $551.79 at 100% = $551.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,HUMANA CHOICE CARE PPO,1531.70,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,531.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,324.58,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,HUMANA NATIIONAL POS HMO,551.79,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $551.79 from Fee Schedule 005543_170 for Rev 310 Proc 81235 * Qty 1 = $551.79 at 100% = $551.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1315.46,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,315.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1802.00,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,264.01,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81235 at $264.01 (Fee Schedule) = $264.01 (Total Line Payment) at 100% = $264.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,324.58,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,264.01,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81235 at $264.01 (Fee Schedule) = $264.01 (Total Line Payment) at 100% = $264.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,279.85,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81235 at $264.01 (Fee Schedule) = $264.01 (Total Line Payment) at 100% = $264.01... $264.01 at 106% = $279.85 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,324.58,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,901.00,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1513.68,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,513.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,730.31,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1351.50,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,351.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1657.84,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,657.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,421.95,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,421.95,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,PREVEA HEALTH NETWORK,PREVEA360,421.95,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,421.95,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1150.22,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,150.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,327.83,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1297.44,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,297.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,TRIOLOGY,TRILOGY MEDICAID,279.85,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81235 at $264.01 (Fee Schedule) = $264.01 (Total Line Payment) at 106% = $279.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,389.50,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $389.50 from Fee Schedule UHC_98227C for Rev 310 Proc 81235 * Qty 1 = $389.50 at 100% = $389.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,389.50,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $389.50 from Fee Schedule UHC_98227C for Rev 310 Proc 81235 * Qty 1 = $389.50 at 100% = $389.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,324.58,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,389.50,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $389.50 from Fee Schedule UHC_98227C for Rev 310 Proc 81235 * Qty 1 = $389.50 at 100% = $389.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,UNITY HEALTH PLAN,UNITY HOSPICE,324.58,,,,,,,264.0100,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1297.44,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,297.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1117.24,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,117.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1297.44,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,297.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1297.44,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,297.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
EGFR GENE COM VARIANTS,81235,CPT,310,RC,31000107,CDM,,,,both,,,1802.0000,1189.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1081.20,,,,,,,264.0100,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,802.00 in Billed Charges for Rev 310 Proc 81235 = $1,081.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,AETNA,AETNA HSHS,406.33,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $406.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,AETNA,AETNA MEDICARE,300.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,AETNA,ALL COMMERCIAL AETNA,629.00,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTEHM MEDICAID,195.07,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81170 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,300.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM POS/HMO,629.00,,,,,,,195.0700,675.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,050.00 from Fee Schedule WII28_25 for Rev 310 Proc 81170 Mod TC * Qty 1 = $1,050.00 at 100% = $1,050.00 (Limited to $629.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM PPO,629.00,,,,,,,195.0700,675.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,050.00 from Fee Schedule WII28_25 for Rev 310 Proc 81170 Mod TC * Qty 1 = $1,050.00 at 100% = $1,050.00 (Limited to $629.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,629.00,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,CENPATICO,ALL MEDICAID CENPATICO,629.00,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,534.65,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,CIGNA,ALL COMMERCIAL CIGNA,440.30,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $440.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,COFINITY,COFINITY,629.00,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,195.07,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81170 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,195.07,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81170 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,597.55,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $597.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,528.36,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $528.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,446.59,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $446.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,459.17,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $459.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,305.69,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $305.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,534.65,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA CHOICE CARE HMO,510.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $510.00 from Fee Schedule 005543_170 for Rev 310 Proc 81170 * Qty 1 = $510.00 at 100% = $510.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA CHOICE CARE PPO,534.65,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,300.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA NATIIONAL POS HMO,510.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $510.00 from Fee Schedule 005543_170 for Rev 310 Proc 81170 * Qty 1 = $510.00 at 100% = $510.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,459.17,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $459.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,629.00,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,195.07,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81170 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,300.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,195.07,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81170 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,206.77,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81170 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07... $195.07 at 106% = $206.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,300.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,314.50,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $314.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,528.36,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $528.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,675.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,471.75,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $471.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,578.68,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $578.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,390.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,390.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA360,390.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,390.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,401.49,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $401.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,303.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,452.88,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,TRIOLOGY,TRILOGY MEDICAID,206.77,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81170 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 106% = $206.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,360.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $360.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81170 * Qty 1 = $360.00 at 100% = $360.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,360.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $360.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81170 * Qty 1 = $360.00 at 100% = $360.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,300.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,360.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $360.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81170 * Qty 1 = $360.00 at 100% = $360.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,UNITY HEALTH PLAN,UNITY HOSPICE,300.00,,,,,,,195.0700,675.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,452.88,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,389.98,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $389.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,452.88,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,452.88,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABL1 GENE ANALYSIS KINASE DOMAIN,81170,CPT,310,RC,31000109,CDM,,,,both,,,629.0000,415.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,377.40,,,,,,,195.0700,675.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $629.00 in Billed Charges for Rev 310 Proc 81170 = $377.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,AETNA,AETNA HSHS,406.33,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $406.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,AETNA,AETNA MEDICARE,241.90,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,AETNA,ALL COMMERCIAL AETNA,629.00,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTEHM MEDICAID,195.07,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81218 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,241.90,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM POS/HMO,629.00,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $846.65 from Fee Schedule WII28_25 for Rev 310 Proc 81218 Mod TC * Qty 1 = $846.65 at 100% = $846.65 (Limited to $629.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM PPO,629.00,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $846.65 from Fee Schedule WII28_25 for Rev 310 Proc 81218 Mod TC * Qty 1 = $846.65 at 100% = $846.65 (Limited to $629.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,629.00,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,CENPATICO,ALL MEDICAID CENPATICO,629.00,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,534.65,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,CIGNA,ALL COMMERCIAL CIGNA,440.30,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $440.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,COFINITY,COFINITY,629.00,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,195.07,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81218 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,195.07,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81218 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,597.55,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $597.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,528.36,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $528.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,446.59,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $446.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,459.17,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $459.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,305.69,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $305.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,534.65,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA CHOICE CARE HMO,411.23,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $411.23 from Fee Schedule 005543_170 for Rev 310 Proc 81218 * Qty 1 = $411.23 at 100% = $411.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA CHOICE CARE PPO,534.65,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,241.90,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA NATIIONAL POS HMO,411.23,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $411.23 from Fee Schedule 005543_170 for Rev 310 Proc 81218 * Qty 1 = $411.23 at 100% = $411.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,459.17,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $459.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,629.00,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,195.07,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81218 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,241.90,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,195.07,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81218 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,206.77,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81218 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07... $195.07 at 106% = $206.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,241.90,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,314.50,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $314.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,528.36,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $528.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,544.28,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,471.75,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $471.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,578.68,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $578.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,314.47,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,314.47,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA360,314.47,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,314.47,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,401.49,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $401.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,244.32,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,452.88,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,TRIOLOGY,TRILOGY MEDICAID,206.77,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81218 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 106% = $206.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,290.28,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $290.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81218 * Qty 1 = $290.28 at 100% = $290.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,290.28,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $290.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81218 * Qty 1 = $290.28 at 100% = $290.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,241.90,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,290.28,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $290.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81218 * Qty 1 = $290.28 at 100% = $290.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,UNITY HEALTH PLAN,UNITY HOSPICE,241.90,,,,,,,195.0700,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,452.88,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,389.98,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $389.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,452.88,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,452.88,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CEBPA GENE ANALYSIS FULL SEQUENCE,81218,CPT,310,RC,31000110,CDM,,,,both,,,629.0000,415.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,377.40,,,,,,,195.0700,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $629.00 in Billed Charges for Rev 310 Proc 81218 = $377.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,AETNA,AETNA HSHS,406.33,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $406.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,AETNA,AETNA MEDICARE,121.63,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,AETNA,ALL COMMERCIAL AETNA,629.00,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTEHM MEDICAID,98.08,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,121.63,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM POS/HMO,425.71,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $425.71 from Fee Schedule WII28_25 for Rev 310 Proc 81219 Mod TC * Qty 1 = $425.71 at 100% = $425.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,ANTHEM,ANTHEM PPO,425.71,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $425.71 from Fee Schedule WII28_25 for Rev 310 Proc 81219 Mod TC * Qty 1 = $425.71 at 100% = $425.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,629.00,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,CENPATICO,ALL MEDICAID CENPATICO,629.00,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,534.65,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,CIGNA,ALL COMMERCIAL CIGNA,440.30,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $440.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,COFINITY,COFINITY,629.00,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,98.08,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,98.08,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,597.55,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $597.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,528.36,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $528.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,446.59,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $446.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,459.17,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $459.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,305.69,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $305.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,534.65,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA CHOICE CARE HMO,206.77,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $206.77 from Fee Schedule 005543_170 for Rev 310 Proc 81219 * Qty 1 = $206.77 at 100% = $206.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA CHOICE CARE PPO,534.65,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $534.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,121.63,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,HUMANA,HUMANA NATIIONAL POS HMO,206.77,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $206.77 from Fee Schedule 005543_170 for Rev 310 Proc 81219 * Qty 1 = $206.77 at 100% = $206.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,459.17,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $459.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,629.00,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $629.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,98.08,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,121.63,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,98.08,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,103.96,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08... $98.08 at 106% = $103.96 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,121.63,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,314.50,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $314.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,528.36,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $528.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,273.67,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,471.75,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $471.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,578.68,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $578.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.12,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.12,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA360,158.12,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.12,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,401.49,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $401.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,122.85,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,452.88,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,TRIOLOGY,TRILOGY MEDICAID,103.96,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 106% = $103.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,145.96,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $145.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81219 * Qty 1 = $145.96 at 100% = $145.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,145.96,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $145.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81219 * Qty 1 = $145.96 at 100% = $145.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,121.63,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,145.96,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $145.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81219 * Qty 1 = $145.96 at 100% = $145.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,UNITY HEALTH PLAN,UNITY HOSPICE,121.63,,,,,,,98.0800,629.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,452.88,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,389.98,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $389.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,452.88,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,452.88,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $452.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CALR GENE ANALYSIS EXON 9,81219,CPT,310,RC,31000111,CDM,,,,both,,,629.0000,415.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,377.40,,,,,,,98.0800,629.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $629.00 in Billed Charges for Rev 310 Proc 81219 = $377.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,AETNA,AETNA HSHS,542.64,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $542.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,AETNA,AETNA MEDICARE,102.26,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,AETNA,ALL COMMERCIAL AETNA,840.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,ANTHEM,ANTEHM MEDICAID,105.67,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81257 at $105.67 (Fee Schedule) = $105.67 (Total Line Payment) at 100% = $105.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,102.26,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,ANTHEM,ANTHEM POS/HMO,357.91,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $357.91 from Fee Schedule WII28_25 for Rev 310 Proc 81257 Mod TC * Qty 1 = $357.91 at 100% = $357.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,ANTHEM,ANTHEM PPO,357.91,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $357.91 from Fee Schedule WII28_25 for Rev 310 Proc 81257 Mod TC * Qty 1 = $357.91 at 100% = $357.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,840.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,CENPATICO,ALL MEDICAID CENPATICO,840.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,714.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $714.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,CIGNA,ALL COMMERCIAL CIGNA,588.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,COFINITY,COFINITY,840.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,105.67,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81257 at $105.67 (Fee Schedule) = $105.67 (Total Line Payment) at 100% = $105.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,105.67,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81257 at $105.67 (Fee Schedule) = $105.67 (Total Line Payment) at 100% = $105.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,798.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,705.60,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $705.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,596.40,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $596.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,613.20,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $613.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,408.24,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $408.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,714.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $714.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HUMANA,HUMANA CHOICE CARE HMO,173.84,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.84 from Fee Schedule 005543_170 for Rev 310 Proc 81257 * Qty 1 = $173.84 at 100% = $173.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HUMANA,HUMANA CHOICE CARE PPO,714.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $714.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,102.26,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,HUMANA,HUMANA NATIIONAL POS HMO,173.84,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.84 from Fee Schedule 005543_170 for Rev 310 Proc 81257 * Qty 1 = $173.84 at 100% = $173.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,613.20,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $613.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,840.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,105.67,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81257 at $105.67 (Fee Schedule) = $105.67 (Total Line Payment) at 100% = $105.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,102.26,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,105.67,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81257 at $105.67 (Fee Schedule) = $105.67 (Total Line Payment) at 100% = $105.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,112.01,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81257 at $105.67 (Fee Schedule) = $105.67 (Total Line Payment) at 100% = $105.67... $105.67 at 106% = $112.01 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,102.26,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,420.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,705.60,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $705.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,230.09,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,630.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,772.80,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $772.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,132.94,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,132.94,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,PREVEA HEALTH NETWORK,PREVEA360,132.94,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,132.94,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,536.17,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $536.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,103.28,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,604.80,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $604.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,TRIOLOGY,TRILOGY MEDICAID,112.01,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81257 at $105.67 (Fee Schedule) = $105.67 (Total Line Payment) at 106% = $112.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,122.71,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.71 from Fee Schedule UHC_98227C for Rev 310 Proc 81257 * Qty 1 = $122.71 at 100% = $122.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,122.71,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.71 from Fee Schedule UHC_98227C for Rev 310 Proc 81257 * Qty 1 = $122.71 at 100% = $122.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,102.26,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,122.71,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.71 from Fee Schedule UHC_98227C for Rev 310 Proc 81257 * Qty 1 = $122.71 at 100% = $122.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,UNITY HEALTH PLAN,UNITY HOSPICE,102.26,,,,,,,102.2600,840.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,604.80,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $604.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,520.80,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $520.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,604.80,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $604.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,604.80,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $604.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1/HBA2 GENE ANALYSIS COM DELETE OR VARIANTS,81257,CPT,310,RC,31000115,CDM,,,,both,,,840.0000,554.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,504.00,,,,,,,102.2600,840.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $840.00 in Billed Charges for Rev 310 Proc 81257 = $504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,AETNA,AETNA HSHS,494.84,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $494.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,AETNA,AETNA MEDICARE,207.31,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,AETNA,ALL COMMERCIAL AETNA,766.00,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $766.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,ANTHEM,ANTEHM MEDICAID,214.21,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,207.31,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,ANTHEM,ANTHEM POS/HMO,725.59,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $725.59 from Fee Schedule WII28_25 for Rev 310 Proc 81315 Mod TC * Qty 1 = $725.59 at 100% = $725.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,ANTHEM,ANTHEM PPO,725.59,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $725.59 from Fee Schedule WII28_25 for Rev 310 Proc 81315 Mod TC * Qty 1 = $725.59 at 100% = $725.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,766.00,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $766.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,CENPATICO,ALL MEDICAID CENPATICO,766.00,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $766.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,651.10,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $651.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,CIGNA,ALL COMMERCIAL CIGNA,536.20,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $536.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,COFINITY,COFINITY,766.00,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $766.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,214.21,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,214.21,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,727.70,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $727.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,643.44,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $643.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,543.86,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $543.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,559.18,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $559.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,372.28,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $372.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,651.10,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $651.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HUMANA,HUMANA CHOICE CARE HMO,352.43,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $352.43 from Fee Schedule 005543_170 for Rev 310 Proc 81315 * Qty 1 = $352.43 at 100% = $352.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HUMANA,HUMANA CHOICE CARE PPO,651.10,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $651.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HUMANA,HUMANA MEDICARE ADVANTAGE,207.31,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,HUMANA,HUMANA NATIIONAL POS HMO,352.43,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $352.43 from Fee Schedule 005543_170 for Rev 310 Proc 81315 * Qty 1 = $352.43 at 100% = $352.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,559.18,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $559.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,766.00,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $766.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,214.21,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,207.31,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,214.21,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,MOLINA HEALTHCARE,MOLINA MEDICAID,227.06,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 100% = $214.21... $214.21 at 106% = $227.06 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,MOLINA HEALTHCARE,MOLINA MEDICARE,207.31,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,383.00,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $383.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,643.44,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $643.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,NAPHCARE,ALL COMMERICAL NAPHCARE,466.45,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,574.50,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $574.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,704.72,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $704.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,269.50,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,269.50,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,PREVEA HEALTH NETWORK,PREVEA360,269.50,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,269.50,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,488.94,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $488.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,209.38,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,551.52,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $551.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,TRIOLOGY,TRILOGY MEDICAID,227.06,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81315 at $214.21 (Fee Schedule) = $214.21 (Total Line Payment) at 106% = $227.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,248.77,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81315 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,248.77,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81315 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,207.31,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,248.77,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81315 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,UNITY HEALTH PLAN,UNITY HOSPICE,207.31,,,,,,,207.3100,766.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,551.52,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $551.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,474.92,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $474.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,551.52,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $551.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,551.52,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $551.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PML/RARALPHA ANALYSIS COMMON BRKPNTS QL/QN,81315,CPT,310,RC,31000119,CDM,,,,both,,,766.0000,505.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,459.60,,,,,,,207.3100,766.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $766.00 in Billed Charges for Rev 310 Proc 81315 = $459.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA HSHS,484.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $484.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA MEDICARE,137.00,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,AETNA,ALL COMMERCIAL AETNA,750.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTEHM MEDICAID,109.60,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,137.00,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM POS/HMO,479.50,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81401 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM PPO,479.50,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81401 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,750.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,CENPATICO,ALL MEDICAID CENPATICO,750.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,637.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,CIGNA,ALL COMMERCIAL CIGNA,525.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $525.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,COFINITY,COFINITY,750.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,109.60,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,109.60,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,712.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $712.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,630.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,532.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $532.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,547.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,364.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $364.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,637.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE HMO,232.90,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81401 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE PPO,637.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,137.00,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA NATIIONAL POS HMO,232.90,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81401 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,547.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,750.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,109.60,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,137.00,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,109.60,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,116.18,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60... $109.60 at 106% = $116.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,137.00,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,375.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,630.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,308.25,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,562.50,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $562.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,690.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,178.10,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,178.10,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360,178.10,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,178.10,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.73,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $478.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,138.37,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,540.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,TRILOGY MEDICAID,116.18,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 106% = $116.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,164.40,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81401 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,164.40,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81401 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,137.00,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,164.40,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81401 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,UNITY HEALTH PLAN,UNITY HOSPICE,137.00,,,,,,,109.6000,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,540.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,465.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,540.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,540.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 2,81401,CPT,310,RC,31000121,CDM,,,,both,,,750.0000,495.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,450.00,,,,,,,109.6000,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $750.00 in Billed Charges for Rev 310 Proc 81401 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,AETNA,AETNA HSHS,310.08,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $310.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,AETNA,AETNA MEDICARE,47.63,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,AETNA,ALL COMMERCIAL AETNA,480.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTEHM MEDICAID,49.22,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80074 at $49.22 (Fee Schedule) = $49.22 (Total Line Payment) at 100% = $49.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,47.63,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM POS/HMO,166.71,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $166.71 from Fee Schedule WII28_25 for Rev 301 Proc 80074 Mod TC * Qty 1 = $166.71 at 100% = $166.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM PPO,166.71,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $166.71 from Fee Schedule WII28_25 for Rev 301 Proc 80074 Mod TC * Qty 1 = $166.71 at 100% = $166.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,480.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,CENPATICO,ALL MEDICAID CENPATICO,480.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,408.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,CIGNA,ALL COMMERCIAL CIGNA,336.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,COFINITY,COFINITY,480.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,49.22,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80074 at $49.22 (Fee Schedule) = $49.22 (Total Line Payment) at 100% = $49.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,49.22,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80074 at $49.22 (Fee Schedule) = $49.22 (Total Line Payment) at 100% = $49.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,456.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $456.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,403.20,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,340.80,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $340.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,350.40,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $350.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,233.28,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $233.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,408.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA CHOICE CARE HMO,80.97,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.97 from Fee Schedule 005543_170 for Rev 301 Proc 80074 * Qty 1 = $80.97 at 100% = $80.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA CHOICE CARE PPO,408.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,47.63,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA NATIIONAL POS HMO,80.97,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.97 from Fee Schedule 005543_170 for Rev 301 Proc 80074 * Qty 1 = $80.97 at 100% = $80.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,350.40,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $350.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,480.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,49.22,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80074 at $49.22 (Fee Schedule) = $49.22 (Total Line Payment) at 100% = $49.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,47.63,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,49.22,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80074 at $49.22 (Fee Schedule) = $49.22 (Total Line Payment) at 100% = $49.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,52.17,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80074 at $49.22 (Fee Schedule) = $49.22 (Total Line Payment) at 100% = $49.22... $49.22 at 106% = $52.17 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,47.63,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,240.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,403.20,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,107.17,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,360.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,441.60,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $441.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,61.92,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,61.92,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA360,61.92,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,61.92,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,306.38,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $306.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,48.11,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,345.60,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,TRIOLOGY,TRILOGY MEDICAID,52.17,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80074 at $49.22 (Fee Schedule) = $49.22 (Total Line Payment) at 106% = $52.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,57.16,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.16 from Fee Schedule UHC_98227C for Rev 301 Proc 80074 * Qty 1 = $57.16 at 100% = $57.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,57.16,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.16 from Fee Schedule UHC_98227C for Rev 301 Proc 80074 * Qty 1 = $57.16 at 100% = $57.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,47.63,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,57.16,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.16 from Fee Schedule UHC_98227C for Rev 301 Proc 80074 * Qty 1 = $57.16 at 100% = $57.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,UNITY HEALTH PLAN,UNITY HOSPICE,47.63,,,,,,,47.6300,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,345.60,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,297.60,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,345.60,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,345.60,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS PANEL ACUTE,80074,CPT,301,RC,30100109,CDM,,,,both,,,480.0000,316.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,288.00,,,,,,,47.6300,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $480.00 in Billed Charges for Rev 301 Proc 80074 = $288.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA HSHS,67.18,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA MEDICARE,8.17,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,AETNA,ALL COMMERCIAL AETNA,104.00,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTEHM MEDICAID,8.44,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80076 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.17,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM POS/HMO,28.60,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.60 from Fee Schedule WII28_25 for Rev 301 Proc 80076 Mod TC * Qty 1 = $28.60 at 100% = $28.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM PPO,28.60,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.60 from Fee Schedule WII28_25 for Rev 301 Proc 80076 Mod TC * Qty 1 = $28.60 at 100% = $28.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,104.00,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,CENPATICO,ALL MEDICAID CENPATICO,104.00,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,88.40,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,CIGNA,ALL COMMERCIAL CIGNA,72.80,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,COFINITY,COFINITY,104.00,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.44,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80076 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.44,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80076 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,98.80,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $98.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,87.36,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,73.84,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $73.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,75.92,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,50.54,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,88.40,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE HMO,13.89,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.89 from Fee Schedule 005543_170 for Rev 301 Proc 80076 * Qty 1 = $13.89 at 100% = $13.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE PPO,88.40,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,8.17,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA NATIIONAL POS HMO,13.89,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.89 from Fee Schedule 005543_170 for Rev 301 Proc 80076 * Qty 1 = $13.89 at 100% = $13.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,75.92,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,104.00,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.44,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80076 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.17,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.44,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80076 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,8.95,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80076 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 100% = $8.44... $8.44 at 106% = $8.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,8.17,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,52.00,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,87.36,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,18.38,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,78.00,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,95.68,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $95.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.62,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.62,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360,10.62,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.62,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,66.38,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $66.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8.25,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,74.88,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,TRILOGY MEDICAID,8.95,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00403 Proc 80076 at $8.44 (Fee Schedule) = $8.44 (Total Line Payment) at 106% = $8.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.80,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.80 from Fee Schedule UHC_98227C for Rev 301 Proc 80076 * Qty 1 = $9.80 at 100% = $9.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,9.80,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.80 from Fee Schedule UHC_98227C for Rev 301 Proc 80076 * Qty 1 = $9.80 at 100% = $9.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.17,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,9.80,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.80 from Fee Schedule UHC_98227C for Rev 301 Proc 80076 * Qty 1 = $9.80 at 100% = $9.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,UNITY HEALTH PLAN,UNITY HOSPICE,8.17,,,,,,,8.1700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,74.88,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,64.48,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $64.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,74.88,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,74.88,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LIVER (HEPATIC) PANEL,80076,CPT,301,RC,30100110,CDM,,,,both,,,104.0000,68.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,62.40,,,,,,,8.1700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.00 in Billed Charges for Rev 301 Proc 80076 = $62.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,AETNA,AETNA HSHS,85.27,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $85.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,AETNA,AETNA MEDICARE,14.57,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,AETNA,ALL COMMERCIAL AETNA,132.00,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,ANTHEM,ANTEHM MEDICAID,15.06,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80156 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.57,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,ANTHEM,ANTHEM POS/HMO,51.00,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule WII28_25 for Rev 301 Proc 80156 Mod TC * Qty 1 = $51.00 at 100% = $51.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,ANTHEM,ANTHEM PPO,51.00,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.00 from Fee Schedule WII28_25 for Rev 301 Proc 80156 Mod TC * Qty 1 = $51.00 at 100% = $51.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,132.00,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,CENPATICO,ALL MEDICAID CENPATICO,132.00,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,112.20,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $112.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,CIGNA,ALL COMMERCIAL CIGNA,92.40,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $92.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,COFINITY,COFINITY,132.00,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.06,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80156 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.06,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80156 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,125.40,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,110.88,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $110.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,93.72,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $93.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,96.36,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $96.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,64.15,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $64.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,112.20,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $112.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HUMANA,HUMANA CHOICE CARE HMO,24.77,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.77 from Fee Schedule 005543_170 for Rev 301 Proc 80156 * Qty 1 = $24.77 at 100% = $24.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HUMANA,HUMANA CHOICE CARE PPO,112.20,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $112.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,14.57,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,HUMANA,HUMANA NATIIONAL POS HMO,24.77,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.77 from Fee Schedule 005543_170 for Rev 301 Proc 80156 * Qty 1 = $24.77 at 100% = $24.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,96.36,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $96.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,132.00,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $132.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.06,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80156 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.57,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.06,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80156 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,15.96,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80156 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 100% = $15.06... $15.06 at 106% = $15.96 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,14.57,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,66.00,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,110.88,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $110.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,32.78,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,99.00,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,121.44,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $121.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.94,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.94,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,PREVEA HEALTH NETWORK,PREVEA360,18.94,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.94,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,84.26,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $84.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.72,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,95.04,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $95.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,TRIOLOGY,TRILOGY MEDICAID,15.96,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80156 at $15.06 (Fee Schedule) = $15.06 (Total Line Payment) at 106% = $15.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.48,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80156 * Qty 1 = $17.48 at 100% = $17.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,17.48,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80156 * Qty 1 = $17.48 at 100% = $17.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.57,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,17.48,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.48 from Fee Schedule UHC_98227C for Rev 301 Proc 80156 * Qty 1 = $17.48 at 100% = $17.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,UNITY HEALTH PLAN,UNITY HOSPICE,14.57,,,,,,,14.5700,132.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,95.04,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $95.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,81.84,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $81.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,95.04,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $95.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,95.04,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $95.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE TOTAL,80156,CPT,301,RC,30100116,CDM,,,,both,,,132.0000,87.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,79.20,,,,,,,14.5700,132.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $132.00 in Billed Charges for Rev 301 Proc 80156 = $79.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,AETNA,AETNA HSHS,97.55,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $97.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,AETNA,AETNA MEDICARE,13.25,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,AETNA,ALL COMMERCIAL AETNA,151.00,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTEHM MEDICAID,13.69,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80157 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.25,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM POS/HMO,46.38,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80157 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,ANTHEM,ANTHEM PPO,46.38,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80157 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,151.00,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,CENPATICO,ALL MEDICAID CENPATICO,151.00,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,128.35,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,CIGNA,ALL COMMERCIAL CIGNA,105.70,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $105.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,COFINITY,COFINITY,151.00,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.69,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80157 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.69,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80157 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,143.45,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $143.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,126.84,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $126.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,107.21,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $107.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,110.23,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $110.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,73.39,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $73.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,128.35,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA CHOICE CARE HMO,22.53,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80157 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA CHOICE CARE PPO,128.35,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $128.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,13.25,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,HUMANA,HUMANA NATIIONAL POS HMO,22.53,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80157 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,110.23,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $110.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,151.00,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.69,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80157 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.25,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.69,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80157 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,14.51,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80157 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69... $13.69 at 106% = $14.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,13.25,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.50,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $75.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.84,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $126.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,29.81,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,113.25,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $113.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.92,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $138.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.23,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.23,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA360,17.23,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.23,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,96.38,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $96.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.38,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.72,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,TRIOLOGY,TRILOGY MEDICAID,14.51,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80157 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 106% = $14.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.90,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80157 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,15.90,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80157 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.25,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,15.90,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80157 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,UNITY HEALTH PLAN,UNITY HOSPICE,13.25,,,,,,,13.2500,151.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.72,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.62,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $93.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.72,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.72,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $108.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARBAMAZEPINE FREE,80157,CPT,301,RC,30100117,CDM,,,,both,,,151.0000,99.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.60,,,,,,,13.2500,151.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $151.00 in Billed Charges for Rev 301 Proc 80157 = $90.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA HSHS,76.23,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $76.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA MEDICARE,13.54,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,AETNA,ALL COMMERCIAL AETNA,118.00,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTEHM MEDICAID,13.99,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80164 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.54,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM POS/HMO,47.39,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $47.39 from Fee Schedule WII28_25 for Rev 301 Proc 80164 Mod TC * Qty 1 = $47.39 at 100% = $47.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM PPO,47.39,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $47.39 from Fee Schedule WII28_25 for Rev 301 Proc 80164 Mod TC * Qty 1 = $47.39 at 100% = $47.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.00,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,CENPATICO,ALL MEDICAID CENPATICO,118.00,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.30,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,CIGNA,ALL COMMERCIAL CIGNA,82.60,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,COFINITY,COFINITY,118.00,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.99,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80164 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.99,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80164 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.10,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $112.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.12,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.78,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $83.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.14,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.35,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $57.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.30,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE HMO,23.02,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.02 from Fee Schedule 005543_170 for Rev 301 Proc 80164 * Qty 1 = $23.02 at 100% = $23.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE PPO,100.30,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,13.54,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA NATIIONAL POS HMO,23.02,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.02 from Fee Schedule 005543_170 for Rev 301 Proc 80164 * Qty 1 = $23.02 at 100% = $23.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.14,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.00,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.99,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80164 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.54,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.99,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80164 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,14.83,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80164 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99... $13.99 at 106% = $14.83 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,13.54,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.00,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $59.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.12,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,30.47,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.50,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,108.56,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $108.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.60,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.60,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360,17.60,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.60,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.32,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $75.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.68,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.96,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,TRILOGY MEDICAID,14.83,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80164 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 106% = $14.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.25,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.25 from Fee Schedule UHC_98227C for Rev 301 Proc 80164 * Qty 1 = $16.25 at 100% = $16.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,16.25,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.25 from Fee Schedule UHC_98227C for Rev 301 Proc 80164 * Qty 1 = $16.25 at 100% = $16.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.54,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,16.25,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.25 from Fee Schedule UHC_98227C for Rev 301 Proc 80164 * Qty 1 = $16.25 at 100% = $16.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,UNITY HEALTH PLAN,UNITY HOSPICE,13.54,,,,,,,13.5400,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.96,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.16,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $73.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.96,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.96,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VALPROIC ACID,80164,CPT,301,RC,30100121,CDM,,,,both,,,118.0000,77.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.80,,,,,,,13.5400,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.00 in Billed Charges for Rev 301 Proc 80164 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,AETNA,AETNA HSHS,42.64,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $42.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,AETNA,ALL COMMERCIAL AETNA,66.00,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,ANTHEM,ANTHEM POS/HMO,66.00,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $66.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,ANTHEM,ANTHEM PPO,66.00,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $66.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,66.00,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,CENPATICO,ALL MEDICAID CENPATICO,66.00,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,56.10,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $56.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,CIGNA,ALL COMMERCIAL CIGNA,46.20,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,COFINITY,COFINITY,66.00,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,62.70,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $62.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,55.44,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $55.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,46.86,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $46.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,48.18,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $48.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,32.08,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $32.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,56.10,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $56.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,HUMANA,HUMANA CHOICE CARE PPO,56.10,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $56.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,48.18,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $48.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,66.00,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,33.00,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,55.44,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $55.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,49.50,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $49.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,60.72,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $60.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,39.60,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,39.60,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,PREVEA HEALTH NETWORK,PREVEA360,39.60,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,39.60,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,42.13,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $42.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,47.52,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,47.52,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,40.92,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $40.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,47.52,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,47.52,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DOXEPIN,80335,CPT,301,RC,30100122,CDM,,,,both,,,66.0000,43.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,39.60,,,,,,,5.1700,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $66.00 in Billed Charges for Rev 301 Proc 80335 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,AETNA,AETNA HSHS,135.66,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $135.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,AETNA,AETNA MEDICARE,16.38,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,AETNA,ALL COMMERCIAL AETNA,210.00,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTEHM MEDICAID,16.93,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80170 at $16.93 (Fee Schedule) = $16.93 (Total Line Payment) at 100% = $16.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.38,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM POS/HMO,57.33,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.33 from Fee Schedule WII28_25 for Rev 301 Proc 80170 Mod TC * Qty 1 = $57.33 at 100% = $57.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,ANTHEM,ANTHEM PPO,57.33,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.33 from Fee Schedule WII28_25 for Rev 301 Proc 80170 Mod TC * Qty 1 = $57.33 at 100% = $57.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,210.00,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,CENPATICO,ALL MEDICAID CENPATICO,210.00,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,178.50,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,CIGNA,ALL COMMERCIAL CIGNA,147.00,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,COFINITY,COFINITY,210.00,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.93,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80170 at $16.93 (Fee Schedule) = $16.93 (Total Line Payment) at 100% = $16.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.93,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80170 at $16.93 (Fee Schedule) = $16.93 (Total Line Payment) at 100% = $16.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,199.50,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $199.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,176.40,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,149.10,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $149.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,153.30,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $153.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,102.06,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $102.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,178.50,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA CHOICE CARE HMO,27.85,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.85 from Fee Schedule 005543_170 for Rev 301 Proc 80170 * Qty 1 = $27.85 at 100% = $27.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA CHOICE CARE PPO,178.50,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,16.38,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,HUMANA,HUMANA NATIIONAL POS HMO,27.85,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.85 from Fee Schedule 005543_170 for Rev 301 Proc 80170 * Qty 1 = $27.85 at 100% = $27.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,153.30,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $153.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,210.00,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.93,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80170 at $16.93 (Fee Schedule) = $16.93 (Total Line Payment) at 100% = $16.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.38,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.93,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80170 at $16.93 (Fee Schedule) = $16.93 (Total Line Payment) at 100% = $16.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,17.95,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80170 at $16.93 (Fee Schedule) = $16.93 (Total Line Payment) at 100% = $16.93... $16.93 at 106% = $17.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,16.38,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,105.00,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,176.40,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,36.86,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,157.50,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,193.20,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $193.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.29,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.29,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA360,21.29,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.29,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,134.04,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $134.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.54,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,151.20,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,TRIOLOGY,TRILOGY MEDICAID,17.95,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80170 at $16.93 (Fee Schedule) = $16.93 (Total Line Payment) at 106% = $17.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.66,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.66 from Fee Schedule UHC_98227C for Rev 301 Proc 80170 * Qty 1 = $19.66 at 100% = $19.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,19.66,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.66 from Fee Schedule UHC_98227C for Rev 301 Proc 80170 * Qty 1 = $19.66 at 100% = $19.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.38,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,19.66,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.66 from Fee Schedule UHC_98227C for Rev 301 Proc 80170 * Qty 1 = $19.66 at 100% = $19.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,UNITY HEALTH PLAN,UNITY HOSPICE,16.38,,,,,,,16.3800,210.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,151.20,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,130.20,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $130.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,151.20,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,151.20,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $151.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTAMICIN,80170,CPT,301,RC,30100124,CDM,,,,both,,,210.0000,138.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,126.00,,,,,,,16.3800,210.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $210.00 in Billed Charges for Rev 301 Proc 80170 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,AETNA,AETNA HSHS,44.57,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $44.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,AETNA,ALL COMMERCIAL AETNA,69.00,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,ANTHEM,ANTHEM POS/HMO,69.00,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $69.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,ANTHEM,ANTHEM PPO,69.00,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80335 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $69.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,69.00,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,CENPATICO,ALL MEDICAID CENPATICO,69.00,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.65,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $58.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,CIGNA,ALL COMMERCIAL CIGNA,48.30,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $48.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,COFINITY,COFINITY,69.00,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.55,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $65.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,57.96,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $57.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.99,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $48.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.37,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $50.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,33.53,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $33.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.65,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $58.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,HUMANA,HUMANA CHOICE CARE PPO,58.65,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $58.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80335 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.37,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $50.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,69.00,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.50,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $34.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.96,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $57.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.75,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $51.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.48,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $63.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,41.40,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,41.40,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,PREVEA HEALTH NETWORK,PREVEA360,41.40,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,41.40,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44.04,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $44.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.68,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,69.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80335 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.68,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.78,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $42.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.68,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.68,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $49.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IMIPRAMINE,80335,CPT,301,RC,30100125,CDM,,,,both,,,69.0000,45.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.40,,,,,,,5.1700,69.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $69.00 in Billed Charges for Rev 301 Proc 80335 = $41.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,AETNA,AETNA HSHS,38.76,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,AETNA,AETNA MEDICARE,6.61,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,AETNA,ALL COMMERCIAL AETNA,60.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTEHM MEDICAID,6.83,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80178 at $6.83 (Fee Schedule) = $6.83 (Total Line Payment) at 100% = $6.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,6.61,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTHEM POS/HMO,23.14,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.14 from Fee Schedule WII28_25 for Rev 301 Proc 80178 Mod TC * Qty 1 = $23.14 at 100% = $23.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTHEM PPO,23.14,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.14 from Fee Schedule WII28_25 for Rev 301 Proc 80178 Mod TC * Qty 1 = $23.14 at 100% = $23.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,60.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,CENPATICO,ALL MEDICAID CENPATICO,60.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,51.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,CIGNA,ALL COMMERCIAL CIGNA,42.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,COFINITY,COFINITY,60.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.83,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80178 at $6.83 (Fee Schedule) = $6.83 (Total Line Payment) at 100% = $6.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.83,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80178 at $6.83 (Fee Schedule) = $6.83 (Total Line Payment) at 100% = $6.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,57.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,50.40,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42.60,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $42.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,43.80,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $43.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,29.16,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $29.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,51.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA CHOICE CARE HMO,11.24,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.24 from Fee Schedule 005543_170 for Rev 301 Proc 80178 * Qty 1 = $11.24 at 100% = $11.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA CHOICE CARE PPO,51.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,6.61,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA NATIIONAL POS HMO,11.24,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.24 from Fee Schedule 005543_170 for Rev 301 Proc 80178 * Qty 1 = $11.24 at 100% = $11.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,43.80,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $43.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,60.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.83,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80178 at $6.83 (Fee Schedule) = $6.83 (Total Line Payment) at 100% = $6.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,6.61,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.83,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80178 at $6.83 (Fee Schedule) = $6.83 (Total Line Payment) at 100% = $6.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,7.24,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80178 at $6.83 (Fee Schedule) = $6.83 (Total Line Payment) at 100% = $6.83... $6.83 at 106% = $7.24 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,6.61,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,30.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $30.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,50.40,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,14.87,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,45.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,55.20,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $55.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.59,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.59,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA360,8.59,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.59,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38.30,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $38.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,6.68,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,43.20,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,TRIOLOGY,TRILOGY MEDICAID,7.24,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80178 at $6.83 (Fee Schedule) = $6.83 (Total Line Payment) at 106% = $7.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.93,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.93 from Fee Schedule UHC_98227C for Rev 301 Proc 80178 * Qty 1 = $7.93 at 100% = $7.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,7.93,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.93 from Fee Schedule UHC_98227C for Rev 301 Proc 80178 * Qty 1 = $7.93 at 100% = $7.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,6.61,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,7.93,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.93 from Fee Schedule UHC_98227C for Rev 301 Proc 80178 * Qty 1 = $7.93 at 100% = $7.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,UNITY HEALTH PLAN,UNITY HOSPICE,6.61,,,,,,,6.6100,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,43.20,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37.20,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $37.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,43.20,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,43.20,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHIUM,80178,CPT,301,RC,30100127,CDM,,,,both,,,60.0000,39.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,36.00,,,,,,,6.6100,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $60.00 in Billed Charges for Rev 301 Proc 80178 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,AETNA,AETNA HSHS,60.08,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $60.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,AETNA,AETNA MEDICARE,13.76,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,AETNA,ALL COMMERCIAL AETNA,93.00,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,ANTHEM,ANTEHM MEDICAID,14.22,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80186 at $14.22 (Fee Schedule) = $14.22 (Total Line Payment) at 100% = $14.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.76,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,ANTHEM,ANTHEM POS/HMO,48.16,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.16 from Fee Schedule WII28_25 for Rev 301 Proc 80186 Mod TC * Qty 1 = $48.16 at 100% = $48.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,ANTHEM,ANTHEM PPO,48.16,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.16 from Fee Schedule WII28_25 for Rev 301 Proc 80186 Mod TC * Qty 1 = $48.16 at 100% = $48.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,93.00,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,CENPATICO,ALL MEDICAID CENPATICO,93.00,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.05,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,CIGNA,ALL COMMERCIAL CIGNA,65.10,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $65.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,COFINITY,COFINITY,93.00,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.22,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80186 at $14.22 (Fee Schedule) = $14.22 (Total Line Payment) at 100% = $14.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.22,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80186 at $14.22 (Fee Schedule) = $14.22 (Total Line Payment) at 100% = $14.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,88.35,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $88.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,78.12,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $78.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.03,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $66.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,67.89,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $67.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,45.20,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $45.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.05,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HUMANA,HUMANA CHOICE CARE HMO,23.39,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.39 from Fee Schedule 005543_170 for Rev 301 Proc 80186 * Qty 1 = $23.39 at 100% = $23.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HUMANA,HUMANA CHOICE CARE PPO,79.05,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HUMANA,HUMANA MEDICARE ADVANTAGE,13.76,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,HUMANA,HUMANA NATIIONAL POS HMO,23.39,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.39 from Fee Schedule 005543_170 for Rev 301 Proc 80186 * Qty 1 = $23.39 at 100% = $23.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,67.89,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $67.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,93.00,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.22,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80186 at $14.22 (Fee Schedule) = $14.22 (Total Line Payment) at 100% = $14.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.76,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.22,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80186 at $14.22 (Fee Schedule) = $14.22 (Total Line Payment) at 100% = $14.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,MOLINA HEALTHCARE,MOLINA MEDICAID,15.07,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80186 at $14.22 (Fee Schedule) = $14.22 (Total Line Payment) at 100% = $14.22... $14.22 at 106% = $15.07 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,MOLINA HEALTHCARE,MOLINA MEDICARE,13.76,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.50,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $46.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.12,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $78.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,NAPHCARE,ALL COMMERICAL NAPHCARE,30.96,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,69.75,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $69.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,85.56,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $85.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.89,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.89,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,PREVEA HEALTH NETWORK,PREVEA360,17.89,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.89,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,59.36,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $59.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.90,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,66.96,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,TRIOLOGY,TRILOGY MEDICAID,15.07,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80186 at $14.22 (Fee Schedule) = $14.22 (Total Line Payment) at 106% = $15.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.51,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.51 from Fee Schedule UHC_98227C for Rev 301 Proc 80186 * Qty 1 = $16.51 at 100% = $16.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,UNITED HEALTHCARE,UHC ONEIDA NATION,16.51,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.51 from Fee Schedule UHC_98227C for Rev 301 Proc 80186 * Qty 1 = $16.51 at 100% = $16.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.76,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,UNITED HEALTHCARE,UNITED HEALTHCARE,16.51,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.51 from Fee Schedule UHC_98227C for Rev 301 Proc 80186 * Qty 1 = $16.51 at 100% = $16.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,UNITY HEALTH PLAN,UNITY HOSPICE,13.76,,,,,,,13.7600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,66.96,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,57.66,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $57.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,66.96,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,66.96,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHENYTOIN FREE,80186,CPT,301,RC,30100131,CDM,,,,both,,,93.0000,61.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.80,,,,,,,13.7600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.00 in Billed Charges for Rev 301 Proc 80186 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,AETNA,AETNA HSHS,86.56,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $86.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,AETNA,AETNA MEDICARE,14.60,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,AETNA,ALL COMMERCIAL AETNA,134.00,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $134.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,ANTHEM,ANTEHM MEDICAID,15.09,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80194 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.60,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,ANTHEM,ANTHEM POS/HMO,51.10,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.10 from Fee Schedule WII28_25 for Rev 301 Proc 80194 Mod TC * Qty 1 = $51.10 at 100% = $51.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,ANTHEM,ANTHEM PPO,51.10,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.10 from Fee Schedule WII28_25 for Rev 301 Proc 80194 Mod TC * Qty 1 = $51.10 at 100% = $51.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,134.00,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $134.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,CENPATICO,ALL MEDICAID CENPATICO,134.00,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $134.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,113.90,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $113.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,CIGNA,ALL COMMERCIAL CIGNA,93.80,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $93.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,COFINITY,COFINITY,134.00,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $134.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.09,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80194 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.09,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80194 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,127.30,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $127.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,112.56,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $112.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,95.14,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $95.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,97.82,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $97.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,65.12,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $65.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,113.90,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $113.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HUMANA,HUMANA CHOICE CARE HMO,24.82,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.82 from Fee Schedule 005543_170 for Rev 301 Proc 80194 * Qty 1 = $24.82 at 100% = $24.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HUMANA,HUMANA CHOICE CARE PPO,113.90,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $113.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,14.60,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,HUMANA,HUMANA NATIIONAL POS HMO,24.82,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.82 from Fee Schedule 005543_170 for Rev 301 Proc 80194 * Qty 1 = $24.82 at 100% = $24.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,97.82,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $97.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,134.00,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $134.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.09,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80194 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.60,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.09,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80194 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,16.00,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80194 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09... $15.09 at 106% = $16.00 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,14.60,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,67.00,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,112.56,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $112.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,32.85,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,100.50,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $100.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,123.28,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $123.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.98,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.98,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,PREVEA HEALTH NETWORK,PREVEA360,18.98,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.98,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,85.53,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $85.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.75,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,96.48,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $96.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,TRIOLOGY,TRILOGY MEDICAID,16.00,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80194 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 106% = $16.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.52,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.52 from Fee Schedule UHC_98227C for Rev 301 Proc 80194 * Qty 1 = $17.52 at 100% = $17.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,17.52,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.52 from Fee Schedule UHC_98227C for Rev 301 Proc 80194 * Qty 1 = $17.52 at 100% = $17.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.60,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,17.52,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.52 from Fee Schedule UHC_98227C for Rev 301 Proc 80194 * Qty 1 = $17.52 at 100% = $17.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,UNITY HEALTH PLAN,UNITY HOSPICE,14.60,,,,,,,14.6000,134.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,96.48,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $96.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,83.08,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $83.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,96.48,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $96.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,96.48,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $96.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUINIDINE,80194,CPT,301,RC,30100134,CDM,,,,both,,,134.0000,88.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,80.40,,,,,,,14.6000,134.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $134.00 in Billed Charges for Rev 301 Proc 80194 = $80.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,AETNA,AETNA HSHS,140.83,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $140.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,AETNA,AETNA MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,AETNA,ALL COMMERCIAL AETNA,218.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,ANTHEM,ANTEHM MEDICAID,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,ANTHEM,ANTHEM POS/HMO,218.00,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $400.51 from Fee Schedule WII28_25 for Rev 301 Proc G0480 Mod TC * Qty 1 = $400.51 at 100% = $400.51 (Limited to $218.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,ANTHEM,ANTHEM PPO,218.00,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $400.51 from Fee Schedule WII28_25 for Rev 301 Proc G0480 Mod TC * Qty 1 = $400.51 at 100% = $400.51 (Limited to $218.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,218.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,CENPATICO,ALL MEDICAID CENPATICO,218.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,185.30,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $185.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,CIGNA,ALL COMMERCIAL CIGNA,152.60,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $152.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,COFINITY,COFINITY,218.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,207.10,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $207.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,183.12,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $183.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,154.78,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $154.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,159.14,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $159.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,105.95,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $105.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,185.30,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $185.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HUMANA,HUMANA CHOICE CARE HMO,194.53,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $194.53 from Fee Schedule 005543_170 for Rev 301 Proc G0480 * Qty 1 = $194.53 at 100% = $194.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HUMANA,HUMANA CHOICE CARE PPO,185.30,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $185.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,HUMANA,HUMANA NATIIONAL POS HMO,194.53,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $194.53 from Fee Schedule 005543_170 for Rev 301 Proc G0480 * Qty 1 = $194.53 at 100% = $194.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,159.14,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $159.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,218.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,63.95,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,67.79,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 100% = $63.95... $63.95 at 106% = $67.79 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,109.00,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,183.12,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $183.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,257.47,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,163.50,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $163.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,200.56,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $200.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,PREVEA HEALTH NETWORK,PREVEA360,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,148.76,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,139.15,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $139.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,115.57,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,156.96,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,TRIOLOGY,TRILOGY MEDICAID,67.79,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02041 Proc G0480 at $63.95 (Fee Schedule) = $63.95 (Total Line Payment) at 106% = $67.79. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 301 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 301 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,137.32,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $137.32 from Fee Schedule UHC_98227C for Rev 301 Proc G0480 * Qty 1 = $137.32 at 100% = $137.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,UNITY HEALTH PLAN,UNITY HOSPICE,114.43,,,,,,,63.9500,257.4700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,156.96,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,135.16,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $135.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,156.96,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,156.96,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,301,RC,30100136,CDM,,,,both,,,218.0000,143.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,130.80,,,,,,,63.9500,257.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $218.00 in Billed Charges for Rev 301 Proc G0480 = $130.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA HSHS,76.23,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $76.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,AETNA,AETNA MEDICARE,11.92,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,AETNA,ALL COMMERCIAL AETNA,118.00,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTEHM MEDICAID,12.32,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80201 at $12.32 (Fee Schedule) = $12.32 (Total Line Payment) at 100% = $12.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.92,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM POS/HMO,41.72,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.72 from Fee Schedule WII28_25 for Rev 301 Proc 80201 Mod TC * Qty 1 = $41.72 at 100% = $41.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,ANTHEM,ANTHEM PPO,41.72,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.72 from Fee Schedule WII28_25 for Rev 301 Proc 80201 Mod TC * Qty 1 = $41.72 at 100% = $41.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.00,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,CENPATICO,ALL MEDICAID CENPATICO,118.00,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.30,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,CIGNA,ALL COMMERCIAL CIGNA,82.60,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $82.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,COFINITY,COFINITY,118.00,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.32,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80201 at $12.32 (Fee Schedule) = $12.32 (Total Line Payment) at 100% = $12.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.32,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80201 at $12.32 (Fee Schedule) = $12.32 (Total Line Payment) at 100% = $12.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.10,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $112.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.12,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.78,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $83.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.14,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.35,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $57.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.30,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE HMO,20.26,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.26 from Fee Schedule 005543_170 for Rev 301 Proc 80201 * Qty 1 = $20.26 at 100% = $20.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA CHOICE CARE PPO,100.30,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $100.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,11.92,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,HUMANA,HUMANA NATIIONAL POS HMO,20.26,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.26 from Fee Schedule 005543_170 for Rev 301 Proc 80201 * Qty 1 = $20.26 at 100% = $20.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.14,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $86.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.00,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $118.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.32,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80201 at $12.32 (Fee Schedule) = $12.32 (Total Line Payment) at 100% = $12.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.92,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.32,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80201 at $12.32 (Fee Schedule) = $12.32 (Total Line Payment) at 100% = $12.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,13.06,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80201 at $12.32 (Fee Schedule) = $12.32 (Total Line Payment) at 100% = $12.32... $12.32 at 106% = $13.06 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,11.92,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.00,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $59.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.12,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $99.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,26.82,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.50,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,108.56,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $108.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.50,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.50,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360,15.50,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.50,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.32,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $75.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.04,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.96,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,TRIOLOGY,TRILOGY MEDICAID,13.06,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80201 at $12.32 (Fee Schedule) = $12.32 (Total Line Payment) at 106% = $13.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.30,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.30 from Fee Schedule UHC_98227C for Rev 301 Proc 80201 * Qty 1 = $14.30 at 100% = $14.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,14.30,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.30 from Fee Schedule UHC_98227C for Rev 301 Proc 80201 * Qty 1 = $14.30 at 100% = $14.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.92,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,14.30,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.30 from Fee Schedule UHC_98227C for Rev 301 Proc 80201 * Qty 1 = $14.30 at 100% = $14.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,UNITY HEALTH PLAN,UNITY HOSPICE,11.92,,,,,,,11.9200,118.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.96,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.16,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $73.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.96,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.96,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $84.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TOPIRAMATE,80201,CPT,301,RC,30100140,CDM,,,,both,,,118.0000,77.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.80,,,,,,,11.9200,118.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.00 in Billed Charges for Rev 301 Proc 80201 = $70.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,AETNA,AETNA HSHS,93.67,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $93.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,AETNA,AETNA MEDICARE,13.54,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,AETNA,ALL COMMERCIAL AETNA,145.00,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTEHM MEDICAID,13.99,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80202 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.54,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM POS/HMO,47.39,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $47.39 from Fee Schedule WII28_25 for Rev 301 Proc 80202 Mod TC * Qty 1 = $47.39 at 100% = $47.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM PPO,47.39,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $47.39 from Fee Schedule WII28_25 for Rev 301 Proc 80202 Mod TC * Qty 1 = $47.39 at 100% = $47.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,145.00,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,CENPATICO,ALL MEDICAID CENPATICO,145.00,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,123.25,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,CIGNA,ALL COMMERCIAL CIGNA,101.50,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $101.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,COFINITY,COFINITY,145.00,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.99,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80202 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.99,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80202 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,137.75,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $137.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,121.80,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,102.95,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $102.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,105.85,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $105.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,70.47,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $70.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,123.25,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA CHOICE CARE HMO,23.02,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.02 from Fee Schedule 005543_170 for Rev 301 Proc 80202 * Qty 1 = $23.02 at 100% = $23.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA CHOICE CARE PPO,123.25,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,13.54,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA NATIIONAL POS HMO,23.02,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.02 from Fee Schedule 005543_170 for Rev 301 Proc 80202 * Qty 1 = $23.02 at 100% = $23.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,105.85,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $105.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,145.00,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.99,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80202 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.54,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.99,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80202 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,14.83,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80202 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 100% = $13.99... $13.99 at 106% = $14.83 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,13.54,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,72.50,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $72.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,121.80,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,30.47,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,108.75,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $108.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,133.40,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $133.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.60,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.60,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA360,17.60,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.60,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,92.55,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $92.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.68,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,104.40,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,TRIOLOGY,TRILOGY MEDICAID,14.83,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80202 at $13.99 (Fee Schedule) = $13.99 (Total Line Payment) at 106% = $14.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.25,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.25 from Fee Schedule UHC_98227C for Rev 301 Proc 80202 * Qty 1 = $16.25 at 100% = $16.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,16.25,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.25 from Fee Schedule UHC_98227C for Rev 301 Proc 80202 * Qty 1 = $16.25 at 100% = $16.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.54,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,16.25,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.25 from Fee Schedule UHC_98227C for Rev 301 Proc 80202 * Qty 1 = $16.25 at 100% = $16.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,UNITY HEALTH PLAN,UNITY HOSPICE,13.54,,,,,,,13.5400,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,104.40,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,89.90,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $89.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,104.40,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,104.40,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VANCOMYCIN,80202,CPT,301,RC,30100141,CDM,,,,both,,,145.0000,95.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.00,,,,,,,13.5400,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.00 in Billed Charges for Rev 301 Proc 80202 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA HSHS,75.58,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $75.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA MEDICARE,21.67,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,AETNA,ALL COMMERCIAL AETNA,117.00,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTEHM MEDICAID,14.48,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80171 at $14.48 (Fee Schedule) = $14.48 (Total Line Payment) at 100% = $14.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,21.67,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM POS/HMO,75.85,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $75.85 from Fee Schedule WII28_25 for Rev 301 Proc 80171 Mod TC * Qty 1 = $75.85 at 100% = $75.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM PPO,75.85,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $75.85 from Fee Schedule WII28_25 for Rev 301 Proc 80171 Mod TC * Qty 1 = $75.85 at 100% = $75.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,117.00,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,CENPATICO,ALL MEDICAID CENPATICO,117.00,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,99.45,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,CIGNA,ALL COMMERCIAL CIGNA,81.90,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $81.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,COFINITY,COFINITY,117.00,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.48,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80171 at $14.48 (Fee Schedule) = $14.48 (Total Line Payment) at 100% = $14.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.48,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80171 at $14.48 (Fee Schedule) = $14.48 (Total Line Payment) at 100% = $14.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,111.15,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $111.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,98.28,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.07,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $83.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,85.41,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,56.86,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $56.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,99.45,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE HMO,36.84,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.84 from Fee Schedule 005543_170 for Rev 301 Proc 80171 * Qty 1 = $36.84 at 100% = $36.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE PPO,99.45,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,21.67,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA NATIIONAL POS HMO,36.84,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.84 from Fee Schedule 005543_170 for Rev 301 Proc 80171 * Qty 1 = $36.84 at 100% = $36.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,85.41,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,117.00,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.48,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80171 at $14.48 (Fee Schedule) = $14.48 (Total Line Payment) at 100% = $14.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,21.67,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.48,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80171 at $14.48 (Fee Schedule) = $14.48 (Total Line Payment) at 100% = $14.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,15.35,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80171 at $14.48 (Fee Schedule) = $14.48 (Total Line Payment) at 100% = $14.48... $14.48 at 106% = $15.35 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,21.67,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,58.50,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,98.28,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,48.76,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,87.75,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $87.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,107.64,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $107.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,28.17,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,28.17,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360,28.17,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,28.17,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,74.68,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $74.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,21.89,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.24,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,TRILOGY MEDICAID,15.35,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80171 at $14.48 (Fee Schedule) = $14.48 (Total Line Payment) at 106% = $15.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,26.00,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.00 from Fee Schedule UHC_98227C for Rev 301 Proc 80171 * Qty 1 = $26.00 at 100% = $26.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,26.00,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.00 from Fee Schedule UHC_98227C for Rev 301 Proc 80171 * Qty 1 = $26.00 at 100% = $26.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,21.67,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,26.00,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.00 from Fee Schedule UHC_98227C for Rev 301 Proc 80171 * Qty 1 = $26.00 at 100% = $26.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,UNITY HEALTH PLAN,UNITY HOSPICE,21.67,,,,,,,14.4800,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.24,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,72.54,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $72.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.24,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.24,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GABAPENTIN PLASMA,80171,CPT,301,RC,30100146,CDM,,,,both,,,117.0000,77.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.20,,,,,,,14.4800,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $117.00 in Billed Charges for Rev 301 Proc 80171 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA MEDICARE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTEHM MEDICAID,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80183 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,46.38,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80183 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM PPO,46.38,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80183 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80183 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80183 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,22.53,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80183 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,22.53,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80183 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80183 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80183 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,14.51,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80183 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69... $13.69 at 106% = $14.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,29.81,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.23,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.23,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,17.23,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.23,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.38,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,TRILOGY MEDICAID,14.51,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80183 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 106% = $14.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.90,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80183 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,15.90,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80183 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,15.90,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80183 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,UNITY HEALTH PLAN,UNITY HOSPICE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,301,RC,30100148,CDM,,,,both,,,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 301 Proc 80183 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA MEDICARE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTEHM MEDICAID,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80203 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,46.38,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80203 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM PPO,46.38,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $46.38 from Fee Schedule WII28_25 for Rev 301 Proc 80203 Mod TC * Qty 1 = $46.38 at 100% = $46.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80203 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80203 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,22.53,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80203 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,22.53,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.53 from Fee Schedule 005543_170 for Rev 301 Proc 80203 * Qty 1 = $22.53 at 100% = $22.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80203 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.69,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80203 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,14.51,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80203 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 100% = $13.69... $13.69 at 106% = $14.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,29.81,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.23,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.23,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,17.23,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.23,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.38,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,TRILOGY MEDICAID,14.51,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00405 Proc 80203 at $13.69 (Fee Schedule) = $13.69 (Total Line Payment) at 106% = $14.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.90,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80203 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,15.90,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80203 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,15.90,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.90 from Fee Schedule UHC_98227C for Rev 301 Proc 80203 * Qty 1 = $15.90 at 100% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,UNITY HEALTH PLAN,UNITY HOSPICE,13.25,,,,,,,13.2500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZONISAMIDE,80203,CPT,301,RC,30100150,CDM,,,,both,,,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,13.2500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 301 Proc 80203 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,AETNA,AETNA HSHS,340.44,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $340.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,AETNA,AETNA MEDICARE,16.87,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,AETNA,ALL COMMERCIAL AETNA,527.00,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,ANTHEM,ANTEHM MEDICAID,17.43,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.87,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,ANTHEM,ANTHEM POS/HMO,59.05,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82017 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,ANTHEM,ANTHEM PPO,59.05,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82017 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,527.00,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,CENPATICO,ALL MEDICAID CENPATICO,527.00,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,447.95,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $447.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,CIGNA,ALL COMMERCIAL CIGNA,368.90,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $368.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,COFINITY,COFINITY,527.00,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.43,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.43,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,500.65,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $500.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,442.68,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $442.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,374.17,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $374.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,384.71,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $384.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,256.12,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $256.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,447.95,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $447.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HUMANA,HUMANA CHOICE CARE HMO,28.68,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82017 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HUMANA,HUMANA CHOICE CARE PPO,447.95,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $447.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,16.87,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,HUMANA,HUMANA NATIIONAL POS HMO,28.68,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82017 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,384.71,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $384.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,527.00,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.43,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.87,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.43,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,18.48,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43... $17.43 at 106% = $18.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,16.87,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,263.50,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,442.68,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $442.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,37.96,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,395.25,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $395.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,484.84,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $484.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.93,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.93,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,PREVEA HEALTH NETWORK,PREVEA360,21.93,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.93,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,336.38,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $336.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.04,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,379.44,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $379.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,TRIOLOGY,TRILOGY MEDICAID,18.48,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82017 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 106% = $18.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.24,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82017 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,20.24,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82017 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.87,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,20.24,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82017 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,UNITY HEALTH PLAN,UNITY HOSPICE,16.87,,,,,,,16.8700,527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,379.44,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $379.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,326.74,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $326.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,379.44,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $379.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,379.44,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $379.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ACYLCARNITINES QN PLASMA MAYO,82017,CPT,301,RC,30100162,CDM,,,,both,,,527.0000,347.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,316.20,,,,,,,16.8700,527.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $527.00 in Billed Charges for Rev 301 Proc 82017 = $316.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,AETNA,AETNA HSHS,42.64,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $42.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,AETNA,AETNA MEDICARE,5.78,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,AETNA,ALL COMMERCIAL AETNA,66.00,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,ANTHEM,ANTEHM MEDICAID,5.97,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 82043 at $5.97 (Fee Schedule) = $5.97 (Total Line Payment) at 100% = $5.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5.78,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,ANTHEM,ANTHEM POS/HMO,20.23,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.23 from Fee Schedule WII28_25 for Rev 301 Proc 82043 Mod TC * Qty 1 = $20.23 at 100% = $20.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,ANTHEM,ANTHEM PPO,20.23,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.23 from Fee Schedule WII28_25 for Rev 301 Proc 82043 Mod TC * Qty 1 = $20.23 at 100% = $20.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,66.00,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,CENPATICO,ALL MEDICAID CENPATICO,66.00,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,56.10,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $56.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,CIGNA,ALL COMMERCIAL CIGNA,46.20,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,COFINITY,COFINITY,66.00,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.97,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 82043 at $5.97 (Fee Schedule) = $5.97 (Total Line Payment) at 100% = $5.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.97,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 82043 at $5.97 (Fee Schedule) = $5.97 (Total Line Payment) at 100% = $5.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,62.70,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $62.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,55.44,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $55.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,46.86,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $46.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,48.18,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $48.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,32.08,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $32.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,56.10,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $56.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HUMANA,HUMANA CHOICE CARE HMO,9.83,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.83 from Fee Schedule 005543_170 for Rev 301 Proc 82043 * Qty 1 = $9.83 at 100% = $9.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HUMANA,HUMANA CHOICE CARE PPO,56.10,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $56.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HUMANA,HUMANA MEDICARE ADVANTAGE,5.78,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,HUMANA,HUMANA NATIIONAL POS HMO,9.83,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.83 from Fee Schedule 005543_170 for Rev 301 Proc 82043 * Qty 1 = $9.83 at 100% = $9.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,48.18,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $48.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,66.00,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.97,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 82043 at $5.97 (Fee Schedule) = $5.97 (Total Line Payment) at 100% = $5.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5.78,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.97,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 82043 at $5.97 (Fee Schedule) = $5.97 (Total Line Payment) at 100% = $5.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,MOLINA HEALTHCARE,MOLINA MEDICAID,6.33,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 82043 at $5.97 (Fee Schedule) = $5.97 (Total Line Payment) at 100% = $5.97... $5.97 at 106% = $6.33 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,MOLINA HEALTHCARE,MOLINA MEDICARE,5.78,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,33.00,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,55.44,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $55.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,NAPHCARE,ALL COMMERICAL NAPHCARE,13.01,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,49.50,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $49.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,60.72,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $60.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.51,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.51,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,PREVEA HEALTH NETWORK,PREVEA360,7.51,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.51,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,42.13,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $42.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5.84,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,47.52,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,TRIOLOGY,TRILOGY MEDICAID,6.33,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 82043 at $5.97 (Fee Schedule) = $5.97 (Total Line Payment) at 106% = $6.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.94,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.94 from Fee Schedule UHC_98227C for Rev 301 Proc 82043 * Qty 1 = $6.94 at 100% = $6.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,6.94,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.94 from Fee Schedule UHC_98227C for Rev 301 Proc 82043 * Qty 1 = $6.94 at 100% = $6.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5.78,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,6.94,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.94 from Fee Schedule UHC_98227C for Rev 301 Proc 82043 * Qty 1 = $6.94 at 100% = $6.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,UNITY HEALTH PLAN,UNITY HOSPICE,5.78,,,,,,,5.7800,66.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,47.52,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,40.92,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $40.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,47.52,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,47.52,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MICROALBUMIN URINE QN,82043,CPT,301,RC,30100168,CDM,,,,both,,,66.0000,43.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,39.60,,,,,,,5.7800,66.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $66.00 in Billed Charges for Rev 301 Proc 82043 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,AETNA,AETNA HSHS,52.97,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $52.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,AETNA,AETNA MEDICARE,9.71,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,AETNA,ALL COMMERCIAL AETNA,82.00,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTEHM MEDICAID,10.03,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82085 at $10.03 (Fee Schedule) = $10.03 (Total Line Payment) at 100% = $10.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,9.71,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM POS/HMO,33.99,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $33.99 from Fee Schedule WII28_25 for Rev 301 Proc 82085 Mod TC * Qty 1 = $33.99 at 100% = $33.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,ANTHEM,ANTHEM PPO,33.99,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $33.99 from Fee Schedule WII28_25 for Rev 301 Proc 82085 Mod TC * Qty 1 = $33.99 at 100% = $33.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,82.00,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,CENPATICO,ALL MEDICAID CENPATICO,82.00,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.70,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,CIGNA,ALL COMMERCIAL CIGNA,57.40,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $57.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,COFINITY,COFINITY,82.00,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.03,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82085 at $10.03 (Fee Schedule) = $10.03 (Total Line Payment) at 100% = $10.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.03,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82085 at $10.03 (Fee Schedule) = $10.03 (Total Line Payment) at 100% = $10.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.90,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $77.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,68.88,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $68.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,58.22,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $58.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.86,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $59.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,39.85,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $39.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.70,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA CHOICE CARE HMO,16.51,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.51 from Fee Schedule 005543_170 for Rev 301 Proc 82085 * Qty 1 = $16.51 at 100% = $16.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA CHOICE CARE PPO,69.70,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $69.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,9.71,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,HUMANA,HUMANA NATIIONAL POS HMO,16.51,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.51 from Fee Schedule 005543_170 for Rev 301 Proc 82085 * Qty 1 = $16.51 at 100% = $16.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.86,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $59.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,82.00,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $82.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.03,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82085 at $10.03 (Fee Schedule) = $10.03 (Total Line Payment) at 100% = $10.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,9.71,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.03,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82085 at $10.03 (Fee Schedule) = $10.03 (Total Line Payment) at 100% = $10.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,10.63,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82085 at $10.03 (Fee Schedule) = $10.03 (Total Line Payment) at 100% = $10.03... $10.03 at 106% = $10.63 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,9.71,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,41.00,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.88,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $68.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,21.85,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.50,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $61.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,75.44,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $75.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.62,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.62,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA360,12.62,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.62,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,52.34,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $52.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,9.81,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,59.04,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,TRIOLOGY,TRILOGY MEDICAID,10.63,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 82085 at $10.03 (Fee Schedule) = $10.03 (Total Line Payment) at 106% = $10.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.65,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.65 from Fee Schedule UHC_98227C for Rev 301 Proc 82085 * Qty 1 = $11.65 at 100% = $11.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,11.65,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.65 from Fee Schedule UHC_98227C for Rev 301 Proc 82085 * Qty 1 = $11.65 at 100% = $11.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,9.71,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,11.65,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.65 from Fee Schedule UHC_98227C for Rev 301 Proc 82085 * Qty 1 = $11.65 at 100% = $11.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,UNITY HEALTH PLAN,UNITY HOSPICE,9.71,,,,,,,9.7100,82.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,59.04,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.84,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $50.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,59.04,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,59.04,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $59.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALDOLASE,82085,CPT,301,RC,30100170,CDM,,,,both,,,82.0000,54.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,49.20,,,,,,,9.7100,82.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $82.00 in Billed Charges for Rev 301 Proc 82085 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,AETNA,AETNA HSHS,79.46,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $79.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,AETNA,AETNA MEDICARE,13.44,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,AETNA,ALL COMMERCIAL AETNA,123.00,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTEHM MEDICAID,13.89,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82103 at $13.89 (Fee Schedule) = $13.89 (Total Line Payment) at 100% = $13.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.44,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM POS/HMO,47.04,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $47.04 from Fee Schedule WII28_25 for Rev 301 Proc 82103 Mod TC * Qty 1 = $47.04 at 100% = $47.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM PPO,47.04,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $47.04 from Fee Schedule WII28_25 for Rev 301 Proc 82103 Mod TC * Qty 1 = $47.04 at 100% = $47.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,123.00,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,CENPATICO,ALL MEDICAID CENPATICO,123.00,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,104.55,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,CIGNA,ALL COMMERCIAL CIGNA,86.10,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $86.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,COFINITY,COFINITY,123.00,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.89,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82103 at $13.89 (Fee Schedule) = $13.89 (Total Line Payment) at 100% = $13.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.89,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82103 at $13.89 (Fee Schedule) = $13.89 (Total Line Payment) at 100% = $13.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,116.85,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $116.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,103.32,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $103.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,87.33,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $87.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.79,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $89.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,59.78,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $59.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,104.55,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA CHOICE CARE HMO,22.85,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.85 from Fee Schedule 005543_170 for Rev 301 Proc 82103 * Qty 1 = $22.85 at 100% = $22.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA CHOICE CARE PPO,104.55,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,13.44,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA NATIIONAL POS HMO,22.85,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.85 from Fee Schedule 005543_170 for Rev 301 Proc 82103 * Qty 1 = $22.85 at 100% = $22.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.79,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $89.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,123.00,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.89,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82103 at $13.89 (Fee Schedule) = $13.89 (Total Line Payment) at 100% = $13.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.44,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.89,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82103 at $13.89 (Fee Schedule) = $13.89 (Total Line Payment) at 100% = $13.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,14.72,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82103 at $13.89 (Fee Schedule) = $13.89 (Total Line Payment) at 100% = $13.89... $13.89 at 106% = $14.72 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,13.44,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.50,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $61.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,103.32,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $103.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,30.24,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,92.25,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $92.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,113.16,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $113.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.47,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.47,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA360,17.47,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.47,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,78.51,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $78.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.57,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,88.56,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,TRIOLOGY,TRILOGY MEDICAID,14.72,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82103 at $13.89 (Fee Schedule) = $13.89 (Total Line Payment) at 106% = $14.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.13,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.13 from Fee Schedule UHC_98227C for Rev 301 Proc 82103 * Qty 1 = $16.13 at 100% = $16.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,16.13,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.13 from Fee Schedule UHC_98227C for Rev 301 Proc 82103 * Qty 1 = $16.13 at 100% = $16.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.44,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,16.13,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $16.13 from Fee Schedule UHC_98227C for Rev 301 Proc 82103 * Qty 1 = $16.13 at 100% = $16.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,UNITY HEALTH PLAN,UNITY HOSPICE,13.44,,,,,,,13.4400,123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,88.56,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,76.26,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $76.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,88.56,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,88.56,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,301,RC,30100172,CDM,,,,both,,,123.0000,81.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.80,,,,,,,13.4400,123.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $123.00 in Billed Charges for Rev 301 Proc 82103 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,16.77,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,17.33,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.77,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,58.70,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.70 from Fee Schedule WII28_25 for Rev 301 Proc 82105 Mod TC * Qty 1 = $58.70 at 100% = $58.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,58.70,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.70 from Fee Schedule WII28_25 for Rev 301 Proc 82105 Mod TC * Qty 1 = $58.70 at 100% = $58.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.33,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.33,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,28.51,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.51 from Fee Schedule 005543_170 for Rev 301 Proc 82105 * Qty 1 = $28.51 at 100% = $28.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,16.77,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,28.51,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.51 from Fee Schedule 005543_170 for Rev 301 Proc 82105 * Qty 1 = $28.51 at 100% = $28.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.33,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.77,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.33,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,18.37,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33... $17.33 at 106% = $18.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,16.77,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,37.73,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.80,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.80,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,21.80,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.80,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.94,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,18.37,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 106% = $18.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.12,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.12 from Fee Schedule UHC_98227C for Rev 301 Proc 82105 * Qty 1 = $20.12 at 100% = $20.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,20.12,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.12 from Fee Schedule UHC_98227C for Rev 301 Proc 82105 * Qty 1 = $20.12 at 100% = $20.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.77,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,20.12,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.12 from Fee Schedule UHC_98227C for Rev 301 Proc 82105 * Qty 1 = $20.12 at 100% = $20.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,16.77,,,,,,,16.7700,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALPHA-FETOPROTEIN SERUM,82105,CPT,301,RC,30100175,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,16.7700,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 301 Proc 82105 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,AETNA,AETNA HSHS,149.23,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $149.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,AETNA,AETNA MEDICARE,16.77,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,AETNA,ALL COMMERCIAL AETNA,231.00,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,ANTHEM,ANTEHM MEDICAID,17.33,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.77,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,ANTHEM,ANTHEM POS/HMO,58.70,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.70 from Fee Schedule WII28_25 for Rev 301 Proc 82105 Mod TC * Qty 1 = $58.70 at 100% = $58.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,ANTHEM,ANTHEM PPO,58.70,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.70 from Fee Schedule WII28_25 for Rev 301 Proc 82105 Mod TC * Qty 1 = $58.70 at 100% = $58.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,231.00,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,CENPATICO,ALL MEDICAID CENPATICO,231.00,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,196.35,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $196.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,CIGNA,ALL COMMERCIAL CIGNA,161.70,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $161.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,COFINITY,COFINITY,231.00,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.33,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.33,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,219.45,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $219.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,194.04,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $194.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,164.01,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $164.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,168.63,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $168.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,112.27,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $112.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,196.35,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $196.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HUMANA,HUMANA CHOICE CARE HMO,28.51,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.51 from Fee Schedule 005543_170 for Rev 301 Proc 82105 * Qty 1 = $28.51 at 100% = $28.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HUMANA,HUMANA CHOICE CARE PPO,196.35,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $196.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,16.77,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,HUMANA,HUMANA NATIIONAL POS HMO,28.51,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.51 from Fee Schedule 005543_170 for Rev 301 Proc 82105 * Qty 1 = $28.51 at 100% = $28.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,168.63,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $168.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,231.00,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.33,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.77,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.33,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,18.37,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 100% = $17.33... $17.33 at 106% = $18.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,16.77,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,115.50,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $115.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,194.04,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $194.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,37.73,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,173.25,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $173.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,212.52,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $212.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.80,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.80,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,PREVEA HEALTH NETWORK,PREVEA360,21.80,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.80,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,147.45,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $147.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.94,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,166.32,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $166.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,TRIOLOGY,TRILOGY MEDICAID,18.37,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82105 at $17.33 (Fee Schedule) = $17.33 (Total Line Payment) at 106% = $18.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.12,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.12 from Fee Schedule UHC_98227C for Rev 301 Proc 82105 * Qty 1 = $20.12 at 100% = $20.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,20.12,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.12 from Fee Schedule UHC_98227C for Rev 301 Proc 82105 * Qty 1 = $20.12 at 100% = $20.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.77,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,20.12,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.12 from Fee Schedule UHC_98227C for Rev 301 Proc 82105 * Qty 1 = $20.12 at 100% = $20.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,UNITY HEALTH PLAN,UNITY HOSPICE,16.77,,,,,,,16.7700,231.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,166.32,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $166.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,143.22,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $143.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,166.32,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $166.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,166.32,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $166.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GL AFP,82105,CPT,301,RC,30100176,CDM,,,,both,,,231.0000,152.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,138.60,,,,,,,16.7700,231.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $231.00 in Billed Charges for Rev 301 Proc 82105 = $138.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,AETNA,AETNA HSHS,123.39,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $123.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,AETNA,AETNA MEDICARE,25.48,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,AETNA,ALL COMMERCIAL AETNA,191.00,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,ANTHEM,ANTEHM MEDICAID,26.33,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82108 at $26.33 (Fee Schedule) = $26.33 (Total Line Payment) at 100% = $26.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,25.48,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,ANTHEM,ANTHEM POS/HMO,89.18,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $89.18 from Fee Schedule WII28_25 for Rev 301 Proc 82108 Mod TC * Qty 1 = $89.18 at 100% = $89.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,ANTHEM,ANTHEM PPO,89.18,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $89.18 from Fee Schedule WII28_25 for Rev 301 Proc 82108 Mod TC * Qty 1 = $89.18 at 100% = $89.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,191.00,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,CENPATICO,ALL MEDICAID CENPATICO,191.00,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,162.35,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $162.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,CIGNA,ALL COMMERCIAL CIGNA,133.70,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,COFINITY,COFINITY,191.00,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.33,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82108 at $26.33 (Fee Schedule) = $26.33 (Total Line Payment) at 100% = $26.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.33,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82108 at $26.33 (Fee Schedule) = $26.33 (Total Line Payment) at 100% = $26.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,181.45,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $181.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,160.44,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $160.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,135.61,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $135.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,139.43,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $139.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,92.83,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $92.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,162.35,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $162.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HUMANA,HUMANA CHOICE CARE HMO,43.32,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.32 from Fee Schedule 005543_170 for Rev 301 Proc 82108 * Qty 1 = $43.32 at 100% = $43.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HUMANA,HUMANA CHOICE CARE PPO,162.35,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $162.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HUMANA,HUMANA MEDICARE ADVANTAGE,25.48,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,HUMANA,HUMANA NATIIONAL POS HMO,43.32,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.32 from Fee Schedule 005543_170 for Rev 301 Proc 82108 * Qty 1 = $43.32 at 100% = $43.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,139.43,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $139.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,191.00,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.33,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82108 at $26.33 (Fee Schedule) = $26.33 (Total Line Payment) at 100% = $26.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,25.48,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.33,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82108 at $26.33 (Fee Schedule) = $26.33 (Total Line Payment) at 100% = $26.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,MOLINA HEALTHCARE,MOLINA MEDICAID,27.91,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82108 at $26.33 (Fee Schedule) = $26.33 (Total Line Payment) at 100% = $26.33... $26.33 at 106% = $27.91 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,MOLINA HEALTHCARE,MOLINA MEDICARE,25.48,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,95.50,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $95.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,160.44,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $160.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,NAPHCARE,ALL COMMERICAL NAPHCARE,57.33,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,143.25,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $143.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,175.72,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $175.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,33.12,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,33.12,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,PREVEA HEALTH NETWORK,PREVEA360,33.12,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,33.12,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,121.92,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $121.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,25.73,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,137.52,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $137.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,TRIOLOGY,TRILOGY MEDICAID,27.91,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00404 Proc 82108 at $26.33 (Fee Schedule) = $26.33 (Total Line Payment) at 106% = $27.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,30.58,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule UHC_98227C for Rev 301 Proc 82108 * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,30.58,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule UHC_98227C for Rev 301 Proc 82108 * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,25.48,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,30.58,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule UHC_98227C for Rev 301 Proc 82108 * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,UNITY HEALTH PLAN,UNITY HOSPICE,25.48,,,,,,,25.4800,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,137.52,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $137.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,118.42,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $118.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,137.52,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $137.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,137.52,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $137.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALUMINUM,82108,CPT,301,RC,30100179,CDM,,,,both,,,191.0000,126.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,114.60,,,,,,,25.4800,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $191.00 in Billed Charges for Rev 301 Proc 82108 = $114.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,AETNA,AETNA HSHS,133.72,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $133.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,AETNA,AETNA MEDICARE,22.98,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,AETNA,ALL COMMERCIAL AETNA,207.00,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,ANTHEM,ANTEHM MEDICAID,21.01,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82131 at $21.01 (Fee Schedule) = $21.01 (Total Line Payment) at 100% = $21.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,22.98,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,ANTHEM,ANTHEM POS/HMO,80.43,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.43 from Fee Schedule WII28_25 for Rev 301 Proc 82131 Mod TC * Qty 1 = $80.43 at 100% = $80.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,ANTHEM,ANTHEM PPO,80.43,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.43 from Fee Schedule WII28_25 for Rev 301 Proc 82131 Mod TC * Qty 1 = $80.43 at 100% = $80.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,207.00,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,CENPATICO,ALL MEDICAID CENPATICO,207.00,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,175.95,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $175.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,CIGNA,ALL COMMERCIAL CIGNA,144.90,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $144.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,COFINITY,COFINITY,207.00,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,21.01,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82131 at $21.01 (Fee Schedule) = $21.01 (Total Line Payment) at 100% = $21.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,21.01,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82131 at $21.01 (Fee Schedule) = $21.01 (Total Line Payment) at 100% = $21.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,196.65,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $196.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,173.88,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $173.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,146.97,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $146.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,151.11,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $151.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,100.60,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $100.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,175.95,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $175.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HUMANA,HUMANA CHOICE CARE HMO,39.07,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.07 from Fee Schedule 005543_170 for Rev 301 Proc 82131 * Qty 1 = $39.07 at 100% = $39.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HUMANA,HUMANA CHOICE CARE PPO,175.95,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $175.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HUMANA,HUMANA MEDICARE ADVANTAGE,22.98,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,HUMANA,HUMANA NATIIONAL POS HMO,39.07,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.07 from Fee Schedule 005543_170 for Rev 301 Proc 82131 * Qty 1 = $39.07 at 100% = $39.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,151.11,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $151.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,207.00,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,21.01,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82131 at $21.01 (Fee Schedule) = $21.01 (Total Line Payment) at 100% = $21.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,22.98,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,21.01,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82131 at $21.01 (Fee Schedule) = $21.01 (Total Line Payment) at 100% = $21.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,MOLINA HEALTHCARE,MOLINA MEDICAID,22.27,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82131 at $21.01 (Fee Schedule) = $21.01 (Total Line Payment) at 100% = $21.01... $21.01 at 106% = $22.27 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,MOLINA HEALTHCARE,MOLINA MEDICARE,22.98,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,103.50,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $103.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,173.88,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $173.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,NAPHCARE,ALL COMMERICAL NAPHCARE,51.71,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,155.25,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $155.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,190.44,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $190.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.87,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.87,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,PREVEA HEALTH NETWORK,PREVEA360,29.87,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.87,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,132.13,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $132.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,23.21,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,149.04,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $149.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,TRIOLOGY,TRILOGY MEDICAID,22.27,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82131 at $21.01 (Fee Schedule) = $21.01 (Total Line Payment) at 106% = $22.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.58,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.58 from Fee Schedule UHC_98227C for Rev 301 Proc 82131 * Qty 1 = $27.58 at 100% = $27.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,UNITED HEALTHCARE,UHC ONEIDA NATION,27.58,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.58 from Fee Schedule UHC_98227C for Rev 301 Proc 82131 * Qty 1 = $27.58 at 100% = $27.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,22.98,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,UNITED HEALTHCARE,UNITED HEALTHCARE,27.58,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.58 from Fee Schedule UHC_98227C for Rev 301 Proc 82131 * Qty 1 = $27.58 at 100% = $27.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,UNITY HEALTH PLAN,UNITY HOSPICE,22.98,,,,,,,21.0100,207.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,149.04,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $149.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,128.34,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $128.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,149.04,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $149.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,149.04,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $149.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMINO ACIDS SINGLE QUANT,82131,CPT,301,RC,30100180,CDM,,,,both,,,207.0000,136.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,124.20,,,,,,,21.0100,207.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $207.00 in Billed Charges for Rev 301 Proc 82131 = $124.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,AETNA,AETNA HSHS,881.79,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $881.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,AETNA,AETNA MEDICARE,16.87,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,AETNA,ALL COMMERCIAL AETNA,1365.00,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,ANTHEM,ANTEHM MEDICAID,17.43,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.87,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,ANTHEM,ANTHEM POS/HMO,59.05,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82139 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,ANTHEM,ANTHEM PPO,59.05,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82139 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1365.00,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,CENPATICO,ALL MEDICAID CENPATICO,1365.00,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1160.25,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,160.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,CIGNA,ALL COMMERCIAL CIGNA,955.50,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $955.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,COFINITY,COFINITY,1365.00,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.43,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.43,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1296.75,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,296.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,1146.60,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,146.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,969.15,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $969.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,996.45,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $996.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,663.39,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $663.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1160.25,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,160.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HUMANA,HUMANA CHOICE CARE HMO,28.68,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82139 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HUMANA,HUMANA CHOICE CARE PPO,1160.25,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,160.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,16.87,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,HUMANA,HUMANA NATIIONAL POS HMO,28.68,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82139 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,996.45,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $996.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1365.00,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.43,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.87,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.43,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,18.48,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43... $17.43 at 106% = $18.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,16.87,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,682.50,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $682.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1146.60,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,146.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,37.96,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1023.75,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,023.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1255.80,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $1,255.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.93,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.93,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,PREVEA HEALTH NETWORK,PREVEA360,21.93,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.93,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,871.28,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $871.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.04,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,982.80,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $982.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,TRIOLOGY,TRILOGY MEDICAID,18.48,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 106% = $18.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.24,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,20.24,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.87,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,20.24,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,UNITY HEALTH PLAN,UNITY HOSPICE,16.87,,,,,,,16.8700,1365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,982.80,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $982.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,846.30,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $846.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,982.80,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $982.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,982.80,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $982.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN PLASMA,82139,CPT,301,RC,30100182,CDM,,,,both,,,1365.0000,900.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,819.00,,,,,,,16.8700,1365.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,365.00 in Billed Charges for Rev 301 Proc 82139 = $819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,AETNA,AETNA HSHS,379.20,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $379.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,AETNA,AETNA MEDICARE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,AETNA,ALL COMMERCIAL AETNA,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,ANTHEM,ANTEHM MEDICAID,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,ANTHEM,ANTHEM POS/HMO,59.05,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82139 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,ANTHEM,ANTHEM PPO,59.05,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.05 from Fee Schedule WII28_25 for Rev 301 Proc 82139 Mod TC * Qty 1 = $59.05 at 100% = $59.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,CENPATICO,ALL MEDICAID CENPATICO,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,498.95,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $498.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,CIGNA,ALL COMMERCIAL CIGNA,410.90,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $410.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,COFINITY,COFINITY,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,557.65,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $557.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,493.08,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $493.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,416.77,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $416.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,428.51,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $428.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,285.28,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $285.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,498.95,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $498.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HUMANA,HUMANA CHOICE CARE HMO,28.68,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82139 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HUMANA,HUMANA CHOICE CARE PPO,498.95,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $498.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HUMANA,HUMANA MEDICARE ADVANTAGE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,HUMANA,HUMANA NATIIONAL POS HMO,28.68,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.68 from Fee Schedule 005543_170 for Rev 301 Proc 82139 * Qty 1 = $28.68 at 100% = $28.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,428.51,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $428.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,587.00,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $587.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.43,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,MOLINA HEALTHCARE,MOLINA MEDICAID,18.48,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 100% = $17.43... $17.43 at 106% = $18.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,MOLINA HEALTHCARE,MOLINA MEDICARE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,293.50,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $293.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,493.08,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $493.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,NAPHCARE,ALL COMMERICAL NAPHCARE,37.96,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,440.25,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $440.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,540.04,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $540.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.93,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.93,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,PREVEA HEALTH NETWORK,PREVEA360,21.93,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.93,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,374.68,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $374.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.04,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,422.64,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $422.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,TRIOLOGY,TRILOGY MEDICAID,18.48,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82139 at $17.43 (Fee Schedule) = $17.43 (Total Line Payment) at 106% = $18.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.24,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,20.24,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,20.24,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.24 from Fee Schedule UHC_98227C for Rev 301 Proc 82139 * Qty 1 = $20.24 at 100% = $20.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,UNITY HEALTH PLAN,UNITY HOSPICE,16.87,,,,,,,16.8700,587.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,422.64,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $422.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,363.94,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $363.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,422.64,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $422.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,422.64,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $422.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMINO ACID 6+ QN URINE,82139,CPT,301,RC,30100183,CDM,,,,both,,,587.0000,387.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,352.20,,,,,,,16.8700,587.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $587.00 in Billed Charges for Rev 301 Proc 82139 = $352.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80324 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,49.00,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80324 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $49.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,ANTHEM,ANTHEM PPO,49.00,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80324 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $49.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80324 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80324 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80324 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80324 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80324 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80324 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80324 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80324 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMPHETAMINE,80324,CPT,301,RC,30100187,CDM,,,,both,,,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,5.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 301 Proc 80324 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,AETNA,AETNA HSHS,176.36,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $176.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,AETNA,AETNA MEDICARE,29.28,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,AETNA,ALL COMMERCIAL AETNA,273.00,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,ANTHEM,ANTEHM MEDICAID,30.26,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00398 Proc 82157 at $30.26 (Fee Schedule) = $30.26 (Total Line Payment) at 100% = $30.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,29.28,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,ANTHEM,ANTHEM POS/HMO,102.48,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $102.48 from Fee Schedule WII28_25 for Rev 301 Proc 82157 Mod TC * Qty 1 = $102.48 at 100% = $102.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,ANTHEM,ANTHEM PPO,102.48,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $102.48 from Fee Schedule WII28_25 for Rev 301 Proc 82157 Mod TC * Qty 1 = $102.48 at 100% = $102.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,273.00,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,CENPATICO,ALL MEDICAID CENPATICO,273.00,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,232.05,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $232.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,CIGNA,ALL COMMERCIAL CIGNA,191.10,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $191.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,COFINITY,COFINITY,273.00,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,30.26,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00398 Proc 82157 at $30.26 (Fee Schedule) = $30.26 (Total Line Payment) at 100% = $30.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,30.26,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00398 Proc 82157 at $30.26 (Fee Schedule) = $30.26 (Total Line Payment) at 100% = $30.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,259.35,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $259.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,229.32,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $229.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,193.83,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $193.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,199.29,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $199.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,132.68,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $132.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,232.05,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $232.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HUMANA,HUMANA CHOICE CARE HMO,49.78,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $49.78 from Fee Schedule 005543_170 for Rev 301 Proc 82157 * Qty 1 = $49.78 at 100% = $49.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HUMANA,HUMANA CHOICE CARE PPO,232.05,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $232.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,29.28,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,HUMANA,HUMANA NATIIONAL POS HMO,49.78,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $49.78 from Fee Schedule 005543_170 for Rev 301 Proc 82157 * Qty 1 = $49.78 at 100% = $49.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,199.29,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $199.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,273.00,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,30.26,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00398 Proc 82157 at $30.26 (Fee Schedule) = $30.26 (Total Line Payment) at 100% = $30.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,29.28,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,30.26,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00398 Proc 82157 at $30.26 (Fee Schedule) = $30.26 (Total Line Payment) at 100% = $30.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,32.08,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00398 Proc 82157 at $30.26 (Fee Schedule) = $30.26 (Total Line Payment) at 100% = $30.26... $30.26 at 106% = $32.08 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,29.28,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,136.50,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $136.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,229.32,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $229.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,65.88,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,204.75,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $204.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,251.16,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $251.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,38.06,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,38.06,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,PREVEA HEALTH NETWORK,PREVEA360,38.06,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,38.06,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,174.26,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $174.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,29.57,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,196.56,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $196.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,TRIOLOGY,TRILOGY MEDICAID,32.08,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00398 Proc 82157 at $30.26 (Fee Schedule) = $30.26 (Total Line Payment) at 106% = $32.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,35.14,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $35.14 from Fee Schedule UHC_98227C for Rev 301 Proc 82157 * Qty 1 = $35.14 at 100% = $35.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,35.14,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $35.14 from Fee Schedule UHC_98227C for Rev 301 Proc 82157 * Qty 1 = $35.14 at 100% = $35.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,29.28,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,35.14,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $35.14 from Fee Schedule UHC_98227C for Rev 301 Proc 82157 * Qty 1 = $35.14 at 100% = $35.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,UNITY HEALTH PLAN,UNITY HOSPICE,29.28,,,,,,,29.2800,273.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,196.56,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $196.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,169.26,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $169.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,196.56,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $196.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,196.56,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $196.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANDROSTENEDIONE,82157,CPT,301,RC,30100189,CDM,,,,both,,,273.0000,180.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,163.80,,,,,,,29.2800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $273.00 in Billed Charges for Rev 301 Proc 82157 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,AETNA,AETNA HSHS,87.86,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $87.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,AETNA,AETNA MEDICARE,14.60,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,AETNA,ALL COMMERCIAL AETNA,136.00,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTEHM MEDICAID,15.09,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82164 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.60,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTHEM POS/HMO,51.10,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.10 from Fee Schedule WII28_25 for Rev 301 Proc 82164 Mod TC * Qty 1 = $51.10 at 100% = $51.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTHEM PPO,51.10,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.10 from Fee Schedule WII28_25 for Rev 301 Proc 82164 Mod TC * Qty 1 = $51.10 at 100% = $51.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,136.00,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,CENPATICO,ALL MEDICAID CENPATICO,136.00,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,115.60,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,CIGNA,ALL COMMERCIAL CIGNA,95.20,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,COFINITY,COFINITY,136.00,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.09,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82164 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.09,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82164 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,129.20,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $129.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,114.24,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $114.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,96.56,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $96.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,99.28,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $99.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,66.10,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $66.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,115.60,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA CHOICE CARE HMO,24.82,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.82 from Fee Schedule 005543_170 for Rev 301 Proc 82164 * Qty 1 = $24.82 at 100% = $24.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA CHOICE CARE PPO,115.60,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,14.60,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA NATIIONAL POS HMO,24.82,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.82 from Fee Schedule 005543_170 for Rev 301 Proc 82164 * Qty 1 = $24.82 at 100% = $24.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,99.28,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $99.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,136.00,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.09,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82164 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.60,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.09,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82164 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,16.00,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82164 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 100% = $15.09... $15.09 at 106% = $16.00 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,14.60,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,68.00,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $68.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,114.24,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $114.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,32.85,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,102.00,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,125.12,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $125.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.98,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.98,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA360,18.98,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.98,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,86.81,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $86.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.75,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,97.92,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,TRIOLOGY,TRILOGY MEDICAID,16.00,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00400 Proc 82164 at $15.09 (Fee Schedule) = $15.09 (Total Line Payment) at 106% = $16.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.52,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.52 from Fee Schedule UHC_98227C for Rev 301 Proc 82164 * Qty 1 = $17.52 at 100% = $17.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,17.52,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.52 from Fee Schedule UHC_98227C for Rev 301 Proc 82164 * Qty 1 = $17.52 at 100% = $17.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.60,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,17.52,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.52 from Fee Schedule UHC_98227C for Rev 301 Proc 82164 * Qty 1 = $17.52 at 100% = $17.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,UNITY HEALTH PLAN,UNITY HOSPICE,14.60,,,,,,,14.6000,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,97.92,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,84.32,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $84.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,97.92,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,97.92,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANGIOTENSIN I ENZYME TEST,82164,CPT,301,RC,30100190,CDM,,,,both,,,136.0000,89.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,81.60,,,,,,,14.6000,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $136.00 in Billed Charges for Rev 301 Proc 82164 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,AETNA,AETNA HSHS,26.49,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $26.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,AETNA,ALL COMMERCIAL AETNA,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,ANTHEM,ANTEHM MEDICAID,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80345 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,ANTHEM,ANTHEM POS/HMO,41.00,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80345 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $41.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,ANTHEM,ANTHEM PPO,41.00,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $79.87 from Fee Schedule WII28_25 for Rev 301 Proc 80345 Mod TC * Qty 1 = $79.87 at 100% = $79.87 (Limited to $41.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,CENPATICO,ALL MEDICAID CENPATICO,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,34.85,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,CIGNA,ALL COMMERCIAL CIGNA,28.70,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $28.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,COFINITY,COFINITY,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80345 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80345 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,38.95,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $38.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,34.44,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $34.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.11,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $29.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,29.93,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,19.93,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $19.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,34.85,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,HUMANA,HUMANA CHOICE CARE HMO,39.00,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80345 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,HUMANA,HUMANA CHOICE CARE PPO,34.85,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,HUMANA,HUMANA NATIIONAL POS HMO,39.00,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.00 from Fee Schedule 005543_170 for Rev 301 Proc 80345 * Qty 1 = $39.00 at 100% = $39.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,29.93,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,41.00,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $41.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80345 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.17,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80345 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,MOLINA HEALTHCARE,MOLINA MEDICAID,5.48,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80345 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 100% = $5.17... $5.17 at 106% = $5.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,20.50,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $20.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,34.44,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $34.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,30.75,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $30.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,37.72,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $37.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,24.60,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,24.60,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,PREVEA HEALTH NETWORK,PREVEA360,24.60,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,24.60,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.17,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $26.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,29.52,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,TRIOLOGY,TRILOGY MEDICAID,5.49,,,,,,,5.1700,41.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02040 Proc 80345 at $125.60 (Base Rate) * 0.0412 (Relative Weight) = $5.17 (Total Line Payment) at 106% = $5.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,29.52,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,25.42,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $25.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,29.52,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,29.52,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BARBITURATE,80345,CPT,301,RC,30100199,CDM,,,,both,,,41.0000,27.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,24.60,,,,,,,5.1700,41.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.00 in Billed Charges for Rev 301 Proc 80345 = $24.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA HSHS,126.62,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $126.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA MEDICARE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,AETNA,ALL COMMERCIAL AETNA,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTEHM MEDICAID,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM POS/HMO,68.46,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.46 from Fee Schedule WII28_25 for Rev 306 Proc 87254 Mod TC * Qty 1 = $68.46 at 100% = $68.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM PPO,68.46,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $68.46 from Fee Schedule WII28_25 for Rev 306 Proc 87254 Mod TC * Qty 1 = $68.46 at 100% = $68.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,CENPATICO,ALL MEDICAID CENPATICO,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,166.60,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,CIGNA,ALL COMMERCIAL CIGNA,137.20,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $137.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,COFINITY,COFINITY,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,186.20,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $186.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,164.64,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.16,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $139.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.08,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,95.26,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $95.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,166.60,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE HMO,33.25,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $33.25 from Fee Schedule 005543_170 for Rev 306 Proc 87254 * Qty 1 = $33.25 at 100% = $33.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE PPO,166.60,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA NATIIONAL POS HMO,33.25,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $33.25 from Fee Schedule 005543_170 for Rev 306 Proc 87254 * Qty 1 = $33.25 at 100% = $33.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.08,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,196.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,7.06,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,7.48,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 100% = $7.06... $7.06 at 106% = $7.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,164.64,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,44.01,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.00,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,180.32,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $180.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,25.43,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,25.43,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360,25.43,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,25.43,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.11,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $125.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,19.76,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.12,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,TRILOGY MEDICAID,7.48,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87254 at $7.06 (Fee Schedule) = $7.06 (Total Line Payment) at 106% = $7.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,23.47,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.47 from Fee Schedule UHC_98227C for Rev 306 Proc 87254 * Qty 1 = $23.47 at 100% = $23.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,23.47,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.47 from Fee Schedule UHC_98227C for Rev 306 Proc 87254 * Qty 1 = $23.47 at 100% = $23.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,23.47,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.47 from Fee Schedule UHC_98227C for Rev 306 Proc 87254 * Qty 1 = $23.47 at 100% = $23.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,UNITY HEALTH PLAN,UNITY HOSPICE,19.56,,,,,,,7.0600,196.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.12,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,121.52,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $121.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.12,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.12,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VIRUS INOCULATION SHELL VIA,87254,CPT,306,RC,30600194,CDM,,,,both,,,196.0000,129.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,117.60,,,,,,,7.0600,196.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $196.00 in Billed Charges for Rev 306 Proc 87254 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA HSHS,94.32,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,AETNA,ALL COMMERCIAL AETNA,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87270 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87270 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87270 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,CENPATICO,ALL MEDICAID CENPATICO,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.10,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,CIGNA,ALL COMMERCIAL CIGNA,102.20,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,COFINITY,COFINITY,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87270 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87270 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.70,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $138.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,122.64,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.66,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $103.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.58,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,70.96,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $70.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.10,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87270 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE PPO,124.10,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87270 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.58,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87270 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87270 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87270 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.64,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.50,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,134.32,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $134.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.19,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $93.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.12,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87270 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87270 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87270 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87270 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.12,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.52,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $90.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.12,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.12,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF CHLAMYDIA AG,87270,CPT,306,RC,30600201,CDM,,,,both,,,146.0000,96.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.60,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.00 in Billed Charges for Rev 306 Proc 87270 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA HSHS,73.64,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $73.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,AETNA,ALL COMMERCIAL AETNA,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87274 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87274 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87274 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,CENPATICO,ALL MEDICAID CENPATICO,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,96.90,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,CIGNA,ALL COMMERCIAL CIGNA,79.80,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,COFINITY,COFINITY,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87274 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87274 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,108.30,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $108.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,95.76,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.94,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $80.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,83.22,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,55.40,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $55.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,96.90,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87274 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE PPO,96.90,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87274 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,83.22,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,114.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87274 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87274 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87274 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,57.00,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,95.76,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,85.50,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,104.88,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $104.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,72.77,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $72.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,82.08,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87274 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87274 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87274 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87274 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,82.08,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,70.68,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $70.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,82.08,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,82.08,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF HERPES SIMPLEX 1 AG,87274,CPT,306,RC,30600203,CDM,,,,both,,,114.0000,75.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,68.40,,,,,,,11.9800,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $114.00 in Billed Charges for Rev 306 Proc 87274 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA HSHS,94.32,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA MEDICARE,12.25,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,AETNA,ALL COMMERCIAL AETNA,146.00,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTEHM MEDICAID,12.66,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87275 at $12.66 (Fee Schedule) = $12.66 (Total Line Payment) at 100% = $12.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,12.25,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM POS/HMO,42.88,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.88 from Fee Schedule WII28_25 for Rev 306 Proc 87275 Mod TC * Qty 1 = $42.88 at 100% = $42.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM PPO,42.88,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.88 from Fee Schedule WII28_25 for Rev 306 Proc 87275 Mod TC * Qty 1 = $42.88 at 100% = $42.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,146.00,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,CENPATICO,ALL MEDICAID CENPATICO,146.00,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.10,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,CIGNA,ALL COMMERCIAL CIGNA,102.20,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,COFINITY,COFINITY,146.00,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.66,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87275 at $12.66 (Fee Schedule) = $12.66 (Total Line Payment) at 100% = $12.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.66,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87275 at $12.66 (Fee Schedule) = $12.66 (Total Line Payment) at 100% = $12.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.70,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $138.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,122.64,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.66,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $103.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.58,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,70.96,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $70.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.10,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE HMO,20.83,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.83 from Fee Schedule 005543_170 for Rev 306 Proc 87275 * Qty 1 = $20.83 at 100% = $20.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE PPO,124.10,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,12.25,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA NATIIONAL POS HMO,20.83,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.83 from Fee Schedule 005543_170 for Rev 306 Proc 87275 * Qty 1 = $20.83 at 100% = $20.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.58,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,146.00,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.66,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87275 at $12.66 (Fee Schedule) = $12.66 (Total Line Payment) at 100% = $12.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.25,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.66,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87275 at $12.66 (Fee Schedule) = $12.66 (Total Line Payment) at 100% = $12.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,13.42,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87275 at $12.66 (Fee Schedule) = $12.66 (Total Line Payment) at 100% = $12.66... $12.66 at 106% = $13.42 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,12.25,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.00,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.64,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,27.56,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.50,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,134.32,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $134.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.93,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.93,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360,15.93,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.93,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.19,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $93.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.37,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.12,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,TRILOGY MEDICAID,13.42,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87275 at $12.66 (Fee Schedule) = $12.66 (Total Line Payment) at 106% = $13.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.70,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.70 from Fee Schedule UHC_98227C for Rev 306 Proc 87275 * Qty 1 = $14.70 at 100% = $14.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,14.70,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.70 from Fee Schedule UHC_98227C for Rev 306 Proc 87275 * Qty 1 = $14.70 at 100% = $14.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,12.25,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,14.70,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.70 from Fee Schedule UHC_98227C for Rev 306 Proc 87275 * Qty 1 = $14.70 at 100% = $14.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,UNITY HEALTH PLAN,UNITY HOSPICE,12.25,,,,,,,12.2500,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.12,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.52,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $90.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.12,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.12,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF INFLUENZA B AG,87275,CPT,306,RC,30600204,CDM,,,,both,,,146.0000,96.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.60,,,,,,,12.2500,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.00 in Billed Charges for Rev 306 Proc 87275 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA HSHS,73.64,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $73.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,AETNA,AETNA MEDICARE,16.43,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,AETNA,ALL COMMERCIAL AETNA,114.00,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTEHM MEDICAID,16.86,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87279 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.43,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM POS/HMO,57.51,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.51 from Fee Schedule WII28_25 for Rev 306 Proc 87279 Mod TC * Qty 1 = $57.51 at 100% = $57.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,ANTHEM,ANTHEM PPO,57.51,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.51 from Fee Schedule WII28_25 for Rev 306 Proc 87279 Mod TC * Qty 1 = $57.51 at 100% = $57.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,114.00,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,CENPATICO,ALL MEDICAID CENPATICO,114.00,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,96.90,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,CIGNA,ALL COMMERCIAL CIGNA,79.80,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,COFINITY,COFINITY,114.00,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.86,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87279 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.86,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87279 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,108.30,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $108.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,95.76,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.94,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $80.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,83.22,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,55.40,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $55.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,96.90,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE HMO,27.93,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.93 from Fee Schedule 005543_170 for Rev 306 Proc 87279 * Qty 1 = $27.93 at 100% = $27.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA CHOICE CARE PPO,96.90,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,16.43,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,HUMANA,HUMANA NATIIONAL POS HMO,27.93,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.93 from Fee Schedule 005543_170 for Rev 306 Proc 87279 * Qty 1 = $27.93 at 100% = $27.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,83.22,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $83.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,114.00,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.86,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87279 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.43,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.86,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87279 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,17.87,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87279 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86... $16.86 at 106% = $17.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,16.43,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,57.00,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,95.76,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $95.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,36.97,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,85.50,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,104.88,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $104.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.36,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.36,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360,21.36,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.36,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,72.77,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $72.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.59,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,82.08,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,TRIOLOGY,TRILOGY MEDICAID,17.87,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87279 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 106% = $17.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.72,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87279 * Qty 1 = $19.72 at 100% = $19.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,19.72,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87279 * Qty 1 = $19.72 at 100% = $19.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.43,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,19.72,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87279 * Qty 1 = $19.72 at 100% = $19.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,UNITY HEALTH PLAN,UNITY HOSPICE,16.43,,,,,,,16.4300,114.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,82.08,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,70.68,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $70.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,82.08,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,82.08,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $82.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF PARAFLUENZA AG,87279,CPT,306,RC,30600207,CDM,,,,both,,,114.0000,75.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,68.40,,,,,,,16.4300,114.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $114.00 in Billed Charges for Rev 306 Proc 87279 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,AETNA,AETNA HSHS,115.63,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $115.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,AETNA,ALL COMMERCIAL AETNA,179.00,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87305 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87305 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87305 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,179.00,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,CENPATICO,ALL MEDICAID CENPATICO,179.00,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,152.15,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $152.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,CIGNA,ALL COMMERCIAL CIGNA,125.30,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $125.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,COFINITY,COFINITY,179.00,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87305 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87305 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,170.05,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $170.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,150.36,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $150.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,127.09,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $127.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,130.67,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $130.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,86.99,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $86.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,152.15,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $152.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87305 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HUMANA,HUMANA CHOICE CARE PPO,152.15,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $152.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87305 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,130.67,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $130.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,179.00,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87305 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87305 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87305 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,89.50,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $89.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,150.36,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $150.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,134.25,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $134.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,164.68,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $164.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,114.26,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $114.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,128.88,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $128.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87305 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87305 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87305 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87305 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,128.88,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $128.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,110.98,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $110.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,128.88,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $128.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,128.88,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $128.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL ASPERGILLUS AG,87305,CPT,306,RC,30600212,CDM,,,,both,,,179.0000,118.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,107.40,,,,,,,11.9800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $179.00 in Billed Charges for Rev 306 Proc 87305 = $107.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA HSHS,94.32,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $94.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,AETNA,AETNA MEDICARE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,AETNA,ALL COMMERCIAL AETNA,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTEHM MEDICAID,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87324 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM POS/HMO,41.93,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87324 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,ANTHEM,ANTHEM PPO,41.93,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.93 from Fee Schedule WII28_25 for Rev 306 Proc 87324 Mod TC * Qty 1 = $41.93 at 100% = $41.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,CENPATICO,ALL MEDICAID CENPATICO,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.10,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,CIGNA,ALL COMMERCIAL CIGNA,102.20,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,COFINITY,COFINITY,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87324 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87324 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.70,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $138.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,122.64,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.66,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $103.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.58,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,70.96,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $70.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.10,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE HMO,20.37,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87324 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA CHOICE CARE PPO,124.10,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $124.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,HUMANA,HUMANA NATIIONAL POS HMO,20.37,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.37 from Fee Schedule 005543_170 for Rev 306 Proc 87324 * Qty 1 = $20.37 at 100% = $20.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.58,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $106.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,146.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87324 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87324 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,13.12,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87324 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 100% = $12.38... $12.38 at 106% = $13.12 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.00,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.64,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,26.96,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.50,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,134.32,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $134.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.57,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.57,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360,15.57,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.57,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.19,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $93.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.10,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.12,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,TRIOLOGY,TRILOGY MEDICAID,13.12,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87324 at $12.38 (Fee Schedule) = $12.38 (Total Line Payment) at 106% = $13.12. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87324 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87324 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.38 from Fee Schedule UHC_98227C for Rev 306 Proc 87324 * Qty 1 = $14.38 at 100% = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,UNITY HEALTH PLAN,UNITY HOSPICE,11.98,,,,,,,11.9800,146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.12,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.52,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $90.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.12,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.12,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL CLOS DIFF TOXIN AG,87324,CPT,306,RC,30600213,CDM,,,,both,,,146.0000,96.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.60,,,,,,,11.9800,146.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.00 in Billed Charges for Rev 306 Proc 87324 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,AETNA,AETNA HSHS,115.63,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $115.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,AETNA,AETNA MEDICARE,14.38,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,AETNA,ALL COMMERCIAL AETNA,179.00,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,ANTHEM,ANTEHM MEDICAID,14.86,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87338 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.38,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,ANTHEM,ANTHEM POS/HMO,50.33,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.33 from Fee Schedule WII28_25 for Rev 306 Proc 87338 Mod TC * Qty 1 = $50.33 at 100% = $50.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,ANTHEM,ANTHEM PPO,50.33,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.33 from Fee Schedule WII28_25 for Rev 306 Proc 87338 Mod TC * Qty 1 = $50.33 at 100% = $50.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,179.00,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,CENPATICO,ALL MEDICAID CENPATICO,179.00,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,152.15,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $152.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,CIGNA,ALL COMMERCIAL CIGNA,125.30,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $125.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,COFINITY,COFINITY,179.00,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.86,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87338 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.86,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87338 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,170.05,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $170.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,150.36,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $150.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,127.09,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $127.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,130.67,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $130.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,86.99,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $86.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,152.15,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $152.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HUMANA,HUMANA CHOICE CARE HMO,24.45,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.45 from Fee Schedule 005543_170 for Rev 306 Proc 87338 * Qty 1 = $24.45 at 100% = $24.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HUMANA,HUMANA CHOICE CARE PPO,152.15,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $152.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,14.38,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,HUMANA,HUMANA NATIIONAL POS HMO,24.45,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.45 from Fee Schedule 005543_170 for Rev 306 Proc 87338 * Qty 1 = $24.45 at 100% = $24.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,130.67,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $130.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,179.00,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.86,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87338 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.38,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.86,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87338 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,15.75,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87338 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86... $14.86 at 106% = $15.75 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,14.38,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,89.50,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $89.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,150.36,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $150.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,32.36,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,134.25,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $134.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,164.68,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $164.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.69,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.69,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,PREVEA HEALTH NETWORK,PREVEA360,18.69,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.69,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,114.26,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $114.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.52,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,128.88,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $128.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,TRIOLOGY,TRILOGY MEDICAID,15.75,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87338 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 106% = $15.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.26,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.26 from Fee Schedule UHC_98227C for Rev 306 Proc 87338 * Qty 1 = $17.26 at 100% = $17.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,17.26,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.26 from Fee Schedule UHC_98227C for Rev 306 Proc 87338 * Qty 1 = $17.26 at 100% = $17.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.38,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,17.26,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.26 from Fee Schedule UHC_98227C for Rev 306 Proc 87338 * Qty 1 = $17.26 at 100% = $17.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,UNITY HEALTH PLAN,UNITY HOSPICE,14.38,,,,,,,14.3800,179.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,128.88,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $128.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,110.98,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $110.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,128.88,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $128.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,128.88,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $128.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL H PYLORI AG STOOL,87338,CPT,306,RC,30600217,CDM,,,,both,,,179.0000,118.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,107.40,,,,,,,14.3800,179.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $179.00 in Billed Charges for Rev 306 Proc 87338 = $107.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA HSHS,67.18,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,AETNA,ALL COMMERCIAL AETNA,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTEHM MEDICAID,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM POS/HMO,36.16,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.16 from Fee Schedule WII28_25 for Rev 306 Proc 87340 Mod TC * Qty 1 = $36.16 at 100% = $36.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM PPO,36.16,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.16 from Fee Schedule WII28_25 for Rev 306 Proc 87340 Mod TC * Qty 1 = $36.16 at 100% = $36.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,CENPATICO,ALL MEDICAID CENPATICO,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,CIGNA,ALL COMMERCIAL CIGNA,72.80,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,COFINITY,COFINITY,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,98.80,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $98.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,87.36,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,73.84,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $73.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,75.92,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,50.54,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE HMO,17.56,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.56 from Fee Schedule 005543_170 for Rev 306 Proc 87340 * Qty 1 = $17.56 at 100% = $17.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE PPO,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA NATIIONAL POS HMO,17.56,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.56 from Fee Schedule 005543_170 for Rev 306 Proc 87340 * Qty 1 = $17.56 at 100% = $17.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,75.92,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,11.31,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67... $10.67 at 106% = $11.31 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,52.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,87.36,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,23.24,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,78.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,95.68,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $95.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,66.38,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $66.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,10.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,TRILOGY MEDICAID,11.31,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87340 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 106% = $11.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87340 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87340 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87340 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,UNITY HEALTH PLAN,UNITY HOSPICE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,64.48,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $64.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG,87340,CPT,306,RC,30600218,CDM,,,,both,,,104.0000,68.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,62.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.00 in Billed Charges for Rev 306 Proc 87340 = $62.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA HSHS,67.18,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,AETNA,ALL COMMERCIAL AETNA,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTEHM MEDICAID,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87341 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM POS/HMO,36.16,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.16 from Fee Schedule WII28_25 for Rev 306 Proc 87341 Mod TC * Qty 1 = $36.16 at 100% = $36.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM PPO,36.16,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.16 from Fee Schedule WII28_25 for Rev 306 Proc 87341 Mod TC * Qty 1 = $36.16 at 100% = $36.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,CENPATICO,ALL MEDICAID CENPATICO,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,CIGNA,ALL COMMERCIAL CIGNA,72.80,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,COFINITY,COFINITY,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87341 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87341 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,98.80,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $98.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,87.36,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,73.84,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $73.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,75.92,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,50.54,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE HMO,17.56,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.56 from Fee Schedule 005543_170 for Rev 306 Proc 87341 * Qty 1 = $17.56 at 100% = $17.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE PPO,88.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA NATIIONAL POS HMO,17.56,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.56 from Fee Schedule 005543_170 for Rev 306 Proc 87341 * Qty 1 = $17.56 at 100% = $17.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,75.92,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,104.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87341 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.67,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87341 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,11.31,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87341 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 100% = $10.67... $10.67 at 106% = $11.31 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,52.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,87.36,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,23.24,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,78.00,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,95.68,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $95.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,66.38,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $66.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,10.43,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,TRILOGY MEDICAID,11.31,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87341 at $10.67 (Fee Schedule) = $10.67 (Total Line Payment) at 106% = $11.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87341 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87341 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,12.40,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.40 from Fee Schedule UHC_98227C for Rev 306 Proc 87341 * Qty 1 = $12.40 at 100% = $12.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,UNITY HEALTH PLAN,UNITY HOSPICE,10.33,,,,,,,10.3300,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,64.48,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $64.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,74.88,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EIA QL HEPATITIS B AG NEUT,87341,CPT,306,RC,30600220,CDM,,,,both,,,104.0000,68.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,62.40,,,,,,,10.3300,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.00 in Billed Charges for Rev 306 Proc 87341 = $62.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA HSHS,58.14,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $58.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,AETNA,AETNA MEDICARE,11.53,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,AETNA,ALL COMMERCIAL AETNA,90.00,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTEHM MEDICAID,11.91,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87350 at $11.91 (Fee Schedule) = $11.91 (Total Line Payment) at 100% = $11.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.53,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM POS/HMO,40.36,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.36 from Fee Schedule WII28_25 for Rev 306 Proc 87350 Mod TC * Qty 1 = $40.36 at 100% = $40.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,ANTHEM,ANTHEM PPO,40.36,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.36 from Fee Schedule WII28_25 for Rev 306 Proc 87350 Mod TC * Qty 1 = $40.36 at 100% = $40.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,90.00,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,CENPATICO,ALL MEDICAID CENPATICO,90.00,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,76.50,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,CIGNA,ALL COMMERCIAL CIGNA,63.00,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,COFINITY,COFINITY,90.00,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,11.91,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87350 at $11.91 (Fee Schedule) = $11.91 (Total Line Payment) at 100% = $11.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,11.91,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87350 at $11.91 (Fee Schedule) = $11.91 (Total Line Payment) at 100% = $11.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,85.50,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $85.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,75.60,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.90,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $63.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,65.70,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,43.74,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $43.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,76.50,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE HMO,19.60,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.60 from Fee Schedule 005543_170 for Rev 306 Proc 87350 * Qty 1 = $19.60 at 100% = $19.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA CHOICE CARE PPO,76.50,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $76.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,11.53,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,HUMANA,HUMANA NATIIONAL POS HMO,19.60,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.60 from Fee Schedule 005543_170 for Rev 306 Proc 87350 * Qty 1 = $19.60 at 100% = $19.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,65.70,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,90.00,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,11.91,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87350 at $11.91 (Fee Schedule) = $11.91 (Total Line Payment) at 100% = $11.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.53,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,11.91,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87350 at $11.91 (Fee Schedule) = $11.91 (Total Line Payment) at 100% = $11.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,12.62,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87350 at $11.91 (Fee Schedule) = $11.91 (Total Line Payment) at 100% = $11.91... $11.91 at 106% = $12.62 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,11.53,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.00,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,75.60,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $75.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,25.94,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,67.50,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $67.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,82.80,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.99,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.99,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360,14.99,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.99,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,57.45,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $57.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,11.65,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,64.80,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,TRIOLOGY,TRILOGY MEDICAID,12.62,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87350 at $11.91 (Fee Schedule) = $11.91 (Total Line Payment) at 106% = $12.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,13.84,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.84 from Fee Schedule UHC_98227C for Rev 306 Proc 87350 * Qty 1 = $13.84 at 100% = $13.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,13.84,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.84 from Fee Schedule UHC_98227C for Rev 306 Proc 87350 * Qty 1 = $13.84 at 100% = $13.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.53,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,13.84,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.84 from Fee Schedule UHC_98227C for Rev 306 Proc 87350 * Qty 1 = $13.84 at 100% = $13.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,UNITY HEALTH PLAN,UNITY HOSPICE,11.53,,,,,,,11.5300,90.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,64.80,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.80,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,64.80,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,64.80,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $64.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HEPATITIS BE AG QL,87350,CPT,306,RC,30600221,CDM,,,,both,,,90.0000,59.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,54.00,,,,,,,11.5300,90.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $90.00 in Billed Charges for Rev 306 Proc 87350 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,AETNA,AETNA HSHS,78.17,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $78.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,AETNA,AETNA MEDICARE,16.81,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,AETNA,ALL COMMERCIAL AETNA,121.00,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTEHM MEDICAID,16.86,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87430 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.81,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM POS/HMO,58.84,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.84 from Fee Schedule WII28_25 for Rev 306 Proc 87430 Mod TC * Qty 1 = $58.84 at 100% = $58.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM PPO,58.84,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.84 from Fee Schedule WII28_25 for Rev 306 Proc 87430 Mod TC * Qty 1 = $58.84 at 100% = $58.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,121.00,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,CENPATICO,ALL MEDICAID CENPATICO,121.00,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,102.85,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,CIGNA,ALL COMMERCIAL CIGNA,84.70,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $84.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,COFINITY,COFINITY,121.00,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.86,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87430 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.86,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87430 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,114.95,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $114.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,101.64,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $101.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,85.91,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $85.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,88.33,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $88.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,58.81,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $58.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,102.85,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA CHOICE CARE HMO,28.58,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.58 from Fee Schedule 005543_170 for Rev 306 Proc 87430 * Qty 1 = $28.58 at 100% = $28.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA CHOICE CARE PPO,102.85,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,16.81,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA NATIIONAL POS HMO,28.58,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.58 from Fee Schedule 005543_170 for Rev 306 Proc 87430 * Qty 1 = $28.58 at 100% = $28.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,88.33,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $88.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,121.00,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.86,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87430 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.81,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.86,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87430 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,17.87,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87430 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86... $16.86 at 106% = $17.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,16.81,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,60.50,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $60.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,101.64,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $101.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,37.82,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,90.75,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $90.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,111.32,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $111.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.85,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.85,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA360,21.85,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.85,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.23,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $77.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.98,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.12,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,TRIOLOGY,TRILOGY MEDICAID,17.87,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87430 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 106% = $17.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.17,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.17 from Fee Schedule UHC_98227C for Rev 306 Proc 87430 * Qty 1 = $20.17 at 100% = $20.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,20.17,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.17 from Fee Schedule UHC_98227C for Rev 306 Proc 87430 * Qty 1 = $20.17 at 100% = $20.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.81,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,20.17,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.17 from Fee Schedule UHC_98227C for Rev 306 Proc 87430 * Qty 1 = $20.17 at 100% = $20.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,UNITY HEALTH PLAN,UNITY HOSPICE,16.81,,,,,,,16.8100,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.12,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.02,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $75.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.12,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.12,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RAPID STREP,87430,CPT,306,RC,30600228,CDM,,,,both,,,121.0000,79.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,72.60,,,,,,,16.8100,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $121.00 in Billed Charges for Rev 306 Proc 87430 = $72.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,AETNA,AETNA HSHS,212.53,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $212.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,AETNA,ALL COMMERCIAL AETNA,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87491 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87491 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87491 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,CENPATICO,ALL MEDICAID CENPATICO,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,279.65,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $279.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,CIGNA,ALL COMMERCIAL CIGNA,230.30,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $230.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,COFINITY,COFINITY,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87491 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87491 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,312.55,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $312.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,276.36,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $276.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,233.59,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $233.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,240.17,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $240.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,159.89,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $159.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,279.65,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $279.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87491 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HUMANA,HUMANA CHOICE CARE PPO,279.65,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $279.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87491 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,240.17,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $240.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87491 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87491 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87491 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,164.50,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $164.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,276.36,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $276.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,246.75,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $246.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,302.68,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $302.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,210.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,236.88,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $236.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87491 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87491 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87491 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87491 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,236.88,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $236.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,203.98,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $203.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,236.88,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $236.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,236.88,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $236.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLMYD TRACH DNA AMP PROBE,87491,CPT,306,RC,30600236,CDM,,,,both,,,329.0000,217.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,197.40,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $329.00 in Billed Charges for Rev 306 Proc 87491 = $197.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,37.27,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,38.51,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87493 at $38.51 (Fee Schedule) = $38.51 (Total Line Payment) at 100% = $38.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,37.27,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,130.45,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $130.45 from Fee Schedule WII28_25 for Rev 306 Proc 87493 Mod TC * Qty 1 = $130.45 at 100% = $130.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,130.45,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $130.45 from Fee Schedule WII28_25 for Rev 306 Proc 87493 Mod TC * Qty 1 = $130.45 at 100% = $130.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,38.51,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87493 at $38.51 (Fee Schedule) = $38.51 (Total Line Payment) at 100% = $38.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,38.51,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87493 at $38.51 (Fee Schedule) = $38.51 (Total Line Payment) at 100% = $38.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,63.36,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $63.36 from Fee Schedule 005543_170 for Rev 306 Proc 87493 * Qty 1 = $63.36 at 100% = $63.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,37.27,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,63.36,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $63.36 from Fee Schedule 005543_170 for Rev 306 Proc 87493 * Qty 1 = $63.36 at 100% = $63.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,38.51,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87493 at $38.51 (Fee Schedule) = $38.51 (Total Line Payment) at 100% = $38.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,37.27,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,38.51,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87493 at $38.51 (Fee Schedule) = $38.51 (Total Line Payment) at 100% = $38.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,40.82,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87493 at $38.51 (Fee Schedule) = $38.51 (Total Line Payment) at 100% = $38.51... $38.51 at 106% = $40.82 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,37.27,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,83.86,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,48.45,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,48.45,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,48.45,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,48.45,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,37.64,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,40.82,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87493 at $38.51 (Fee Schedule) = $38.51 (Total Line Payment) at 106% = $40.82. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,44.72,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $44.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87493 * Qty 1 = $44.72 at 100% = $44.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,44.72,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $44.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87493 * Qty 1 = $44.72 at 100% = $44.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,37.27,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,44.72,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $44.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87493 * Qty 1 = $44.72 at 100% = $44.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,37.27,,,,,,,37.2700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLOSTRIDUM DIFFICILE,87493,CPT,306,RC,30600237,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,37.2700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87493 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87498 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87498 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87498 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87498 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87498 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87498 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87498 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87498 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87498 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87498 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87498 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87498 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87498 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87498 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENTEROVIRUS AMP PROBE,87498,CPT,306,RC,30600239,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87498 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,AETNA,AETNA HSHS,320.42,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $320.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,AETNA,AETNA MEDICARE,42.84,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,AETNA,ALL COMMERCIAL AETNA,496.00,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,ANTHEM,ANTEHM MEDICAID,44.27,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87517 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,42.84,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,ANTHEM,ANTHEM POS/HMO,149.94,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87517 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,ANTHEM,ANTHEM PPO,149.94,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87517 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,496.00,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,CENPATICO,ALL MEDICAID CENPATICO,496.00,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,421.60,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $421.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,CIGNA,ALL COMMERCIAL CIGNA,347.20,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $347.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,COFINITY,COFINITY,496.00,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,44.27,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87517 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,44.27,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87517 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,471.20,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $471.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,416.64,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $416.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,352.16,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $352.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,362.08,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $362.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,241.06,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $241.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,421.60,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $421.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HUMANA,HUMANA CHOICE CARE HMO,72.83,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87517 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HUMANA,HUMANA CHOICE CARE PPO,421.60,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $421.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,42.84,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,HUMANA,HUMANA NATIIONAL POS HMO,72.83,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87517 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,362.08,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $362.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,496.00,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,44.27,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87517 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,42.84,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,44.27,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87517 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,46.93,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87517 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27... $44.27 at 106% = $46.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,42.84,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,248.00,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $248.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,416.64,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $416.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,96.39,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,372.00,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,456.32,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $456.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,55.69,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,55.69,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,PREVEA HEALTH NETWORK,PREVEA360,55.69,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,55.69,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,316.60,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $316.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,43.27,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,357.12,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $357.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,TRIOLOGY,TRILOGY MEDICAID,46.93,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87517 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 106% = $46.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,51.41,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87517 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,51.41,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87517 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,42.84,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,51.41,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87517 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,UNITY HEALTH PLAN,UNITY HOSPICE,42.84,,,,,,,42.8400,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,357.12,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $357.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,307.52,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $307.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,357.12,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $357.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,357.12,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $357.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS B DNA QUANT,87517,CPT,306,RC,30600240,CDM,,,,both,,,496.0000,327.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,297.60,,,,,,,42.8400,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $496.00 in Billed Charges for Rev 306 Proc 87517 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,AETNA,AETNA HSHS,281.66,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $281.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,AETNA,AETNA MEDICARE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,AETNA,ALL COMMERCIAL AETNA,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTEHM MEDICAID,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87522 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM POS/HMO,149.94,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87522 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM PPO,149.94,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87522 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,CENPATICO,ALL MEDICAID CENPATICO,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,370.60,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,CIGNA,ALL COMMERCIAL CIGNA,305.20,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $305.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,COFINITY,COFINITY,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87522 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87522 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,414.20,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $414.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,366.24,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,309.56,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $309.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,318.28,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,211.90,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $211.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,370.60,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE HMO,72.83,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87522 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE PPO,370.60,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA NATIIONAL POS HMO,72.83,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87522 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,318.28,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87522 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87522 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,46.93,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87522 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27... $44.27 at 106% = $46.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,218.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,366.24,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,96.39,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,327.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $327.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,401.12,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $401.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,55.69,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,55.69,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360,55.69,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,55.69,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,278.30,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $278.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,43.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,313.92,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,TRIOLOGY,TRILOGY MEDICAID,46.93,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87522 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 106% = $46.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,51.41,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87522 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,51.41,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87522 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,51.41,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87522 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,UNITY HEALTH PLAN,UNITY HOSPICE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,313.92,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,270.32,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $270.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,313.92,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,313.92,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,30600242,CDM,,,,both,,,436.0000,287.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,261.60,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 306 Proc 87522 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,AETNA,AETNA HSHS,281.66,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $281.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,AETNA,ALL COMMERCIAL AETNA,436.00,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87535 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87535 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87535 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,436.00,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,CENPATICO,ALL MEDICAID CENPATICO,436.00,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,370.60,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,CIGNA,ALL COMMERCIAL CIGNA,305.20,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $305.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,COFINITY,COFINITY,436.00,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87535 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87535 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,414.20,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $414.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,366.24,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,309.56,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $309.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,318.28,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,211.90,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $211.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,370.60,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87535 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE PPO,370.60,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87535 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,318.28,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,436.00,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87535 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87535 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87535 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,218.00,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,366.24,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,327.00,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $327.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,401.12,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $401.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,278.30,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $278.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,313.92,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87535 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87535 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87535 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87535 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,313.92,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,270.32,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $270.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,313.92,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,313.92,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROBE HIV-1 AMP,87535,CPT,306,RC,30600245,CDM,,,,both,,,436.0000,287.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,261.60,,,,,,,35.0900,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 306 Proc 87535 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,AETNA,AETNA HSHS,281.66,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $281.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,AETNA,AETNA MEDICARE,85.10,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,AETNA,ALL COMMERCIAL AETNA,436.00,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTEHM MEDICAID,87.93,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87536 at $87.93 (Fee Schedule) = $87.93 (Total Line Payment) at 100% = $87.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,85.10,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM POS/HMO,297.85,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $297.85 from Fee Schedule WII28_25 for Rev 306 Proc 87536 Mod TC * Qty 1 = $297.85 at 100% = $297.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM PPO,297.85,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $297.85 from Fee Schedule WII28_25 for Rev 306 Proc 87536 Mod TC * Qty 1 = $297.85 at 100% = $297.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,436.00,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,CENPATICO,ALL MEDICAID CENPATICO,436.00,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,370.60,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,CIGNA,ALL COMMERCIAL CIGNA,305.20,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $305.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,COFINITY,COFINITY,436.00,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,87.93,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87536 at $87.93 (Fee Schedule) = $87.93 (Total Line Payment) at 100% = $87.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,87.93,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87536 at $87.93 (Fee Schedule) = $87.93 (Total Line Payment) at 100% = $87.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,414.20,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $414.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,366.24,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,309.56,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $309.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,318.28,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,211.90,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $211.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,370.60,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE HMO,144.67,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $144.67 from Fee Schedule 005543_170 for Rev 306 Proc 87536 * Qty 1 = $144.67 at 100% = $144.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE PPO,370.60,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,85.10,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA NATIIONAL POS HMO,144.67,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $144.67 from Fee Schedule 005543_170 for Rev 306 Proc 87536 * Qty 1 = $144.67 at 100% = $144.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,318.28,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,436.00,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,87.93,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87536 at $87.93 (Fee Schedule) = $87.93 (Total Line Payment) at 100% = $87.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,85.10,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,87.93,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87536 at $87.93 (Fee Schedule) = $87.93 (Total Line Payment) at 100% = $87.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,93.21,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87536 at $87.93 (Fee Schedule) = $87.93 (Total Line Payment) at 100% = $87.93... $87.93 at 106% = $93.21 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,85.10,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,218.00,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,366.24,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,191.48,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,327.00,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $327.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,401.12,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $401.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,110.63,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,110.63,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360,110.63,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,110.63,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,278.30,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $278.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,85.95,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,313.92,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,TRIOLOGY,TRILOGY MEDICAID,93.21,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87536 at $87.93 (Fee Schedule) = $87.93 (Total Line Payment) at 106% = $93.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,102.12,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $102.12 from Fee Schedule UHC_98227C for Rev 306 Proc 87536 * Qty 1 = $102.12 at 100% = $102.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,102.12,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $102.12 from Fee Schedule UHC_98227C for Rev 306 Proc 87536 * Qty 1 = $102.12 at 100% = $102.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,85.10,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,102.12,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $102.12 from Fee Schedule UHC_98227C for Rev 306 Proc 87536 * Qty 1 = $102.12 at 100% = $102.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,UNITY HEALTH PLAN,UNITY HOSPICE,85.10,,,,,,,85.1000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,313.92,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,270.32,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $270.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,313.92,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,313.92,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HIV-1 QUANT&REVRSE TRNSCRPJ,87536,CPT,306,RC,30600246,CDM,,,,both,,,436.0000,287.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,261.60,,,,,,,85.1000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 306 Proc 87536 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87591 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87591 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87591 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87591 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87591 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87591 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87591 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEISSERIA AMP,87591,CPT,306,RC,30600249,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87591 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87640 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87640 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87640 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87640 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87640 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87640 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87640 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87640 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87640 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87640 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87640 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87640 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87640 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87640 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC STAPH AURE AMP PROBE,87640,CPT,306,RC,30600254,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87640 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,AETNA,AETNA HSHS,106.59,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $106.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,AETNA,ALL COMMERCIAL AETNA,165.00,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $165.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87641 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87641 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,165.00,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $165.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,CENPATICO,ALL MEDICAID CENPATICO,165.00,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $165.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,140.25,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $140.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,CIGNA,ALL COMMERCIAL CIGNA,115.50,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $115.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,COFINITY,COFINITY,165.00,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $165.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,156.75,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $156.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,138.60,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $138.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,117.15,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $117.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,120.45,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $120.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,80.19,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $80.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,140.25,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $140.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87641 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HUMANA,HUMANA CHOICE CARE PPO,140.25,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $140.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87641 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,120.45,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $120.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,165.00,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $165.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,82.50,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $82.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,138.60,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $138.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,123.75,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $123.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,151.80,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $151.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,105.32,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $105.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,118.80,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $118.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87641 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87641 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87641 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,165.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,118.80,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $118.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,102.30,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $102.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,118.80,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $118.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,118.80,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $118.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MRSA AMP,87641,CPT,306,RC,30600255,CDM,,,,both,,,165.0000,108.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,99.00,,,,,,,35.0900,165.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $165.00 in Billed Charges for Rev 306 Proc 87641 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87653 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87653 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87653 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87653 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87653 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87653 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87653 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87653 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87653 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87653 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87653 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87653 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87653 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87653 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STREP B DNA AMP PROBE,87653,CPT,306,RC,30600257,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87653 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87798 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87798 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87798 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87798 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP,87798,CPT,306,RC,30600266,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87798 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,AETNA,AETNA HSHS,281.66,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $281.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,AETNA,AETNA MEDICARE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,AETNA,ALL COMMERCIAL AETNA,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTEHM MEDICAID,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87799 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM POS/HMO,149.94,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87799 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,ANTHEM,ANTHEM PPO,149.94,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87799 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,CENPATICO,ALL MEDICAID CENPATICO,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,370.60,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,CIGNA,ALL COMMERCIAL CIGNA,305.20,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $305.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,COFINITY,COFINITY,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87799 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87799 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,414.20,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $414.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,366.24,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,309.56,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $309.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,318.28,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,211.90,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $211.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,370.60,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE HMO,72.83,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87799 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE PPO,370.60,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,HUMANA,HUMANA NATIIONAL POS HMO,72.83,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87799 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,318.28,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,436.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87799 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,44.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87799 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,46.93,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87799 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27... $44.27 at 106% = $46.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,218.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,366.24,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,96.39,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,327.00,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $327.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,401.12,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $401.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,55.69,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,55.69,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360,55.69,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,55.69,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,278.30,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $278.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,43.27,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,313.92,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,TRIOLOGY,TRILOGY MEDICAID,46.93,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87799 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 106% = $46.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,51.41,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87799 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,51.41,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87799 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,51.41,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87799 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,UNITY HEALTH PLAN,UNITY HOSPICE,42.84,,,,,,,42.8400,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,313.92,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,270.32,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $270.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,313.92,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,313.92,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DETECT AGENT NOS DNA QUANT,87799,CPT,306,RC,30600267,CDM,,,,both,,,436.0000,287.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,261.60,,,,,,,42.8400,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 306 Proc 87799 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,AETNA,AETNA HSHS,114.34,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $114.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,AETNA,AETNA MEDICARE,12.73,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,AETNA,ALL COMMERCIAL AETNA,177.00,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,ANTHEM,ANTEHM MEDICAID,13.15,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87802 at $13.15 (Fee Schedule) = $13.15 (Total Line Payment) at 100% = $13.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,12.73,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,ANTHEM,ANTHEM POS/HMO,44.56,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $44.56 from Fee Schedule WII28_25 for Rev 306 Proc 87802 Mod TC * Qty 1 = $44.56 at 100% = $44.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,ANTHEM,ANTHEM PPO,44.56,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $44.56 from Fee Schedule WII28_25 for Rev 306 Proc 87802 Mod TC * Qty 1 = $44.56 at 100% = $44.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,177.00,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,CENPATICO,ALL MEDICAID CENPATICO,177.00,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,150.45,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $150.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,CIGNA,ALL COMMERCIAL CIGNA,123.90,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $123.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,COFINITY,COFINITY,177.00,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.15,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87802 at $13.15 (Fee Schedule) = $13.15 (Total Line Payment) at 100% = $13.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.15,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87802 at $13.15 (Fee Schedule) = $13.15 (Total Line Payment) at 100% = $13.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,168.15,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $168.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,148.68,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $148.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,125.67,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $125.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,129.21,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $129.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,86.02,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $86.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,150.45,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $150.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HUMANA,HUMANA CHOICE CARE HMO,21.64,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.64 from Fee Schedule 005543_170 for Rev 306 Proc 87802 * Qty 1 = $21.64 at 100% = $21.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HUMANA,HUMANA CHOICE CARE PPO,150.45,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $150.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,12.73,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,HUMANA,HUMANA NATIIONAL POS HMO,21.64,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.64 from Fee Schedule 005543_170 for Rev 306 Proc 87802 * Qty 1 = $21.64 at 100% = $21.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,129.21,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $129.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,177.00,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.15,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87802 at $13.15 (Fee Schedule) = $13.15 (Total Line Payment) at 100% = $13.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.73,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.15,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87802 at $13.15 (Fee Schedule) = $13.15 (Total Line Payment) at 100% = $13.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,13.94,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87802 at $13.15 (Fee Schedule) = $13.15 (Total Line Payment) at 100% = $13.15... $13.15 at 106% = $13.94 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,12.73,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,88.50,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,148.68,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $148.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,28.64,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,132.75,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $132.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,162.84,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $162.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.55,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.55,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,PREVEA HEALTH NETWORK,PREVEA360,16.55,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.55,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,112.98,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $112.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.86,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,127.44,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $127.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,TRIOLOGY,TRILOGY MEDICAID,13.94,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87802 at $13.15 (Fee Schedule) = $13.15 (Total Line Payment) at 106% = $13.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.28,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87802 * Qty 1 = $15.28 at 100% = $15.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,15.28,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87802 * Qty 1 = $15.28 at 100% = $15.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,12.73,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,15.28,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87802 * Qty 1 = $15.28 at 100% = $15.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,UNITY HEALTH PLAN,UNITY HOSPICE,12.73,,,,,,,12.7300,177.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,127.44,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $127.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,109.74,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $109.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,127.44,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $127.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,127.44,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $127.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP B,87802,CPT,306,RC,30600268,CDM,,,,both,,,177.0000,116.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,106.20,,,,,,,12.7300,177.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $177.00 in Billed Charges for Rev 306 Proc 87802 = $106.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,AETNA,AETNA HSHS,465.12,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $465.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,AETNA,AETNA MEDICARE,175.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,AETNA,ALL COMMERCIAL AETNA,720.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,ANTHEM,ANTEHM MEDICAID,143.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81210 at $143.40 (Fee Schedule) = $143.40 (Total Line Payment) at 100% = $143.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,175.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,ANTHEM,ANTHEM POS/HMO,613.90,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $613.90 from Fee Schedule WII28_25 for Rev 310 Proc 81210 Mod TC * Qty 1 = $613.90 at 100% = $613.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,ANTHEM,ANTHEM PPO,613.90,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $613.90 from Fee Schedule WII28_25 for Rev 310 Proc 81210 Mod TC * Qty 1 = $613.90 at 100% = $613.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,720.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,CENPATICO,ALL MEDICAID CENPATICO,720.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,612.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $612.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,CIGNA,ALL COMMERCIAL CIGNA,504.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,COFINITY,COFINITY,720.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,143.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81210 at $143.40 (Fee Schedule) = $143.40 (Total Line Payment) at 100% = $143.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,143.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81210 at $143.40 (Fee Schedule) = $143.40 (Total Line Payment) at 100% = $143.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,684.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $684.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,604.80,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $604.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,511.20,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,525.60,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $525.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,349.92,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $349.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,612.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $612.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HUMANA,HUMANA CHOICE CARE HMO,298.18,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $298.18 from Fee Schedule 005543_170 for Rev 310 Proc 81210 * Qty 1 = $298.18 at 100% = $298.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HUMANA,HUMANA CHOICE CARE PPO,612.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $612.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,175.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,HUMANA,HUMANA NATIIONAL POS HMO,298.18,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $298.18 from Fee Schedule 005543_170 for Rev 310 Proc 81210 * Qty 1 = $298.18 at 100% = $298.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,525.60,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $525.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,720.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,143.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81210 at $143.40 (Fee Schedule) = $143.40 (Total Line Payment) at 100% = $143.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,175.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,143.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81210 at $143.40 (Fee Schedule) = $143.40 (Total Line Payment) at 100% = $143.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,152.00,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81210 at $143.40 (Fee Schedule) = $143.40 (Total Line Payment) at 100% = $143.40... $143.40 at 106% = $152.00 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,175.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,360.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,604.80,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $604.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,394.65,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,540.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,662.40,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $662.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,228.02,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,228.02,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,PREVEA HEALTH NETWORK,PREVEA360,228.02,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,228.02,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,459.58,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $459.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,177.15,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,518.40,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $518.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,TRIOLOGY,TRILOGY MEDICAID,152.00,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81210 at $143.40 (Fee Schedule) = $143.40 (Total Line Payment) at 106% = $152.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,210.48,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81210 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,210.48,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81210 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,175.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,210.48,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81210 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,UNITY HEALTH PLAN,UNITY HOSPICE,175.40,,,,,,,143.4000,720.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,518.40,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $518.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,446.40,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $446.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,518.40,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $518.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,518.40,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $518.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRAF GENE ANALYS V600E VAR,81210,CPT,310,RC,31000211,CDM,,,,both,,,720.0000,475.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,432.00,,,,,,,143.4000,720.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $720.00 in Billed Charges for Rev 310 Proc 81210 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,AETNA,AETNA HSHS,2328.18,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,328.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,AETNA,AETNA MEDICARE,1160.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,AETNA,ALL COMMERCIAL AETNA,3604.00,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,ANTHEM,ANTEHM MEDICAID,608.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1160.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,ANTHEM,ANTHEM POS/HMO,3604.00,,,,,,,608.0000,3604.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,060.00 from Fee Schedule WII28_25 for Rev 310 Proc 81229 Mod TC * Qty 1 = $4,060.00 at 100% = $4,060.00 (Limited to $3,604.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,ANTHEM,ANTHEM PPO,3604.00,,,,,,,608.0000,3604.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,060.00 from Fee Schedule WII28_25 for Rev 310 Proc 81229 Mod TC * Qty 1 = $4,060.00 at 100% = $4,060.00 (Limited to $3,604.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3604.00,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,CENPATICO,ALL MEDICAID CENPATICO,3604.00,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3063.40,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,063.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,CIGNA,ALL COMMERCIAL CIGNA,2522.80,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,522.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,COFINITY,COFINITY,3604.00,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,608.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,608.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3423.80,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,423.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,3027.36,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,027.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2558.84,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,558.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2630.92,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,630.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,1751.54,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $1,751.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3063.40,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,063.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HUMANA,HUMANA CHOICE CARE HMO,1972.00,,,,,,,608.0000,3604.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,972.00 from Fee Schedule 005543_170 for Rev 310 Proc 81229 * Qty 1 = $1,972.00 at 100% = $1,972.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HUMANA,HUMANA CHOICE CARE PPO,3063.40,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,063.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,1160.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,HUMANA,HUMANA NATIIONAL POS HMO,1972.00,,,,,,,608.0000,3604.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,972.00 from Fee Schedule 005543_170 for Rev 310 Proc 81229 * Qty 1 = $1,972.00 at 100% = $1,972.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2630.92,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,630.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3604.00,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,608.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1160.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,608.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,644.48,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00... $608.00 at 106% = $644.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,1160.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1802.00,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3027.36,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,027.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,2610.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2703.00,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,703.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3315.68,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $3,315.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1508.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1508.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,PREVEA HEALTH NETWORK,PREVEA360,1508.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1508.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2300.43,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,300.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1171.60,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2594.88,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,594.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,TRIOLOGY,TRILOGY MEDICAID,644.48,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 106% = $644.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1392.00,,,,,,,608.0000,3604.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,392.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81229 * Qty 1 = $1,392.00 at 100% = $1,392.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,1392.00,,,,,,,608.0000,3604.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,392.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81229 * Qty 1 = $1,392.00 at 100% = $1,392.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1160.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,1392.00,,,,,,,608.0000,3604.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,392.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81229 * Qty 1 = $1,392.00 at 100% = $1,392.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,UNITY HEALTH PLAN,UNITY HOSPICE,1160.00,,,,,,,608.0000,3604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2594.88,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,594.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2234.48,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,234.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2594.88,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,594.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2594.88,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,594.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOMAL MICROARRAY,81229,CPT,310,RC,31000231,CDM,,,,both,,,3604.0000,2378.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2162.40,,,,,,,608.0000,3604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,604.00 in Billed Charges for Rev 310 Proc 81229 = $2,162.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,AETNA,AETNA HSHS,509.05,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $509.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,AETNA,AETNA MEDICARE,121.63,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,AETNA,ALL COMMERCIAL AETNA,788.00,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,ANTHEM,ANTEHM MEDICAID,98.08,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,121.63,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,ANTHEM,ANTHEM POS/HMO,425.71,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $425.71 from Fee Schedule WII28_25 for Rev 310 Proc 81219 Mod TC * Qty 1 = $425.71 at 100% = $425.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,ANTHEM,ANTHEM PPO,425.71,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $425.71 from Fee Schedule WII28_25 for Rev 310 Proc 81219 Mod TC * Qty 1 = $425.71 at 100% = $425.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,788.00,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,CENPATICO,ALL MEDICAID CENPATICO,788.00,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,669.80,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $669.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,CIGNA,ALL COMMERCIAL CIGNA,551.60,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $551.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,COFINITY,COFINITY,788.00,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,98.08,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,98.08,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,748.60,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $748.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,661.92,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $661.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,559.48,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $559.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,575.24,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $575.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,382.97,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $382.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,669.80,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $669.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HUMANA,HUMANA CHOICE CARE HMO,206.77,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $206.77 from Fee Schedule 005543_170 for Rev 310 Proc 81219 * Qty 1 = $206.77 at 100% = $206.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HUMANA,HUMANA CHOICE CARE PPO,669.80,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $669.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HUMANA,HUMANA MEDICARE ADVANTAGE,121.63,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,HUMANA,HUMANA NATIIONAL POS HMO,206.77,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $206.77 from Fee Schedule 005543_170 for Rev 310 Proc 81219 * Qty 1 = $206.77 at 100% = $206.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,575.24,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $575.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,788.00,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,98.08,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,121.63,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,98.08,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,103.96,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 100% = $98.08... $98.08 at 106% = $103.96 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,MOLINA HEALTHCARE,MOLINA MEDICARE,121.63,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,394.00,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,661.92,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $661.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,NAPHCARE,ALL COMMERICAL NAPHCARE,273.67,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,591.00,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $591.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,724.96,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $724.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.12,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.12,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,PREVEA HEALTH NETWORK,PREVEA360,158.12,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.12,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,502.98,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $502.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,122.85,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,567.36,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $567.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,TRIOLOGY,TRILOGY MEDICAID,103.96,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81219 at $98.08 (Fee Schedule) = $98.08 (Total Line Payment) at 106% = $103.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,145.96,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $145.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81219 * Qty 1 = $145.96 at 100% = $145.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,145.96,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $145.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81219 * Qty 1 = $145.96 at 100% = $145.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,121.63,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,145.96,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $145.96 from Fee Schedule UHC_98227C for Rev 310 Proc 81219 * Qty 1 = $145.96 at 100% = $145.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,UNITY HEALTH PLAN,UNITY HOSPICE,121.63,,,,,,,98.0800,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,567.36,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $567.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,488.56,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $488.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,567.36,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $567.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,567.36,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $567.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CALRETICULIN,81219,CPT,310,RC,31000235,CDM,,,,both,,,788.0000,520.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,472.80,,,,,,,98.0800,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $788.00 in Billed Charges for Rev 310 Proc 81219 = $472.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,AETNA,AETNA HSHS,334.63,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $334.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,AETNA,ALL COMMERCIAL AETNA,518.00,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $518.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,ANTHEM,ANTEHM MEDICAID,17.32,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,ANTHEM,ANTHEM POS/HMO,352.24,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81479 $518.00 in Billed Charges at 68% = $352.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,ANTHEM,ANTHEM PPO,352.24,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81479 $518.00 in Billed Charges at 68% = $352.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,518.00,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $518.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,CENPATICO,ALL MEDICAID CENPATICO,518.00,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $518.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,440.30,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $440.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,CIGNA,ALL COMMERCIAL CIGNA,362.60,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $362.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,COFINITY,COFINITY,518.00,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $518.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.32,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.32,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,492.10,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $492.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,435.12,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $435.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,367.78,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $367.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,378.14,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $378.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,251.75,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $251.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,440.30,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $440.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,HUMANA,HUMANA CHOICE CARE PPO,440.30,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $440.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,378.14,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $378.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,518.00,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $518.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.32,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.32,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,18.36,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32... $17.32 at 106% = $18.36 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,362.60,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $362.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,259.00,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $259.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,435.12,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $435.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,310.80,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $310.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,388.50,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $388.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,476.56,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $476.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,310.80,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,310.80,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,PREVEA HEALTH NETWORK,PREVEA360,310.80,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,310.80,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,330.64,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $330.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,372.96,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $372.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,TRIOLOGY,TRILOGY MEDICAID,18.36,,,,,,,17.3200,518.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 106% = $18.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,372.96,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $372.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,321.16,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $321.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,372.96,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $372.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,372.96,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $372.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MUTATION ANALYSIS CSF3R,81479,CPT,310,RC,31000238,CDM,,,,both,,,518.0000,341.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,310.80,,,,,,,17.3200,518.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $518.00 in Billed Charges for Rev 310 Proc 81479 = $310.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,AETNA,AETNA HSHS,401.17,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $401.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,AETNA,AETNA MEDICARE,91.66,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,AETNA,ALL COMMERCIAL AETNA,621.00,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,ANTHEM,ANTEHM MEDICAID,94.71,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,91.66,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,ANTHEM,ANTHEM POS/HMO,320.81,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $320.81 from Fee Schedule WII28_25 for Rev 310 Proc 81270 Mod TC * Qty 1 = $320.81 at 100% = $320.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,ANTHEM,ANTHEM PPO,320.81,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $320.81 from Fee Schedule WII28_25 for Rev 310 Proc 81270 Mod TC * Qty 1 = $320.81 at 100% = $320.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,621.00,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,CENPATICO,ALL MEDICAID CENPATICO,621.00,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,527.85,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $527.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,CIGNA,ALL COMMERCIAL CIGNA,434.70,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $434.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,COFINITY,COFINITY,621.00,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,94.71,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,94.71,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,589.95,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $589.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,521.64,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $521.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,440.91,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $440.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,453.33,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $453.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,301.81,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $301.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,527.85,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $527.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HUMANA,HUMANA CHOICE CARE HMO,155.82,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $155.82 from Fee Schedule 005543_170 for Rev 310 Proc 81270 * Qty 1 = $155.82 at 100% = $155.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HUMANA,HUMANA CHOICE CARE PPO,527.85,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $527.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,91.66,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,HUMANA,HUMANA NATIIONAL POS HMO,155.82,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $155.82 from Fee Schedule 005543_170 for Rev 310 Proc 81270 * Qty 1 = $155.82 at 100% = $155.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,453.33,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $453.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,621.00,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,94.71,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,91.66,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,94.71,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,100.39,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71... $94.71 at 106% = $100.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,91.66,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,310.50,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $310.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,521.64,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $521.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,206.24,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,465.75,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $465.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,571.32,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $571.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,119.16,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,119.16,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,PREVEA HEALTH NETWORK,PREVEA360,119.16,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,119.16,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,396.38,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $396.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,92.58,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,447.12,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $447.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,TRIOLOGY,TRILOGY MEDICAID,100.39,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 106% = $100.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,109.99,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,109.99,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,91.66,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,109.99,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,UNITY HEALTH PLAN,UNITY HOSPICE,91.66,,,,,,,91.6600,621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,447.12,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $447.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,385.02,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $385.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,447.12,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $447.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,447.12,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $447.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 MUTATION ANALYSIS,81270,CPT,310,RC,31000239,CDM,,,,both,,,621.0000,409.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,372.60,,,,,,,91.6600,621.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $621.00 in Billed Charges for Rev 310 Proc 81270 = $372.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,AETNA,AETNA HSHS,2909.58,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $2,909.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,AETNA,AETNA MEDICARE,896.87,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,AETNA,ALL COMMERCIAL AETNA,4504.00,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $4,504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,ANTHEM,ANTEHM MEDICAID,133.58,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,896.87,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,ANTHEM,ANTHEM POS/HMO,3062.72,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81457 $4,504.00 in Billed Charges at 68% = $3,062.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,ANTHEM,ANTHEM PPO,3062.72,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81457 $4,504.00 in Billed Charges at 68% = $3,062.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4504.00,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $4,504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,CENPATICO,ALL MEDICAID CENPATICO,4504.00,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $4,504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3828.40,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,828.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,CIGNA,ALL COMMERCIAL CIGNA,3152.80,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,152.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,COFINITY,COFINITY,4504.00,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $4,504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,133.58,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,133.58,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4278.80,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $4,278.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,3783.36,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,783.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3197.84,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,197.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3287.92,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,287.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,2188.94,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $2,188.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3828.40,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,828.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,HUMANA,HUMANA CHOICE CARE PPO,3828.40,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,828.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,896.87,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3287.92,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,287.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,4504.00,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $4,504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,133.58,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,896.87,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,133.58,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,141.59,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58... $133.58 at 106% = $141.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,896.87,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2252.00,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $2,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3783.36,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,783.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,2017.96,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3378.00,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,378.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4143.68,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $4,143.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1165.93,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1165.93,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,PREVEA HEALTH NETWORK,PREVEA360,1165.93,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1165.93,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2874.90,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $2,874.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,905.84,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3242.88,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,242.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,TRIOLOGY,TRILOGY MEDICAID,141.59,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 106% = $141.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1076.24,,,,,,,133.5800,4504.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,1076.24,,,,,,,133.5800,4504.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,896.87,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,1076.24,,,,,,,133.5800,4504.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,UNITY HEALTH PLAN,UNITY HOSPICE,896.87,,,,,,,133.5800,4504.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3242.88,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,242.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2792.48,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $2,792.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3242.88,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,242.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3242.88,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $3,242.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ NEOPLASM 5-50 GENES LUNG W/REARRANG TUMOR,81457,CPT,310,RC,31000265,CDM,,,,both,,,4504.0000,2972.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2702.40,,,,,,,133.5800,4504.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,504.00 in Billed Charges for Rev 310 Proc 81457 = $2,702.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,AETNA,AETNA HSHS,665.38,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $665.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,AETNA,AETNA MEDICARE,175.40,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,AETNA,ALL COMMERCIAL AETNA,1030.00,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $1,030.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,ANTHEM,ANTEHM MEDICAID,140.32,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81305 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,175.40,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,ANTHEM,ANTHEM POS/HMO,613.90,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $613.90 from Fee Schedule WII28_25 for Rev 310 Proc 81305 Mod TC * Qty 1 = $613.90 at 100% = $613.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,ANTHEM,ANTHEM PPO,613.90,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $613.90 from Fee Schedule WII28_25 for Rev 310 Proc 81305 Mod TC * Qty 1 = $613.90 at 100% = $613.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1030.00,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $1,030.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,CENPATICO,ALL MEDICAID CENPATICO,1030.00,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $1,030.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,875.50,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $875.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,CIGNA,ALL COMMERCIAL CIGNA,721.00,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $721.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,COFINITY,COFINITY,1030.00,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $1,030.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,140.32,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81305 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,140.32,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81305 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,978.50,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $978.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,865.20,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $865.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,731.30,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $731.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,751.90,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $751.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,500.58,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $500.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,875.50,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $875.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HUMANA,HUMANA CHOICE CARE HMO,298.18,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $298.18 from Fee Schedule 005543_170 for Rev 310 Proc 81305 * Qty 1 = $298.18 at 100% = $298.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HUMANA,HUMANA CHOICE CARE PPO,875.50,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $875.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,175.40,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,HUMANA,HUMANA NATIIONAL POS HMO,298.18,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $298.18 from Fee Schedule 005543_170 for Rev 310 Proc 81305 * Qty 1 = $298.18 at 100% = $298.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,751.90,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $751.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1030.00,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $1,030.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,140.32,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81305 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,175.40,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,140.32,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81305 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,148.74,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81305 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32... $140.32 at 106% = $148.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,175.40,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,515.00,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $515.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,865.20,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $865.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,394.65,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,772.50,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $772.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,947.60,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $947.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,228.02,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,228.02,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,PREVEA HEALTH NETWORK,PREVEA360,228.02,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,228.02,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,657.45,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $657.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,177.15,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,741.60,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $741.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,TRIOLOGY,TRILOGY MEDICAID,148.74,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81305 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 106% = $148.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,210.48,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81305 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,210.48,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81305 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,175.40,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,210.48,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81305 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,UNITY HEALTH PLAN,UNITY HOSPICE,175.40,,,,,,,140.3200,1030.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,741.60,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $741.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,638.60,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $638.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,741.60,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $741.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,741.60,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $741.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MYD88 L265P GENE MUTATION ANALYSIS,81305,CPT,310,RC,31000274,CDM,,,,both,,,1030.0000,679.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,618.00,,,,,,,140.3200,1030.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,030.00 in Billed Charges for Rev 310 Proc 81305 = $618.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,AETNA,AETNA HSHS,2034.90,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,034.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,AETNA,AETNA MEDICARE,584.90,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,AETNA,ALL COMMERCIAL AETNA,3150.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $3,150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,ANTHEM,ANTEHM MEDICAID,133.58,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81448 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,584.90,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,ANTHEM,ANTHEM POS/HMO,2047.15,,,,,,,133.5800,3150.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,047.15 from Fee Schedule WII28_25 for Rev 310 Proc 81448 Mod TC * Qty 1 = $2,047.15 at 100% = $2,047.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,ANTHEM,ANTHEM PPO,2047.15,,,,,,,133.5800,3150.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,047.15 from Fee Schedule WII28_25 for Rev 310 Proc 81448 Mod TC * Qty 1 = $2,047.15 at 100% = $2,047.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3150.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $3,150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,CENPATICO,ALL MEDICAID CENPATICO,3150.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $3,150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2677.50,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,677.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,CIGNA,ALL COMMERCIAL CIGNA,2205.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,205.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,COFINITY,COFINITY,3150.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $3,150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,133.58,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81448 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,133.58,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81448 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2992.50,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,992.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,2646.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,646.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2236.50,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,236.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2299.50,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,299.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,1530.90,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $1,530.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2677.50,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,677.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HUMANA,HUMANA CHOICE CARE HMO,994.33,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $994.33 from Fee Schedule 005543_170 for Rev 310 Proc 81448 * Qty 1 = $994.33 at 100% = $994.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HUMANA,HUMANA CHOICE CARE PPO,2677.50,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,677.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,584.90,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,HUMANA,HUMANA NATIIONAL POS HMO,994.33,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $994.33 from Fee Schedule 005543_170 for Rev 310 Proc 81448 * Qty 1 = $994.33 at 100% = $994.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2299.50,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,299.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3150.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $3,150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,133.58,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81448 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,584.90,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,133.58,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81448 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,141.59,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81448 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58... $133.58 at 106% = $141.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,584.90,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1575.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $1,575.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2646.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,646.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,1316.03,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2362.50,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,362.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2898.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,898.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,760.37,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,760.37,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,PREVEA HEALTH NETWORK,PREVEA360,760.37,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,760.37,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2010.65,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,010.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,590.75,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2268.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,268.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,TRIOLOGY,TRILOGY MEDICAID,141.59,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81448 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 106% = $141.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,701.88,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81448 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,701.88,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81448 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,584.90,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,701.88,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $701.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81448 * Qty 1 = $701.88 at 100% = $701.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,UNITY HEALTH PLAN,UNITY HOSPICE,584.90,,,,,,,133.5800,3150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2268.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,268.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1953.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $1,953.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2268.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,268.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2268.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $2,268.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEREDITY PERPH NEUR GEN SEQ,81448,CPT,310,RC,31000287,CDM,,,,both,,,3150.0000,2079.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1890.00,,,,,,,133.5800,3150.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,150.00 in Billed Charges for Rev 310 Proc 81448 = $1,890.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,AETNA,AETNA HSHS,268.09,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $268.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,AETNA,AETNA MEDICARE,214.62,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,AETNA,ALL COMMERCIAL AETNA,415.00,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,ANTHEM,ANTEHM MEDICAID,175.54,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81208 at $175.54 (Fee Schedule) = $175.54 (Total Line Payment) at 100% = $175.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,214.62,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,ANTHEM,ANTHEM POS/HMO,415.00,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $751.17 from Fee Schedule WII28_25 for Rev 310 Proc 81208 Mod TC * Qty 1 = $751.17 at 100% = $751.17 (Limited to $415.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,ANTHEM,ANTHEM PPO,415.00,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $751.17 from Fee Schedule WII28_25 for Rev 310 Proc 81208 Mod TC * Qty 1 = $751.17 at 100% = $751.17 (Limited to $415.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,415.00,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,CENPATICO,ALL MEDICAID CENPATICO,415.00,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,352.75,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $352.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,CIGNA,ALL COMMERCIAL CIGNA,290.50,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $290.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,COFINITY,COFINITY,415.00,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,175.54,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81208 at $175.54 (Fee Schedule) = $175.54 (Total Line Payment) at 100% = $175.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,175.54,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81208 at $175.54 (Fee Schedule) = $175.54 (Total Line Payment) at 100% = $175.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,394.25,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $394.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,348.60,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $348.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,294.65,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $294.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,302.95,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $302.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,201.69,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $201.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,352.75,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $352.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HUMANA,HUMANA CHOICE CARE HMO,364.85,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $364.85 from Fee Schedule 005543_170 for Rev 310 Proc 81208 * Qty 1 = $364.85 at 100% = $364.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HUMANA,HUMANA CHOICE CARE PPO,352.75,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $352.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,214.62,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,HUMANA,HUMANA NATIIONAL POS HMO,364.85,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $364.85 from Fee Schedule 005543_170 for Rev 310 Proc 81208 * Qty 1 = $364.85 at 100% = $364.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,302.95,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $302.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,415.00,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,175.54,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81208 at $175.54 (Fee Schedule) = $175.54 (Total Line Payment) at 100% = $175.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,214.62,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,175.54,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81208 at $175.54 (Fee Schedule) = $175.54 (Total Line Payment) at 100% = $175.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,186.07,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81208 at $175.54 (Fee Schedule) = $175.54 (Total Line Payment) at 100% = $175.54... $175.54 at 106% = $186.07 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,214.62,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,207.50,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $207.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,348.60,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $348.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,482.90,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,311.25,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $311.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,381.80,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $381.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,279.01,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,279.01,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,PREVEA HEALTH NETWORK,PREVEA360,279.01,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,279.01,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,264.89,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $264.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,216.77,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,298.80,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $298.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,TRIOLOGY,TRILOGY MEDICAID,186.07,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81208 at $175.54 (Fee Schedule) = $175.54 (Total Line Payment) at 106% = $186.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,257.54,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $257.54 from Fee Schedule UHC_98227C for Rev 310 Proc 81208 * Qty 1 = $257.54 at 100% = $257.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,257.54,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $257.54 from Fee Schedule UHC_98227C for Rev 310 Proc 81208 * Qty 1 = $257.54 at 100% = $257.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,214.62,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,257.54,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $257.54 from Fee Schedule UHC_98227C for Rev 310 Proc 81208 * Qty 1 = $257.54 at 100% = $257.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,UNITY HEALTH PLAN,UNITY HOSPICE,214.62,,,,,,,175.5400,482.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,298.80,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $298.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,257.30,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $257.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,298.80,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $298.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,298.80,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $298.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE OTH BP QL/QN,81208,CPT,310,RC,31000308,CDM,,,,both,,,415.0000,273.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,249.00,,,,,,,175.5400,482.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $415.00 in Billed Charges for Rev 310 Proc 81208 = $249.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,AETNA,AETNA HSHS,671.84,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $671.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,AETNA,AETNA MEDICARE,301.35,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,AETNA,ALL COMMERCIAL AETNA,1040.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $1,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,ANTHEM,ANTEHM MEDICAID,241.08,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81405 at $241.08 (Fee Schedule) = $241.08 (Total Line Payment) at 100% = $241.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,301.35,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,ANTHEM,ANTHEM POS/HMO,1040.00,,,,,,,241.0800,1040.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,054.73 from Fee Schedule WII28_25 for Rev 310 Proc 81405 Mod TC * Qty 1 = $1,054.73 at 100% = $1,054.73 (Limited to $1,040.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,ANTHEM,ANTHEM PPO,1040.00,,,,,,,241.0800,1040.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,054.73 from Fee Schedule WII28_25 for Rev 310 Proc 81405 Mod TC * Qty 1 = $1,054.73 at 100% = $1,054.73 (Limited to $1,040.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1040.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $1,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,CENPATICO,ALL MEDICAID CENPATICO,1040.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $1,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,884.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $884.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,CIGNA,ALL COMMERCIAL CIGNA,728.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $728.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,COFINITY,COFINITY,1040.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $1,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,241.08,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81405 at $241.08 (Fee Schedule) = $241.08 (Total Line Payment) at 100% = $241.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,241.08,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81405 at $241.08 (Fee Schedule) = $241.08 (Total Line Payment) at 100% = $241.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,988.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $988.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,873.60,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $873.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,738.40,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $738.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,759.20,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $759.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,505.44,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $505.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,884.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $884.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HUMANA,HUMANA CHOICE CARE HMO,512.30,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $512.30 from Fee Schedule 005543_170 for Rev 310 Proc 81405 * Qty 1 = $512.30 at 100% = $512.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HUMANA,HUMANA CHOICE CARE PPO,884.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $884.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,301.35,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,HUMANA,HUMANA NATIIONAL POS HMO,512.30,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $512.30 from Fee Schedule 005543_170 for Rev 310 Proc 81405 * Qty 1 = $512.30 at 100% = $512.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,759.20,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $759.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1040.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $1,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,241.08,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81405 at $241.08 (Fee Schedule) = $241.08 (Total Line Payment) at 100% = $241.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,301.35,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,241.08,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81405 at $241.08 (Fee Schedule) = $241.08 (Total Line Payment) at 100% = $241.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,255.54,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81405 at $241.08 (Fee Schedule) = $241.08 (Total Line Payment) at 100% = $241.08... $241.08 at 106% = $255.54 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,301.35,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,520.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,873.60,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $873.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,678.04,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,780.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $780.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,956.80,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $956.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,391.76,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,391.76,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,PREVEA HEALTH NETWORK,PREVEA360,391.76,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,391.76,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,663.83,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $663.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,304.36,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,748.80,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $748.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,TRIOLOGY,TRILOGY MEDICAID,255.54,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81405 at $241.08 (Fee Schedule) = $241.08 (Total Line Payment) at 106% = $255.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,361.62,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $361.62 from Fee Schedule UHC_98227C for Rev 310 Proc 81405 * Qty 1 = $361.62 at 100% = $361.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,361.62,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $361.62 from Fee Schedule UHC_98227C for Rev 310 Proc 81405 * Qty 1 = $361.62 at 100% = $361.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,301.35,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,361.62,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $361.62 from Fee Schedule UHC_98227C for Rev 310 Proc 81405 * Qty 1 = $361.62 at 100% = $361.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,UNITY HEALTH PLAN,UNITY HOSPICE,301.35,,,,,,,241.0800,1040.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,748.80,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $748.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,644.80,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $644.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,748.80,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $748.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,748.80,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $748.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 6,81405,CPT,310,RC,31000313,CDM,,,,both,,,1040.0000,686.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,624.00,,,,,,,241.0800,1040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,040.00 in Billed Charges for Rev 310 Proc 81405 = $624.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,AETNA,AETNA HSHS,1913.45,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $1,913.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,AETNA,AETNA MEDICARE,759.53,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,AETNA,ALL COMMERCIAL AETNA,2962.00,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,962.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,ANTHEM,ANTEHM MEDICAID,607.62,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81450 at $607.62 (Fee Schedule) = $607.62 (Total Line Payment) at 100% = $607.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,759.53,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,ANTHEM,ANTHEM POS/HMO,2658.36,,,,,,,607.6200,2962.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,658.36 from Fee Schedule WII28_25 for Rev 310 Proc 81450 Mod TC * Qty 1 = $2,658.36 at 100% = $2,658.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,ANTHEM,ANTHEM PPO,2658.36,,,,,,,607.6200,2962.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,658.36 from Fee Schedule WII28_25 for Rev 310 Proc 81450 Mod TC * Qty 1 = $2,658.36 at 100% = $2,658.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2962.00,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,962.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,CENPATICO,ALL MEDICAID CENPATICO,2962.00,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,962.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2517.70,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,517.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,CIGNA,ALL COMMERCIAL CIGNA,2073.40,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,073.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,COFINITY,COFINITY,2962.00,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,962.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,607.62,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81450 at $607.62 (Fee Schedule) = $607.62 (Total Line Payment) at 100% = $607.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,607.62,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81450 at $607.62 (Fee Schedule) = $607.62 (Total Line Payment) at 100% = $607.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2813.90,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,813.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,2488.08,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,488.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2103.02,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,103.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2162.26,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,162.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,1439.53,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $1,439.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2517.70,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,517.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HUMANA,HUMANA CHOICE CARE HMO,1291.20,,,,,,,607.6200,2962.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,291.20 from Fee Schedule 005543_170 for Rev 310 Proc 81450 * Qty 1 = $1,291.20 at 100% = $1,291.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HUMANA,HUMANA CHOICE CARE PPO,2517.70,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,517.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,759.53,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,HUMANA,HUMANA NATIIONAL POS HMO,1291.20,,,,,,,607.6200,2962.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,291.20 from Fee Schedule 005543_170 for Rev 310 Proc 81450 * Qty 1 = $1,291.20 at 100% = $1,291.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2162.26,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,162.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2962.00,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,962.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,607.62,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81450 at $607.62 (Fee Schedule) = $607.62 (Total Line Payment) at 100% = $607.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,759.53,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,607.62,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81450 at $607.62 (Fee Schedule) = $607.62 (Total Line Payment) at 100% = $607.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,644.08,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81450 at $607.62 (Fee Schedule) = $607.62 (Total Line Payment) at 100% = $607.62... $607.62 at 106% = $644.08 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,759.53,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1481.00,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2488.08,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,488.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,1708.94,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2221.50,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,221.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2725.04,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,725.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,987.39,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,987.39,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,PREVEA HEALTH NETWORK,PREVEA360,987.39,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,987.39,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1890.64,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $1,890.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,767.13,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2132.64,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,132.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,TRIOLOGY,TRILOGY MEDICAID,644.08,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81450 at $607.62 (Fee Schedule) = $607.62 (Total Line Payment) at 106% = $644.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,911.44,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $911.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81450 * Qty 1 = $911.44 at 100% = $911.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,911.44,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $911.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81450 * Qty 1 = $911.44 at 100% = $911.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,759.53,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,911.44,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $911.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81450 * Qty 1 = $911.44 at 100% = $911.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,UNITY HEALTH PLAN,UNITY HOSPICE,759.53,,,,,,,607.6200,2962.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2132.64,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,132.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1836.44,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $1,836.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2132.64,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,132.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2132.64,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $2,132.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGET GENOMIC SEQ ANALYSIS HEMATOLYMPHOID 5-50 GENES,81450,CPT,310,RC,31000318,CDM,,,,both,,,2962.0000,1954.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1777.20,,,,,,,607.6200,2962.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,962.00 in Billed Charges for Rev 310 Proc 81450 = $1,777.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,AETNA,AETNA HSHS,956.73,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $956.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,AETNA,AETNA MEDICARE,846.27,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,AETNA,ALL COMMERCIAL AETNA,1481.00,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,ANTHEM,ANTEHM MEDICAID,677.01,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81185 at $677.01 (Fee Schedule) = $677.01 (Total Line Payment) at 100% = $677.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,846.27,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,ANTHEM,ANTHEM POS/HMO,1481.00,,,,,,,677.0100,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,961.95 from Fee Schedule WII28_25 for Rev 310 Proc 81185 Mod TC * Qty 1 = $2,961.95 at 100% = $2,961.95 (Limited to $1,481.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,ANTHEM,ANTHEM PPO,1481.00,,,,,,,677.0100,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,961.95 from Fee Schedule WII28_25 for Rev 310 Proc 81185 Mod TC * Qty 1 = $2,961.95 at 100% = $2,961.95 (Limited to $1,481.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1481.00,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,CENPATICO,ALL MEDICAID CENPATICO,1481.00,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1258.85,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,258.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,CIGNA,ALL COMMERCIAL CIGNA,1036.70,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,036.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,COFINITY,COFINITY,1481.00,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,677.01,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81185 at $677.01 (Fee Schedule) = $677.01 (Total Line Payment) at 100% = $677.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,677.01,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81185 at $677.01 (Fee Schedule) = $677.01 (Total Line Payment) at 100% = $677.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1406.95,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,406.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,1244.04,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,244.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1051.51,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,051.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1081.13,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,081.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,719.77,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $719.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1258.85,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,258.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HUMANA,HUMANA CHOICE CARE HMO,1438.66,,,,,,,677.0100,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,438.66 from Fee Schedule 005543_170 for Rev 310 Proc 81185 * Qty 1 = $1,438.66 at 100% = $1,438.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HUMANA,HUMANA CHOICE CARE PPO,1258.85,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,258.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,846.27,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,HUMANA,HUMANA NATIIONAL POS HMO,1438.66,,,,,,,677.0100,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,438.66 from Fee Schedule 005543_170 for Rev 310 Proc 81185 * Qty 1 = $1,438.66 at 100% = $1,438.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1081.13,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,081.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1481.00,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,677.01,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81185 at $677.01 (Fee Schedule) = $677.01 (Total Line Payment) at 100% = $677.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,846.27,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,677.01,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81185 at $677.01 (Fee Schedule) = $677.01 (Total Line Payment) at 100% = $677.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,717.63,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81185 at $677.01 (Fee Schedule) = $677.01 (Total Line Payment) at 100% = $677.01... $677.01 at 106% = $717.63 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,846.27,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,740.50,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $740.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1244.04,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,244.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,1904.11,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1110.75,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,110.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1362.52,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,362.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1100.15,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1100.15,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,PREVEA HEALTH NETWORK,PREVEA360,1100.15,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1100.15,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,945.32,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $945.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,854.73,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1066.32,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,TRIOLOGY,TRILOGY MEDICAID,717.63,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81185 at $677.01 (Fee Schedule) = $677.01 (Total Line Payment) at 106% = $717.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1015.52,,,,,,,677.0100,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,015.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81185 * Qty 1 = $1,015.52 at 100% = $1,015.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,1015.52,,,,,,,677.0100,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,015.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81185 * Qty 1 = $1,015.52 at 100% = $1,015.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,846.27,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,1015.52,,,,,,,677.0100,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,015.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81185 * Qty 1 = $1,015.52 at 100% = $1,015.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,UNITY HEALTH PLAN,UNITY HOSPICE,846.27,,,,,,,677.0100,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1066.32,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,918.22,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $918.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1066.32,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1066.32,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $1,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CACNA1A GENE FULL GENE SEQ,81185,CPT,310,RC,31000319,CDM,,,,both,,,1481.0000,977.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,888.60,,,,,,,677.0100,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,481.00 in Billed Charges for Rev 310 Proc 81185 = $888.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,AETNA,AETNA HSHS,310.73,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $310.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,AETNA,AETNA MEDICARE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,AETNA,ALL COMMERCIAL AETNA,481.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,ANTHEM,ANTEHM MEDICAID,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81189 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,ANTHEM,ANTHEM POS/HMO,481.00,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $961.91 from Fee Schedule WII28_25 for Rev 310 Proc 81189 Mod TC * Qty 1 = $961.91 at 100% = $961.91 (Limited to $481.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,ANTHEM,ANTHEM PPO,481.00,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $961.91 from Fee Schedule WII28_25 for Rev 310 Proc 81189 Mod TC * Qty 1 = $961.91 at 100% = $961.91 (Limited to $481.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,481.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,CENPATICO,ALL MEDICAID CENPATICO,481.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,408.85,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $408.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,CIGNA,ALL COMMERCIAL CIGNA,336.70,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $336.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,COFINITY,COFINITY,481.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81189 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81189 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,456.95,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $456.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,404.04,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $404.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,341.51,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $341.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,351.13,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $351.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,233.77,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $233.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,408.85,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $408.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HUMANA,HUMANA CHOICE CARE HMO,467.21,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $467.21 from Fee Schedule 005543_170 for Rev 310 Proc 81189 * Qty 1 = $467.21 at 100% = $467.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HUMANA,HUMANA CHOICE CARE PPO,408.85,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $408.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,HUMANA,HUMANA NATIIONAL POS HMO,467.21,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $467.21 from Fee Schedule 005543_170 for Rev 310 Proc 81189 * Qty 1 = $467.21 at 100% = $467.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,351.13,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $351.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,481.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81189 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81189 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,233.05,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81189 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86... $219.86 at 106% = $233.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,240.50,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $240.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,404.04,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $404.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,618.37,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,360.75,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $360.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,442.52,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $442.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,357.28,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,357.28,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,PREVEA HEALTH NETWORK,PREVEA360,357.28,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,357.28,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,307.02,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $307.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,277.58,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,346.32,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,TRIOLOGY,TRILOGY MEDICAID,233.05,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81189 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 106% = $233.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,329.80,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81189 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,329.80,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81189 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,329.80,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81189 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,UNITY HEALTH PLAN,UNITY HOSPICE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,346.32,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,298.22,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $298.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,346.32,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,346.32,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CSTB GENE FULL GENE SEQUENCE,81189,CPT,310,RC,31000320,CDM,,,,both,,,481.0000,317.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,288.60,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $481.00 in Billed Charges for Rev 310 Proc 81189 = $288.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,AETNA,AETNA HSHS,630.50,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $630.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,AETNA,AETNA MEDICARE,185.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,AETNA,ALL COMMERCIAL AETNA,976.00,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $976.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,ANTHEM,ANTEHM MEDICAID,148.16,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81339 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,185.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,ANTHEM,ANTHEM POS/HMO,648.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $648.20 from Fee Schedule WII28_25 for Rev 310 Proc 81339 Mod TC * Qty 1 = $648.20 at 100% = $648.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,ANTHEM,ANTHEM PPO,648.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $648.20 from Fee Schedule WII28_25 for Rev 310 Proc 81339 Mod TC * Qty 1 = $648.20 at 100% = $648.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,976.00,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $976.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,CENPATICO,ALL MEDICAID CENPATICO,976.00,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $976.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,829.60,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $829.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,CIGNA,ALL COMMERCIAL CIGNA,683.20,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $683.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,COFINITY,COFINITY,976.00,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $976.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,148.16,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81339 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,148.16,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81339 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,927.20,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $927.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,819.84,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $819.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,692.96,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $692.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,712.48,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $712.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,474.34,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $474.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,829.60,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $829.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HUMANA,HUMANA CHOICE CARE HMO,314.84,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $314.84 from Fee Schedule 005543_170 for Rev 310 Proc 81339 * Qty 1 = $314.84 at 100% = $314.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HUMANA,HUMANA CHOICE CARE PPO,829.60,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $829.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,185.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,HUMANA,HUMANA NATIIONAL POS HMO,314.84,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $314.84 from Fee Schedule 005543_170 for Rev 310 Proc 81339 * Qty 1 = $314.84 at 100% = $314.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,712.48,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $712.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,976.00,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $976.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,148.16,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81339 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,185.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,148.16,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81339 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,MOLINA HEALTHCARE,MOLINA MEDICAID,157.05,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81339 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16... $148.16 at 106% = $157.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,185.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,488.00,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $488.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,819.84,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $819.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,416.70,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,732.00,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $732.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,897.92,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $897.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,240.76,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,240.76,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,PREVEA HEALTH NETWORK,PREVEA360,240.76,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,240.76,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,622.98,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $622.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,187.05,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,702.72,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $702.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,TRIOLOGY,TRILOGY MEDICAID,157.05,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81339 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 106% = $157.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,222.24,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81339 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,222.24,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81339 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,185.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,222.24,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81339 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,UNITY HEALTH PLAN,UNITY HOSPICE,185.20,,,,,,,148.1600,976.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,702.72,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $702.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,605.12,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $605.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,702.72,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $702.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,702.72,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $702.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MPL GENE SEQ ANLY EXON,81339,CPT,310,RC,31000321,CDM,,,,both,,,976.0000,644.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,585.60,,,,,,,148.1600,976.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $976.00 in Billed Charges for Rev 310 Proc 81339 = $585.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,AETNA,AETNA HSHS,5403.79,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $5,403.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,AETNA,AETNA MEDICARE,4780.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,AETNA,ALL COMMERCIAL AETNA,8365.00,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $8,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,ANTHEM,ANTEHM MEDICAID,866.06,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81415 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,4780.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,ANTHEM,ANTHEM POS/HMO,8365.00,,,,,,,866.0600,10755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $16,730.00 from Fee Schedule WII28_25 for Rev 310 Proc 81415 Mod TC * Qty 1 = $16,730.00 at 100% = $16,730.00 (Limited to $8,365.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,ANTHEM,ANTHEM PPO,8365.00,,,,,,,866.0600,10755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $16,730.00 from Fee Schedule WII28_25 for Rev 310 Proc 81415 Mod TC * Qty 1 = $16,730.00 at 100% = $16,730.00 (Limited to $8,365.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8365.00,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $8,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,CENPATICO,ALL MEDICAID CENPATICO,8365.00,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $8,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7110.25,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $7,110.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,CIGNA,ALL COMMERCIAL CIGNA,5855.50,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $5,855.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,COFINITY,COFINITY,8365.00,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $8,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,866.06,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81415 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,866.06,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81415 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7946.75,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $7,946.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,7026.60,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $7,026.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5939.15,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $5,939.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6106.45,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $6,106.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,4065.39,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $4,065.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7110.25,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $7,110.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HUMANA,HUMANA CHOICE CARE HMO,8126.00,,,,,,,866.0600,10755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,126.00 from Fee Schedule 005543_170 for Rev 310 Proc 81415 * Qty 1 = $8,126.00 at 100% = $8,126.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HUMANA,HUMANA CHOICE CARE PPO,7110.25,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $7,110.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,4780.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,HUMANA,HUMANA NATIIONAL POS HMO,8126.00,,,,,,,866.0600,10755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,126.00 from Fee Schedule 005543_170 for Rev 310 Proc 81415 * Qty 1 = $8,126.00 at 100% = $8,126.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6106.45,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $6,106.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,8365.00,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $8,365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,866.06,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81415 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,4780.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,866.06,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81415 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,918.02,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81415 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06... $866.06 at 106% = $918.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,4780.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4182.50,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $4,182.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7026.60,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $7,026.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,10755.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6273.75,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $6,273.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7695.80,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $7,695.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6214.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6214.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,PREVEA HEALTH NETWORK,PREVEA360,6214.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6214.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5339.38,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $5,339.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,4827.80,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6022.80,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $6,022.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,TRIOLOGY,TRILOGY MEDICAID,918.03,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81415 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 106% = $918.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5736.00,,,,,,,866.0600,10755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,736.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81415 * Qty 1 = $5,736.00 at 100% = $5,736.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,5736.00,,,,,,,866.0600,10755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,736.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81415 * Qty 1 = $5,736.00 at 100% = $5,736.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,4780.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,5736.00,,,,,,,866.0600,10755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,736.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81415 * Qty 1 = $5,736.00 at 100% = $5,736.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,UNITY HEALTH PLAN,UNITY HOSPICE,4780.00,,,,,,,866.0600,10755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6022.80,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $6,022.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5186.30,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $5,186.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6022.80,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $6,022.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6022.80,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $6,022.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQ ANALYSIS,81415,CPT,310,RC,31000323,CDM,,,,both,,,8365.0000,5520.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5019.00,,,,,,,866.0600,10755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,365.00 in Billed Charges for Rev 310 Proc 81415 = $5,019.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,AETNA,AETNA HSHS,4275.87,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,275.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,AETNA,AETNA MEDICARE,2919.60,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,AETNA,ALL COMMERCIAL AETNA,6619.00,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $6,619.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,ANTHEM,ANTEHM MEDICAID,2335.68,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81455 at $2,335.68 (Fee Schedule) = $2,335.68 (Total Line Payment) at 100% = $2,335.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2919.60,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,ANTHEM,ANTHEM POS/HMO,6619.00,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,218.60 from Fee Schedule WII28_25 for Rev 310 Proc 81455 Mod TC * Qty 1 = $10,218.60 at 100% = $10,218.60 (Limited to $6,619.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,ANTHEM,ANTHEM PPO,6619.00,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,218.60 from Fee Schedule WII28_25 for Rev 310 Proc 81455 Mod TC * Qty 1 = $10,218.60 at 100% = $10,218.60 (Limited to $6,619.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6619.00,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $6,619.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,CENPATICO,ALL MEDICAID CENPATICO,6619.00,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $6,619.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5626.15,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $5,626.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,CIGNA,ALL COMMERCIAL CIGNA,4633.30,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,633.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,COFINITY,COFINITY,6619.00,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $6,619.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2335.68,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81455 at $2,335.68 (Fee Schedule) = $2,335.68 (Total Line Payment) at 100% = $2,335.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2335.68,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81455 at $2,335.68 (Fee Schedule) = $2,335.68 (Total Line Payment) at 100% = $2,335.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6288.05,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $6,288.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,5559.96,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $5,559.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4699.49,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,699.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4831.87,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,831.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,3216.83,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $3,216.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5626.15,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $5,626.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HUMANA,HUMANA CHOICE CARE HMO,4963.32,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,963.32 from Fee Schedule 005543_170 for Rev 310 Proc 81455 * Qty 1 = $4,963.32 at 100% = $4,963.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HUMANA,HUMANA CHOICE CARE PPO,5626.15,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $5,626.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HUMANA,HUMANA MEDICARE ADVANTAGE,2919.60,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,HUMANA,HUMANA NATIIONAL POS HMO,4963.32,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,963.32 from Fee Schedule 005543_170 for Rev 310 Proc 81455 * Qty 1 = $4,963.32 at 100% = $4,963.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4831.87,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,831.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,6619.00,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $6,619.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2335.68,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81455 at $2,335.68 (Fee Schedule) = $2,335.68 (Total Line Payment) at 100% = $2,335.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2919.60,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2335.68,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81455 at $2,335.68 (Fee Schedule) = $2,335.68 (Total Line Payment) at 100% = $2,335.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,MOLINA HEALTHCARE,MOLINA MEDICAID,2475.82,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81455 at $2,335.68 (Fee Schedule) = $2,335.68 (Total Line Payment) at 100% = $2,335.68... $2,335.68 at 106% = $2,475.82 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,MOLINA HEALTHCARE,MOLINA MEDICARE,2919.60,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3309.50,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $3,309.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5559.96,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $5,559.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,NAPHCARE,ALL COMMERICAL NAPHCARE,6569.10,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4964.25,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,964.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6089.48,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $6,089.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3795.48,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3795.48,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,PREVEA HEALTH NETWORK,PREVEA360,3795.48,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3795.48,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4224.91,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,224.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2948.80,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4765.68,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,TRIOLOGY,TRILOGY MEDICAID,2475.82,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81455 at $2,335.68 (Fee Schedule) = $2,335.68 (Total Line Payment) at 106% = $2,475.82. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3503.52,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,503.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81455 * Qty 1 = $3,503.52 at 100% = $3,503.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,3503.52,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,503.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81455 * Qty 1 = $3,503.52 at 100% = $3,503.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2919.60,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,3503.52,,,,,,,2335.6800,6619.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,503.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81455 * Qty 1 = $3,503.52 at 100% = $3,503.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,UNITY HEALTH PLAN,UNITY HOSPICE,2919.60,,,,,,,2335.6800,6619.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4765.68,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4103.78,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,103.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4765.68,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4765.68,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $4,765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TARGETED GENOMIC SEQ ANLYS,81455,CPT,310,RC,31000324,CDM,,,,both,,,6619.0000,4368.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3971.40,,,,,,,2335.6800,6619.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,619.00 in Billed Charges for Rev 310 Proc 81455 = $3,971.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,AETNA,AETNA HSHS,496.77,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $496.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,AETNA,AETNA MEDICARE,246.52,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,AETNA,ALL COMMERCIAL AETNA,769.00,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $769.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,ANTHEM,ANTEHM MEDICAID,197.71,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81310 at $197.71 (Fee Schedule) = $197.71 (Total Line Payment) at 100% = $197.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,246.52,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,ANTHEM,ANTHEM POS/HMO,769.00,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $862.82 from Fee Schedule WII28_25 for Rev 310 Proc 81310 Mod TC * Qty 1 = $862.82 at 100% = $862.82 (Limited to $769.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,ANTHEM,ANTHEM PPO,769.00,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $862.82 from Fee Schedule WII28_25 for Rev 310 Proc 81310 Mod TC * Qty 1 = $862.82 at 100% = $862.82 (Limited to $769.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,769.00,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $769.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,CENPATICO,ALL MEDICAID CENPATICO,769.00,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $769.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,653.65,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $653.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,CIGNA,ALL COMMERCIAL CIGNA,538.30,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $538.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,COFINITY,COFINITY,769.00,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $769.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,197.71,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81310 at $197.71 (Fee Schedule) = $197.71 (Total Line Payment) at 100% = $197.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,197.71,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81310 at $197.71 (Fee Schedule) = $197.71 (Total Line Payment) at 100% = $197.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,730.55,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $730.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,645.96,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $645.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,545.99,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $545.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,561.37,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $561.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,373.73,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $373.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,653.65,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $653.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HUMANA,HUMANA CHOICE CARE HMO,419.08,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $419.08 from Fee Schedule 005543_170 for Rev 310 Proc 81310 * Qty 1 = $419.08 at 100% = $419.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HUMANA,HUMANA CHOICE CARE PPO,653.65,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $653.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HUMANA,HUMANA MEDICARE ADVANTAGE,246.52,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,HUMANA,HUMANA NATIIONAL POS HMO,419.08,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $419.08 from Fee Schedule 005543_170 for Rev 310 Proc 81310 * Qty 1 = $419.08 at 100% = $419.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,561.37,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $561.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,769.00,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $769.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,197.71,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81310 at $197.71 (Fee Schedule) = $197.71 (Total Line Payment) at 100% = $197.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,246.52,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,197.71,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81310 at $197.71 (Fee Schedule) = $197.71 (Total Line Payment) at 100% = $197.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,MOLINA HEALTHCARE,MOLINA MEDICAID,209.57,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81310 at $197.71 (Fee Schedule) = $197.71 (Total Line Payment) at 100% = $197.71... $197.71 at 106% = $209.57 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,MOLINA HEALTHCARE,MOLINA MEDICARE,246.52,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,384.50,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $384.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,645.96,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $645.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,NAPHCARE,ALL COMMERICAL NAPHCARE,554.67,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,576.75,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $576.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,707.48,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $707.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,320.48,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,320.48,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,PREVEA HEALTH NETWORK,PREVEA360,320.48,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,320.48,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,490.85,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $490.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,248.99,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,553.68,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $553.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,TRIOLOGY,TRILOGY MEDICAID,209.57,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81310 at $197.71 (Fee Schedule) = $197.71 (Total Line Payment) at 106% = $209.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,295.82,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $295.82 from Fee Schedule UHC_98227C for Rev 310 Proc 81310 * Qty 1 = $295.82 at 100% = $295.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,295.82,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $295.82 from Fee Schedule UHC_98227C for Rev 310 Proc 81310 * Qty 1 = $295.82 at 100% = $295.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,246.52,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,295.82,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $295.82 from Fee Schedule UHC_98227C for Rev 310 Proc 81310 * Qty 1 = $295.82 at 100% = $295.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,UNITY HEALTH PLAN,UNITY HOSPICE,246.52,,,,,,,197.7100,769.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,553.68,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $553.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,476.78,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $476.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,553.68,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $553.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,553.68,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $553.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NPM1 GENE EXON 12 VARIANT,81310,CPT,310,RC,31000325,CDM,,,,both,,,769.0000,507.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,461.40,,,,,,,197.7100,769.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $769.00 in Billed Charges for Rev 310 Proc 81310 = $461.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,AETNA,AETNA HSHS,527.14,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $527.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,AETNA,AETNA MEDICARE,466.17,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,AETNA,ALL COMMERCIAL AETNA,816.00,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $816.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,ANTHEM,ANTEHM MEDICAID,133.58,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0034U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,466.17,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,ANTHEM,ANTHEM POS/HMO,816.00,,,,,,,133.5800,1048.8800,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,631.60 from Fee Schedule WII28_25 for Rev 310 Proc 0034U Mod TC * Qty 1 = $1,631.60 at 100% = $1,631.60 (Limited to $816.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,ANTHEM,ANTHEM PPO,816.00,,,,,,,133.5800,1048.8800,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,631.60 from Fee Schedule WII28_25 for Rev 310 Proc 0034U Mod TC * Qty 1 = $1,631.60 at 100% = $1,631.60 (Limited to $816.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,816.00,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $816.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,CENPATICO,ALL MEDICAID CENPATICO,816.00,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $816.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,693.60,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $693.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,CIGNA,ALL COMMERCIAL CIGNA,571.20,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $571.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,COFINITY,COFINITY,816.00,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $816.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,133.58,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0034U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,133.58,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0034U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,775.20,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $775.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,685.44,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $685.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,579.36,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $579.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,595.68,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $595.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,396.58,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $396.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,693.60,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $693.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HUMANA,HUMANA CHOICE CARE HMO,792.49,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $792.49 from Fee Schedule 005543_170 for Rev 310 Proc 0034U * Qty 1 = $792.49 at 100% = $792.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HUMANA,HUMANA CHOICE CARE PPO,693.60,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $693.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HUMANA,HUMANA MEDICARE ADVANTAGE,466.17,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,HUMANA,HUMANA NATIIONAL POS HMO,792.49,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $792.49 from Fee Schedule 005543_170 for Rev 310 Proc 0034U * Qty 1 = $792.49 at 100% = $792.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,595.68,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $595.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,816.00,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $816.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,133.58,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0034U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,466.17,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,133.58,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0034U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,MOLINA HEALTHCARE,MOLINA MEDICAID,141.59,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0034U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58... $133.58 at 106% = $141.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,MOLINA HEALTHCARE,MOLINA MEDICARE,466.17,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,408.00,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,685.44,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $685.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,NAPHCARE,ALL COMMERICAL NAPHCARE,1048.88,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,612.00,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $612.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,750.72,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $750.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,606.02,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,606.02,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,PREVEA HEALTH NETWORK,PREVEA360,606.02,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,606.02,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,520.85,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $520.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,470.83,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,587.52,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $587.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,TRIOLOGY,TRILOGY MEDICAID,141.59,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 0034U at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 106% = $141.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,559.40,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $559.40 from Fee Schedule UHC_98227C for Rev 310 Proc 0034U * Qty 1 = $559.40 at 100% = $559.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,559.40,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $559.40 from Fee Schedule UHC_98227C for Rev 310 Proc 0034U * Qty 1 = $559.40 at 100% = $559.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,466.17,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,559.40,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $559.40 from Fee Schedule UHC_98227C for Rev 310 Proc 0034U * Qty 1 = $559.40 at 100% = $559.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,UNITY HEALTH PLAN,UNITY HOSPICE,466.17,,,,,,,133.5800,1048.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,587.52,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $587.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,505.92,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $505.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,587.52,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $587.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,587.52,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $587.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TPMT NUDT15 GENES ANLYS,0034U,CPT,310,RC,31000327,CDM,,,,both,,,816.0000,538.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,489.60,,,,,,,133.5800,1048.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $816.00 in Billed Charges for Rev 310 Proc 0034U = $489.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,AETNA,AETNA HSHS,668.61,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $668.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,AETNA,AETNA MEDICARE,124.87,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,AETNA,ALL COMMERCIAL AETNA,1035.00,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $1,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,ANTHEM,ANTEHM MEDICAID,73.92,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81273 at $73.92 (Fee Schedule) = $73.92 (Total Line Payment) at 100% = $73.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,124.87,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,ANTHEM,ANTHEM POS/HMO,437.05,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $437.05 from Fee Schedule WII28_25 for Rev 310 Proc 81273 Mod TC * Qty 1 = $437.05 at 100% = $437.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,ANTHEM,ANTHEM PPO,437.05,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $437.05 from Fee Schedule WII28_25 for Rev 310 Proc 81273 Mod TC * Qty 1 = $437.05 at 100% = $437.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1035.00,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $1,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,CENPATICO,ALL MEDICAID CENPATICO,1035.00,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $1,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,879.75,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $879.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,CIGNA,ALL COMMERCIAL CIGNA,724.50,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $724.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,COFINITY,COFINITY,1035.00,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $1,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,73.92,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81273 at $73.92 (Fee Schedule) = $73.92 (Total Line Payment) at 100% = $73.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,73.92,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81273 at $73.92 (Fee Schedule) = $73.92 (Total Line Payment) at 100% = $73.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,983.25,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $983.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,869.40,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $869.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,734.85,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $734.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,755.55,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $755.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,503.01,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $503.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,879.75,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $879.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HUMANA,HUMANA CHOICE CARE HMO,212.28,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $212.28 from Fee Schedule 005543_170 for Rev 310 Proc 81273 * Qty 1 = $212.28 at 100% = $212.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HUMANA,HUMANA CHOICE CARE PPO,879.75,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $879.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,124.87,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,HUMANA,HUMANA NATIIONAL POS HMO,212.28,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $212.28 from Fee Schedule 005543_170 for Rev 310 Proc 81273 * Qty 1 = $212.28 at 100% = $212.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,755.55,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $755.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1035.00,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $1,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,73.92,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81273 at $73.92 (Fee Schedule) = $73.92 (Total Line Payment) at 100% = $73.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,124.87,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,73.92,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81273 at $73.92 (Fee Schedule) = $73.92 (Total Line Payment) at 100% = $73.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,78.36,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81273 at $73.92 (Fee Schedule) = $73.92 (Total Line Payment) at 100% = $73.92... $73.92 at 106% = $78.36 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,124.87,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,517.50,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $517.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,869.40,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $869.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,280.96,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,776.25,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $776.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,952.20,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $952.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,162.33,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,162.33,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,PREVEA HEALTH NETWORK,PREVEA360,162.33,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,162.33,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,660.64,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $660.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,126.12,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,745.20,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $745.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,TRIOLOGY,TRILOGY MEDICAID,78.36,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81273 at $73.92 (Fee Schedule) = $73.92 (Total Line Payment) at 106% = $78.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,149.84,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.84 from Fee Schedule UHC_98227C for Rev 310 Proc 81273 * Qty 1 = $149.84 at 100% = $149.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,149.84,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.84 from Fee Schedule UHC_98227C for Rev 310 Proc 81273 * Qty 1 = $149.84 at 100% = $149.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,124.87,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,149.84,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.84 from Fee Schedule UHC_98227C for Rev 310 Proc 81273 * Qty 1 = $149.84 at 100% = $149.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,UNITY HEALTH PLAN,UNITY HOSPICE,124.87,,,,,,,73.9200,1035.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,745.20,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $745.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,641.70,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $641.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,745.20,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $745.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,745.20,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $745.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KIT GENE ANALYSIS D816 VAR,81273,CPT,310,RC,31000329,CDM,,,,both,,,1035.0000,683.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,621.00,,,,,,,73.9200,1035.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,035.00 in Billed Charges for Rev 310 Proc 81273 = $621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81107 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81107 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81107 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81107 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81107 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81107 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81107 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81107 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81107 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81107 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71... $120.71 at 106% = $127.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81107 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 106% = $127.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81107 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81107 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81107 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-3 GENOTYPING GENE ANALYSIS COMMON VAR,81107,CPT,310,RC,31000335,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81107 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81108 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81108 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81108 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81108 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81108 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81108 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81108 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81108 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81108 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81108 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71... $120.71 at 106% = $127.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81108 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 106% = $127.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81108 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81108 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81108 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-4 GENOTYPING GENE ANALYSIS COMMON VAR,81108,CPT,310,RC,31000336,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81108 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81111 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81111 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81111 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81111 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81111 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81111 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81111 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81111 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81111 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81111 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71... $120.71 at 106% = $127.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81111 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 106% = $127.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81111 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81111 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81111 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-9 GENOTYPING GENE ANALYSIS COMMON VAR,81111,CPT,310,RC,31000339,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81111 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81112 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81112 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81112 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81112 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81112 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81112 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81112 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81112 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81112 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81112 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71... $120.71 at 106% = $127.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81112 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 106% = $127.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81112 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81112 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81112 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-15 GENOTYPING GENE ANALYSIS COMMON VAR,81112,CPT,310,RC,31000340,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81112 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,AETNA,AETNA HSHS,804.92,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $804.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,AETNA,AETNA MEDICARE,174.81,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,AETNA,ALL COMMERCIAL AETNA,1246.00,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,ANTHEM,ANTEHM MEDICAID,61.22,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81232 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,174.81,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,ANTHEM,ANTHEM POS/HMO,611.84,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $611.84 from Fee Schedule WII28_25 for Rev 310 Proc 81232 Mod TC * Qty 1 = $611.84 at 100% = $611.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,ANTHEM,ANTHEM PPO,611.84,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $611.84 from Fee Schedule WII28_25 for Rev 310 Proc 81232 Mod TC * Qty 1 = $611.84 at 100% = $611.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1246.00,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,CENPATICO,ALL MEDICAID CENPATICO,1246.00,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1059.10,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,059.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,CIGNA,ALL COMMERCIAL CIGNA,872.20,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $872.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,COFINITY,COFINITY,1246.00,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,61.22,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81232 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,61.22,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81232 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1183.70,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,183.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,1046.64,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,046.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,884.66,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $884.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,909.58,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $909.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,605.56,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $605.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1059.10,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,059.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HUMANA,HUMANA CHOICE CARE HMO,297.18,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $297.18 from Fee Schedule 005543_170 for Rev 310 Proc 81232 * Qty 1 = $297.18 at 100% = $297.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HUMANA,HUMANA CHOICE CARE PPO,1059.10,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,059.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,174.81,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,HUMANA,HUMANA NATIIONAL POS HMO,297.18,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $297.18 from Fee Schedule 005543_170 for Rev 310 Proc 81232 * Qty 1 = $297.18 at 100% = $297.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,909.58,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $909.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1246.00,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,61.22,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81232 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,174.81,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,61.22,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81232 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,64.89,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81232 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22... $61.22 at 106% = $64.89 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,174.81,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,623.00,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $623.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1046.64,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,046.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,393.32,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,934.50,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $934.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1146.32,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $1,146.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,227.25,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,227.25,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,PREVEA HEALTH NETWORK,PREVEA360,227.25,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,227.25,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,795.32,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $795.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,176.56,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,897.12,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $897.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,TRIOLOGY,TRILOGY MEDICAID,64.89,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81232 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 106% = $64.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,209.77,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $209.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81232 * Qty 1 = $209.77 at 100% = $209.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,209.77,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $209.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81232 * Qty 1 = $209.77 at 100% = $209.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,174.81,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,209.77,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $209.77 from Fee Schedule UHC_98227C for Rev 310 Proc 81232 * Qty 1 = $209.77 at 100% = $209.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,UNITY HEALTH PLAN,UNITY HOSPICE,174.81,,,,,,,61.2200,1246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,897.12,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $897.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,772.52,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $772.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,897.12,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $897.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,897.12,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $897.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPYD GENE ANALYSIS COMMON VARIANT,81232,CPT,310,RC,31000341,CDM,,,,both,,,1246.0000,822.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,747.60,,,,,,,61.2200,1246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,246.00 in Billed Charges for Rev 310 Proc 81232 = $747.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,AETNA,AETNA HSHS,2063.32,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,063.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,AETNA,AETNA MEDICARE,1824.88,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,AETNA,ALL COMMERCIAL AETNA,3194.00,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $3,194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,ANTHEM,ANTEHM MEDICAID,1471.63,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81162 at $1,471.63 (Fee Schedule) = $1,471.63 (Total Line Payment) at 100% = $1,471.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1824.88,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,ANTHEM,ANTHEM POS/HMO,3194.00,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). $6,387.08 from Fee Schedule WII28_25 for Rev 310 Proc 81162 Mod TC * Qty 1 = $6,387.08 at 100% = $6,387.08 (Limited to $3,194.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,ANTHEM,ANTHEM PPO,3194.00,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). $6,387.08 from Fee Schedule WII28_25 for Rev 310 Proc 81162 Mod TC * Qty 1 = $6,387.08 at 100% = $6,387.08 (Limited to $3,194.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3194.00,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $3,194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,CENPATICO,ALL MEDICAID CENPATICO,3194.00,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $3,194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2714.90,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,714.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,CIGNA,ALL COMMERCIAL CIGNA,2235.80,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,235.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,COFINITY,COFINITY,3194.00,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $3,194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1471.63,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81162 at $1,471.63 (Fee Schedule) = $1,471.63 (Total Line Payment) at 100% = $1,471.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1471.63,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81162 at $1,471.63 (Fee Schedule) = $1,471.63 (Total Line Payment) at 100% = $1,471.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3034.30,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $3,034.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,2682.96,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,682.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2267.74,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,267.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2331.62,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,331.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,1552.28,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $1,552.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2714.90,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,714.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HUMANA,HUMANA CHOICE CARE HMO,3102.30,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,102.30 from Fee Schedule 005543_170 for Rev 310 Proc 81162 * Qty 1 = $3,102.30 at 100% = $3,102.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HUMANA,HUMANA CHOICE CARE PPO,2714.90,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,714.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HUMANA,HUMANA MEDICARE ADVANTAGE,1824.88,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,HUMANA,HUMANA NATIIONAL POS HMO,3102.30,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,102.30 from Fee Schedule 005543_170 for Rev 310 Proc 81162 * Qty 1 = $3,102.30 at 100% = $3,102.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2331.62,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,331.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3194.00,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $3,194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1471.63,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81162 at $1,471.63 (Fee Schedule) = $1,471.63 (Total Line Payment) at 100% = $1,471.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1824.88,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1471.63,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81162 at $1,471.63 (Fee Schedule) = $1,471.63 (Total Line Payment) at 100% = $1,471.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,MOLINA HEALTHCARE,MOLINA MEDICAID,1559.93,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81162 at $1,471.63 (Fee Schedule) = $1,471.63 (Total Line Payment) at 100% = $1,471.63... $1,471.63 at 106% = $1,559.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,MOLINA HEALTHCARE,MOLINA MEDICARE,1824.88,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1597.00,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $1,597.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2682.96,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,682.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,NAPHCARE,ALL COMMERICAL NAPHCARE,4105.98,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2395.50,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,395.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2938.48,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,938.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2372.34,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2372.34,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,PREVEA HEALTH NETWORK,PREVEA360,2372.34,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2372.34,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2038.73,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,038.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1843.13,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2299.68,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,299.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,TRIOLOGY,TRILOGY MEDICAID,1559.93,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81162 at $1,471.63 (Fee Schedule) = $1,471.63 (Total Line Payment) at 106% = $1,559.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2189.86,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,189.86 from Fee Schedule UHC_98227C for Rev 310 Proc 81162 * Qty 1 = $2,189.86 at 100% = $2,189.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,2189.86,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,189.86 from Fee Schedule UHC_98227C for Rev 310 Proc 81162 * Qty 1 = $2,189.86 at 100% = $2,189.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1824.88,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,2189.86,,,,,,,1471.6300,4105.9800,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,189.86 from Fee Schedule UHC_98227C for Rev 310 Proc 81162 * Qty 1 = $2,189.86 at 100% = $2,189.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,UNITY HEALTH PLAN,UNITY HOSPICE,1824.88,,,,,,,1471.6300,4105.9800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2299.68,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,299.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1980.28,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $1,980.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2299.68,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,299.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2299.68,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $2,299.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRCA1 & BRCA2 FULL SEQ/DUPE/DEL ANALYSIS,81162,CPT,310,RC,31000343,CDM,,,,both,,,3194.0000,2108.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1916.40,,,,,,,1471.6300,4105.9800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,194.00 in Billed Charges for Rev 310 Proc 81162 = $1,916.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,AETNA,AETNA HSHS,3063.33,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,063.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,AETNA,AETNA MEDICARE,2709.95,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,AETNA,ALL COMMERCIAL AETNA,4742.00,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,ANTHEM,ANTEHM MEDICAID,866.06,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81426 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2709.95,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,ANTHEM,ANTHEM POS/HMO,4742.00,,,,,,,866.0600,6097.3900,fee schedule,"ST VINCENT HOSPITAL (ACU). $9,484.83 from Fee Schedule WII28_25 for Rev 310 Proc 81426 Mod TC * Qty 1 = $9,484.83 at 100% = $9,484.83 (Limited to $4,742.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,ANTHEM,ANTHEM PPO,4742.00,,,,,,,866.0600,6097.3900,fee schedule,"ST VINCENT HOSPITAL (ACU). $9,484.83 from Fee Schedule WII28_25 for Rev 310 Proc 81426 Mod TC * Qty 1 = $9,484.83 at 100% = $9,484.83 (Limited to $4,742.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4742.00,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,CENPATICO,ALL MEDICAID CENPATICO,4742.00,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4030.70,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,030.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,CIGNA,ALL COMMERCIAL CIGNA,3319.40,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,319.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,COFINITY,COFINITY,4742.00,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,866.06,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81426 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,866.06,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81426 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4504.90,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,504.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,3983.28,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,983.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3366.82,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,366.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3461.66,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,461.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,2304.61,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $2,304.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4030.70,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,030.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HUMANA,HUMANA CHOICE CARE HMO,4606.92,,,,,,,866.0600,6097.3900,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,606.92 from Fee Schedule 005543_170 for Rev 310 Proc 81426 * Qty 1 = $4,606.92 at 100% = $4,606.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HUMANA,HUMANA CHOICE CARE PPO,4030.70,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,030.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,2709.95,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,HUMANA,HUMANA NATIIONAL POS HMO,4606.92,,,,,,,866.0600,6097.3900,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,606.92 from Fee Schedule 005543_170 for Rev 310 Proc 81426 * Qty 1 = $4,606.92 at 100% = $4,606.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3461.66,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,461.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,4742.00,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,866.06,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81426 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2709.95,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,866.06,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81426 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,918.02,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81426 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06... $866.06 at 106% = $918.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,2709.95,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2371.00,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $2,371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3983.28,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,983.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,6097.39,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3556.50,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,556.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4362.64,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $4,362.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3522.94,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3522.94,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,PREVEA HEALTH NETWORK,PREVEA360,3522.94,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3522.94,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3026.82,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,026.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2737.05,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3414.24,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,414.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,TRIOLOGY,TRILOGY MEDICAID,918.03,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81426 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 106% = $918.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3251.94,,,,,,,866.0600,6097.3900,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,251.94 from Fee Schedule UHC_98227C for Rev 310 Proc 81426 * Qty 1 = $3,251.94 at 100% = $3,251.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,3251.94,,,,,,,866.0600,6097.3900,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,251.94 from Fee Schedule UHC_98227C for Rev 310 Proc 81426 * Qty 1 = $3,251.94 at 100% = $3,251.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2709.95,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,3251.94,,,,,,,866.0600,6097.3900,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,251.94 from Fee Schedule UHC_98227C for Rev 310 Proc 81426 * Qty 1 = $3,251.94 at 100% = $3,251.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,UNITY HEALTH PLAN,UNITY HOSPICE,2709.95,,,,,,,866.0600,6097.3900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3414.24,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,414.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2940.04,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $2,940.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3414.24,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,414.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3414.24,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $3,414.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC GENOME; SEQUENCE ANALSYS, EACH COMPARATOR GENOME",81426,CPT,310,RC,31000345,CDM,,,,both,,,4742.0000,3129.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2845.20,,,,,,,866.0600,6097.3900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,742.00 in Billed Charges for Rev 310 Proc 81426 = $2,845.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,AETNA,AETNA HSHS,2235.81,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,235.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,AETNA,AETNA MEDICARE,504.00,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,AETNA,ALL COMMERCIAL AETNA,3461.00,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $3,461.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,ANTHEM,ANTEHM MEDICAID,403.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81410 at $403.20 (Fee Schedule) = $403.20 (Total Line Payment) at 100% = $403.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,504.00,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,ANTHEM,ANTHEM POS/HMO,1764.00,,,,,,,403.2000,3461.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,764.00 from Fee Schedule WII28_25 for Rev 310 Proc 81410 Mod TC * Qty 1 = $1,764.00 at 100% = $1,764.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,ANTHEM,ANTHEM PPO,1764.00,,,,,,,403.2000,3461.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,764.00 from Fee Schedule WII28_25 for Rev 310 Proc 81410 Mod TC * Qty 1 = $1,764.00 at 100% = $1,764.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3461.00,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $3,461.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,CENPATICO,ALL MEDICAID CENPATICO,3461.00,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $3,461.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2941.85,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,941.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,CIGNA,ALL COMMERCIAL CIGNA,2422.70,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,422.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,COFINITY,COFINITY,3461.00,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $3,461.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,403.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81410 at $403.20 (Fee Schedule) = $403.20 (Total Line Payment) at 100% = $403.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,403.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81410 at $403.20 (Fee Schedule) = $403.20 (Total Line Payment) at 100% = $403.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3287.95,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $3,287.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,2907.24,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,907.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2457.31,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,457.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2526.53,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,526.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,1682.05,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $1,682.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2941.85,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,941.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HUMANA,HUMANA CHOICE CARE HMO,856.80,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $856.80 from Fee Schedule 005543_170 for Rev 310 Proc 81410 * Qty 1 = $856.80 at 100% = $856.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HUMANA,HUMANA CHOICE CARE PPO,2941.85,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,941.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,504.00,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,HUMANA,HUMANA NATIIONAL POS HMO,856.80,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $856.80 from Fee Schedule 005543_170 for Rev 310 Proc 81410 * Qty 1 = $856.80 at 100% = $856.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2526.53,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,526.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,3461.00,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $3,461.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,403.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81410 at $403.20 (Fee Schedule) = $403.20 (Total Line Payment) at 100% = $403.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,504.00,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,403.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81410 at $403.20 (Fee Schedule) = $403.20 (Total Line Payment) at 100% = $403.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,427.39,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81410 at $403.20 (Fee Schedule) = $403.20 (Total Line Payment) at 100% = $403.20... $403.20 at 106% = $427.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,504.00,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1730.50,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $1,730.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2907.24,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,907.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,1134.00,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2595.75,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,595.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3184.12,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $3,184.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,655.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,655.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,PREVEA HEALTH NETWORK,PREVEA360,655.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,655.20,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2209.16,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,209.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,509.04,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2491.92,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,491.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,TRIOLOGY,TRILOGY MEDICAID,427.39,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81410 at $403.20 (Fee Schedule) = $403.20 (Total Line Payment) at 106% = $427.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,604.80,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $604.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81410 * Qty 1 = $604.80 at 100% = $604.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,604.80,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $604.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81410 * Qty 1 = $604.80 at 100% = $604.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,504.00,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,604.80,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $604.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81410 * Qty 1 = $604.80 at 100% = $604.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,UNITY HEALTH PLAN,UNITY HOSPICE,504.00,,,,,,,403.2000,3461.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2491.92,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,491.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2145.82,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,145.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2491.92,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,491.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2491.92,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,491.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AORTIC DYSFUNCTION OR DILATION; GENOMIC SEQUENCE ANALYSIS PANEL,81410,CPT,310,RC,31000346,CDM,,,,both,,,3461.0000,2284.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2076.60,,,,,,,403.2000,3461.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,461.00 in Billed Charges for Rev 310 Proc 81410 = $2,076.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,AETNA,AETNA HSHS,445.74,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $445.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,AETNA,AETNA MEDICARE,208.92,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,AETNA,ALL COMMERCIAL AETNA,690.00,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,ANTHEM,ANTEHM MEDICAID,215.88,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81340 at $215.88 (Fee Schedule) = $215.88 (Total Line Payment) at 100% = $215.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,208.92,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,ANTHEM,ANTHEM POS/HMO,690.00,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $731.22 from Fee Schedule WII28_25 for Rev 310 Proc 81340 Mod TC * Qty 1 = $731.22 at 100% = $731.22 (Limited to $690.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,ANTHEM,ANTHEM PPO,690.00,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $731.22 from Fee Schedule WII28_25 for Rev 310 Proc 81340 Mod TC * Qty 1 = $731.22 at 100% = $731.22 (Limited to $690.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,690.00,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,CENPATICO,ALL MEDICAID CENPATICO,690.00,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,586.50,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $586.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,CIGNA,ALL COMMERCIAL CIGNA,483.00,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $483.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,COFINITY,COFINITY,690.00,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,215.88,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81340 at $215.88 (Fee Schedule) = $215.88 (Total Line Payment) at 100% = $215.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,215.88,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81340 at $215.88 (Fee Schedule) = $215.88 (Total Line Payment) at 100% = $215.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,655.50,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $655.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,579.60,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,489.90,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $489.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,503.70,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $503.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,335.34,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $335.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,586.50,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $586.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HUMANA,HUMANA CHOICE CARE HMO,355.16,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $355.16 from Fee Schedule 005543_170 for Rev 310 Proc 81340 * Qty 1 = $355.16 at 100% = $355.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HUMANA,HUMANA CHOICE CARE PPO,586.50,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $586.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,208.92,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,HUMANA,HUMANA NATIIONAL POS HMO,355.16,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $355.16 from Fee Schedule 005543_170 for Rev 310 Proc 81340 * Qty 1 = $355.16 at 100% = $355.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,503.70,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $503.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,690.00,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,215.88,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81340 at $215.88 (Fee Schedule) = $215.88 (Total Line Payment) at 100% = $215.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,208.92,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,215.88,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81340 at $215.88 (Fee Schedule) = $215.88 (Total Line Payment) at 100% = $215.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,228.83,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81340 at $215.88 (Fee Schedule) = $215.88 (Total Line Payment) at 100% = $215.88... $215.88 at 106% = $228.83 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,208.92,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,345.00,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $345.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,579.60,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,470.07,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,517.50,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $517.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,634.80,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $634.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,271.60,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,271.60,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,PREVEA HEALTH NETWORK,PREVEA360,271.60,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,271.60,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,440.43,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $440.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,211.01,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,496.80,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $496.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,TRIOLOGY,TRILOGY MEDICAID,228.83,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81340 at $215.88 (Fee Schedule) = $215.88 (Total Line Payment) at 106% = $228.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,250.70,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $250.70 from Fee Schedule UHC_98227C for Rev 310 Proc 81340 * Qty 1 = $250.70 at 100% = $250.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,250.70,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $250.70 from Fee Schedule UHC_98227C for Rev 310 Proc 81340 * Qty 1 = $250.70 at 100% = $250.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,208.92,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,250.70,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $250.70 from Fee Schedule UHC_98227C for Rev 310 Proc 81340 * Qty 1 = $250.70 at 100% = $250.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,UNITY HEALTH PLAN,UNITY HOSPICE,208.92,,,,,,,208.9200,690.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,496.80,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $496.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,427.80,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $427.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,496.80,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $496.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,496.80,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $496.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRB GENE ANALYSIS,81340,CPT,310,RC,31000347,CDM,,,,both,,,690.0000,455.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,414.00,,,,,,,208.9200,690.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $690.00 in Billed Charges for Rev 310 Proc 81340 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,AETNA,AETNA HSHS,440.57,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $440.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,AETNA,AETNA MEDICARE,207.46,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,AETNA,ALL COMMERCIAL AETNA,682.00,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $682.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,ANTHEM,ANTEHM MEDICAID,214.37,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81267 at $214.37 (Fee Schedule) = $214.37 (Total Line Payment) at 100% = $214.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,207.46,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,ANTHEM,ANTHEM POS/HMO,682.00,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $726.11 from Fee Schedule WII28_25 for Rev 310 Proc 81267 Mod TC * Qty 1 = $726.11 at 100% = $726.11 (Limited to $682.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,ANTHEM,ANTHEM PPO,682.00,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $726.11 from Fee Schedule WII28_25 for Rev 310 Proc 81267 Mod TC * Qty 1 = $726.11 at 100% = $726.11 (Limited to $682.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,682.00,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $682.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,CENPATICO,ALL MEDICAID CENPATICO,682.00,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $682.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,579.70,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $579.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,CIGNA,ALL COMMERCIAL CIGNA,477.40,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $477.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,COFINITY,COFINITY,682.00,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $682.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,214.37,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81267 at $214.37 (Fee Schedule) = $214.37 (Total Line Payment) at 100% = $214.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,214.37,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81267 at $214.37 (Fee Schedule) = $214.37 (Total Line Payment) at 100% = $214.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,647.90,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $647.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,572.88,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $572.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,484.22,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $484.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,497.86,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $497.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,331.45,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $331.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,579.70,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $579.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HUMANA,HUMANA CHOICE CARE HMO,352.68,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $352.68 from Fee Schedule 005543_170 for Rev 310 Proc 81267 * Qty 1 = $352.68 at 100% = $352.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HUMANA,HUMANA CHOICE CARE PPO,579.70,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $579.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,207.46,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,HUMANA,HUMANA NATIIONAL POS HMO,352.68,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $352.68 from Fee Schedule 005543_170 for Rev 310 Proc 81267 * Qty 1 = $352.68 at 100% = $352.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,497.86,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $497.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,682.00,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $682.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,214.37,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81267 at $214.37 (Fee Schedule) = $214.37 (Total Line Payment) at 100% = $214.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,207.46,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,214.37,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81267 at $214.37 (Fee Schedule) = $214.37 (Total Line Payment) at 100% = $214.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,227.23,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81267 at $214.37 (Fee Schedule) = $214.37 (Total Line Payment) at 100% = $214.37... $214.37 at 106% = $227.23 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,207.46,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,341.00,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $341.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,572.88,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $572.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,466.79,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,511.50,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $511.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,627.44,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $627.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,269.70,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,269.70,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,PREVEA HEALTH NETWORK,PREVEA360,269.70,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,269.70,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,435.32,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $435.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,209.53,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,491.04,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $491.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,TRIOLOGY,TRILOGY MEDICAID,227.23,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81267 at $214.37 (Fee Schedule) = $214.37 (Total Line Payment) at 106% = $227.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,248.95,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.95 from Fee Schedule UHC_98227C for Rev 310 Proc 81267 * Qty 1 = $248.95 at 100% = $248.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,248.95,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.95 from Fee Schedule UHC_98227C for Rev 310 Proc 81267 * Qty 1 = $248.95 at 100% = $248.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,207.46,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,248.95,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.95 from Fee Schedule UHC_98227C for Rev 310 Proc 81267 * Qty 1 = $248.95 at 100% = $248.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,UNITY HEALTH PLAN,UNITY HOSPICE,207.46,,,,,,,207.4600,682.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,491.04,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $491.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,422.84,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $422.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,491.04,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $491.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,491.04,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $491.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHIMERIS ANALYSIS POST TRANSPLANTATION SPECIMEN,81267,CPT,310,RC,31000348,CDM,,,,both,,,682.0000,450.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,409.20,,,,,,,207.4600,682.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $682.00 in Billed Charges for Rev 310 Proc 81267 = $409.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,AETNA,AETNA HSHS,332.04,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $332.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,AETNA,AETNA MEDICARE,173.17,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,AETNA,ALL COMMERCIAL AETNA,514.00,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $514.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,ANTHEM,ANTEHM MEDICAID,178.94,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 88249 at $178.94 (Fee Schedule) = $178.94 (Total Line Payment) at 100% = $178.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,173.17,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,ANTHEM,ANTHEM POS/HMO,514.00,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $606.10 from Fee Schedule WII28_25 for Rev 310 Proc 88249 Mod TC * Qty 1 = $606.10 at 100% = $606.10 (Limited to $514.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,ANTHEM,ANTHEM PPO,514.00,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $606.10 from Fee Schedule WII28_25 for Rev 310 Proc 88249 Mod TC * Qty 1 = $606.10 at 100% = $606.10 (Limited to $514.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,514.00,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $514.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,CENPATICO,ALL MEDICAID CENPATICO,514.00,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $514.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,436.90,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $436.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,CIGNA,ALL COMMERCIAL CIGNA,359.80,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $359.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,COFINITY,COFINITY,514.00,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $514.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,178.94,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 88249 at $178.94 (Fee Schedule) = $178.94 (Total Line Payment) at 100% = $178.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,178.94,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 88249 at $178.94 (Fee Schedule) = $178.94 (Total Line Payment) at 100% = $178.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,488.30,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $488.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,431.76,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $431.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,364.94,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $364.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,375.22,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $375.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,249.80,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $249.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,436.90,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $436.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HUMANA,HUMANA CHOICE CARE HMO,294.39,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $294.39 from Fee Schedule 005543_170 for Rev 310 Proc 88249 * Qty 1 = $294.39 at 100% = $294.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HUMANA,HUMANA CHOICE CARE PPO,436.90,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $436.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,173.17,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,HUMANA,HUMANA NATIIONAL POS HMO,294.39,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $294.39 from Fee Schedule 005543_170 for Rev 310 Proc 88249 * Qty 1 = $294.39 at 100% = $294.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,375.22,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $375.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,514.00,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $514.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,178.94,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 88249 at $178.94 (Fee Schedule) = $178.94 (Total Line Payment) at 100% = $178.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,173.17,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,178.94,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 88249 at $178.94 (Fee Schedule) = $178.94 (Total Line Payment) at 100% = $178.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,189.68,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 88249 at $178.94 (Fee Schedule) = $178.94 (Total Line Payment) at 100% = $178.94... $178.94 at 106% = $189.68 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,173.17,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,257.00,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $257.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,431.76,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $431.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,389.63,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,385.50,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $385.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,472.88,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $472.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,225.12,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,225.12,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,PREVEA HEALTH NETWORK,PREVEA360,225.12,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,225.12,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,328.09,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $328.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,174.90,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,370.08,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $370.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,TRIOLOGY,TRILOGY MEDICAID,189.68,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 88249 at $178.94 (Fee Schedule) = $178.94 (Total Line Payment) at 106% = $189.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,207.80,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.80 from Fee Schedule UHC_98227C for Rev 310 Proc 88249 * Qty 1 = $207.80 at 100% = $207.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,207.80,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.80 from Fee Schedule UHC_98227C for Rev 310 Proc 88249 * Qty 1 = $207.80 at 100% = $207.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,173.17,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,207.80,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.80 from Fee Schedule UHC_98227C for Rev 310 Proc 88249 * Qty 1 = $207.80 at 100% = $207.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,UNITY HEALTH PLAN,UNITY HOSPICE,173.17,,,,,,,173.1700,514.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,370.08,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $370.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,318.68,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $318.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,370.08,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $370.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,370.08,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $370.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC CHROMOSOME ANAL:BREAKGE,100 CELLS",88249,CPT,310,RC,31000351,CDM,,,,both,,,514.0000,339.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,308.40,,,,,,,173.1700,514.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $514.00 in Billed Charges for Rev 310 Proc 88249 = $308.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,AETNA,AETNA HSHS,361.11,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $361.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,AETNA,AETNA MEDICARE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,AETNA,ALL COMMERCIAL AETNA,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,ANTHEM,ANTEHM MEDICAID,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81234 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,ANTHEM,ANTHEM POS/HMO,479.50,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81234 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,ANTHEM,ANTHEM PPO,479.50,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81234 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,CENPATICO,ALL MEDICAID CENPATICO,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,475.15,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $475.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,CIGNA,ALL COMMERCIAL CIGNA,391.30,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $391.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,COFINITY,COFINITY,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81234 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81234 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,531.05,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $531.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,469.56,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $469.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,396.89,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $396.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,408.07,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $408.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,271.67,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $271.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,475.15,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $475.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HUMANA,HUMANA CHOICE CARE HMO,232.90,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81234 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HUMANA,HUMANA CHOICE CARE PPO,475.15,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $475.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,HUMANA,HUMANA NATIIONAL POS HMO,232.90,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81234 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,408.07,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $408.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81234 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81234 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,116.18,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81234 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60... $109.60 at 106% = $116.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,279.50,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $279.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,469.56,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $469.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,308.25,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,419.25,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $419.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,514.28,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $514.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,178.10,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,178.10,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,PREVEA HEALTH NETWORK,PREVEA360,178.10,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,178.10,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,356.81,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $356.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,138.37,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,402.48,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $402.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,TRIOLOGY,TRILOGY MEDICAID,116.18,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81234 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 106% = $116.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,164.40,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81234 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,164.40,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81234 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,164.40,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81234 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,UNITY HEALTH PLAN,UNITY HOSPICE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,402.48,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $402.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,346.58,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $346.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,402.48,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $402.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,402.48,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $402.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMPK GENE DETC ABNOR ALLELE,81234,CPT,310,RC,31000353,CDM,,,,both,,,559.0000,368.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,335.40,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $559.00 in Billed Charges for Rev 310 Proc 81234 = $335.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,AETNA,AETNA HSHS,412.79,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $412.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,AETNA,AETNA MEDICARE,185.20,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,AETNA,ALL COMMERCIAL AETNA,639.00,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $639.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,ANTHEM,ANTEHM MEDICAID,148.16,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81279 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,185.20,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,ANTHEM,ANTHEM POS/HMO,639.00,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $648.20 from Fee Schedule WII28_25 for Rev 310 Proc 81279 Mod TC * Qty 1 = $648.20 at 100% = $648.20 (Limited to $639.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,ANTHEM,ANTHEM PPO,639.00,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $648.20 from Fee Schedule WII28_25 for Rev 310 Proc 81279 Mod TC * Qty 1 = $648.20 at 100% = $648.20 (Limited to $639.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,639.00,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $639.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,CENPATICO,ALL MEDICAID CENPATICO,639.00,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $639.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,543.15,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $543.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,CIGNA,ALL COMMERCIAL CIGNA,447.30,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $447.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,COFINITY,COFINITY,639.00,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $639.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,148.16,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81279 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,148.16,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81279 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,607.05,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $607.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,536.76,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $536.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,453.69,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $453.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,466.47,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $466.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,310.55,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $310.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,543.15,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $543.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HUMANA,HUMANA CHOICE CARE HMO,314.84,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $314.84 from Fee Schedule 005543_170 for Rev 310 Proc 81279 * Qty 1 = $314.84 at 100% = $314.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HUMANA,HUMANA CHOICE CARE PPO,543.15,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $543.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,185.20,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,HUMANA,HUMANA NATIIONAL POS HMO,314.84,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $314.84 from Fee Schedule 005543_170 for Rev 310 Proc 81279 * Qty 1 = $314.84 at 100% = $314.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,466.47,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $466.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,639.00,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $639.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,148.16,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81279 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,185.20,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,148.16,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81279 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,157.05,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81279 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16... $148.16 at 106% = $157.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,185.20,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,319.50,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $319.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,536.76,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $536.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,416.70,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,479.25,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $479.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,587.88,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $587.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,240.76,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,240.76,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,PREVEA HEALTH NETWORK,PREVEA360,240.76,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,240.76,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,407.87,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $407.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,187.05,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,460.08,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $460.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,TRIOLOGY,TRILOGY MEDICAID,157.05,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81279 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 106% = $157.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,222.24,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81279 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,222.24,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81279 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,185.20,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,222.24,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81279 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,UNITY HEALTH PLAN,UNITY HOSPICE,185.20,,,,,,,148.1600,639.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,460.08,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $460.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,396.18,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $396.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,460.08,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $460.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,460.08,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $460.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TARGETED SEQ ALYS,81279,CPT,310,RC,31000354,CDM,,,,both,,,639.0000,421.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,383.40,,,,,,,148.1600,639.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $639.00 in Billed Charges for Rev 310 Proc 81279 = $383.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,AETNA,AETNA HSHS,3832.72,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $3,832.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,AETNA,AETNA MEDICARE,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,AETNA,ALL COMMERCIAL AETNA,5933.00,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,ANTHEM,ANTEHM MEDICAID,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81443 at $2,448.56 (Fee Schedule) = $2,448.56 (Total Line Payment) at 100% = $2,448.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,ANTHEM,ANTHEM POS/HMO,5933.00,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,569.96 from Fee Schedule WII28_25 for Rev 310 Proc 81443 Mod TC * Qty 1 = $8,569.96 at 100% = $8,569.96 (Limited to $5,933.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,ANTHEM,ANTHEM PPO,5933.00,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,569.96 from Fee Schedule WII28_25 for Rev 310 Proc 81443 Mod TC * Qty 1 = $8,569.96 at 100% = $8,569.96 (Limited to $5,933.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5933.00,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,CENPATICO,ALL MEDICAID CENPATICO,5933.00,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5043.05,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,043.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,CIGNA,ALL COMMERCIAL CIGNA,4153.10,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,153.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,COFINITY,COFINITY,5933.00,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81443 at $2,448.56 (Fee Schedule) = $2,448.56 (Total Line Payment) at 100% = $2,448.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81443 at $2,448.56 (Fee Schedule) = $2,448.56 (Total Line Payment) at 100% = $2,448.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5636.35,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,636.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,4983.72,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,983.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4212.43,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,212.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4331.09,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,2883.44,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $2,883.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5043.05,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,043.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HUMANA,HUMANA CHOICE CARE HMO,4162.55,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,162.55 from Fee Schedule 005543_170 for Rev 310 Proc 81443 * Qty 1 = $4,162.55 at 100% = $4,162.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HUMANA,HUMANA CHOICE CARE PPO,5043.05,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,043.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,HUMANA,HUMANA NATIIONAL POS HMO,4162.55,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,162.55 from Fee Schedule 005543_170 for Rev 310 Proc 81443 * Qty 1 = $4,162.55 at 100% = $4,162.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4331.09,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,331.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,5933.00,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81443 at $2,448.56 (Fee Schedule) = $2,448.56 (Total Line Payment) at 100% = $2,448.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81443 at $2,448.56 (Fee Schedule) = $2,448.56 (Total Line Payment) at 100% = $2,448.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,2595.47,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81443 at $2,448.56 (Fee Schedule) = $2,448.56 (Total Line Payment) at 100% = $2,448.56... $2,448.56 at 106% = $2,595.47 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2966.50,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $2,966.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4983.72,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,983.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,5509.26,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4449.75,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,449.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5458.36,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $5,458.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3183.13,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3183.13,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,PREVEA HEALTH NETWORK,PREVEA360,3183.13,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3183.13,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3787.03,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $3,787.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2473.05,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4271.76,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,271.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,TRIOLOGY,TRILOGY MEDICAID,2595.47,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81443 at $2,448.56 (Fee Schedule) = $2,448.56 (Total Line Payment) at 106% = $2,595.47. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2938.27,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,938.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81443 * Qty 1 = $2,938.27 at 100% = $2,938.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,2938.27,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,938.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81443 * Qty 1 = $2,938.27 at 100% = $2,938.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,2938.27,,,,,,,2448.5600,5933.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,938.27 from Fee Schedule UHC_98227C for Rev 310 Proc 81443 * Qty 1 = $2,938.27 at 100% = $2,938.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,UNITY HEALTH PLAN,UNITY HOSPICE,2448.56,,,,,,,2448.5600,5933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4271.76,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,271.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3678.46,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $3,678.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4271.76,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,271.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4271.76,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $4,271.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENETIC TSTG SEVERE INH COND,81443,CPT,310,RC,31000358,CDM,,,,both,,,5933.0000,3915.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3559.80,,,,,,,2448.5600,5933.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,933.00 in Billed Charges for Rev 310 Proc 81443 = $3,559.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,AETNA,AETNA HSHS,105.30,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $105.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,AETNA,AETNA MEDICARE,50.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,AETNA,ALL COMMERCIAL AETNA,163.00,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $163.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,ANTHEM,ANTEHM MEDICAID,17.07,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 80503 at $17.07 (Fee Schedule) = $17.07 (Total Line Payment) at 100% = $17.07
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,50.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,ANTHEM,ANTHEM POS/HMO,75.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $75.62 from Fee Schedule WII28_25 for Rev 310 Proc 80503 Mod TC * Qty 1 = $75.62 at 100% = $75.62
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,ANTHEM,ANTHEM PPO,75.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $75.62 from Fee Schedule WII28_25 for Rev 310 Proc 80503 Mod TC * Qty 1 = $75.62 at 100% = $75.62
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,163.00,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $163.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,CENPATICO,ALL MEDICAID CENPATICO,163.00,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $163.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,138.55,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $138.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,CIGNA,ALL COMMERCIAL CIGNA,114.10,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $114.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,COFINITY,COFINITY,163.00,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $163.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.07,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 80503 at $17.07 (Fee Schedule) = $17.07 (Total Line Payment) at 100% = $17.07
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.07,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 80503 at $17.07 (Fee Schedule) = $17.07 (Total Line Payment) at 100% = $17.07
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,154.85,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $154.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,136.92,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $136.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,115.73,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $115.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,118.99,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $118.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,79.22,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $79.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,138.55,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $138.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HUMANA,HUMANA CHOICE CARE HMO,43.66,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.66 from Fee Schedule 005543_170 for Rev 310 Proc 80503 * Qty 1 = $43.66 at 100% = $43.66
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HUMANA,HUMANA CHOICE CARE PPO,138.55,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $138.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HUMANA,HUMANA MEDICARE ADVANTAGE,50.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,HUMANA,HUMANA NATIIONAL POS HMO,43.66,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.66 from Fee Schedule 005543_170 for Rev 310 Proc 80503 * Qty 1 = $43.66 at 100% = $43.66
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,118.99,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $118.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,163.00,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $163.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.07,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 80503 at $17.07 (Fee Schedule) = $17.07 (Total Line Payment) at 100% = $17.07
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,50.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.07,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 80503 at $17.07 (Fee Schedule) = $17.07 (Total Line Payment) at 100% = $17.07
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,MOLINA HEALTHCARE,MOLINA MEDICAID,18.09,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 80503 at $17.07 (Fee Schedule) = $17.07 (Total Line Payment) at 100% = $17.07... $17.07 at 106% = $18.09 Final Expected
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,MOLINA HEALTHCARE,MOLINA MEDICARE,50.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,81.50,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $81.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,136.92,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $136.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,NAPHCARE,ALL COMMERICAL NAPHCARE,113.89,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,122.25,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $122.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,149.96,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $149.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,97.80,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,97.80,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,PREVEA HEALTH NETWORK,PREVEA360,97.80,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,97.80,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,104.04,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $104.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.13,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,117.36,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $117.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,TRIOLOGY,TRILOGY MEDICAID,18.09,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 80503 at $17.07 (Fee Schedule) = $17.07 (Total Line Payment) at 106% = $18.09
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.17,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 310 Proc 80503 * Qty 1 = $60.17 at 100% = $60.17
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,60.17,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 310 Proc 80503 * Qty 1 = $60.17 at 100% = $60.17
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,50.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,60.17,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 310 Proc 80503 * Qty 1 = $60.17 at 100% = $60.17
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,UNITY HEALTH PLAN,UNITY HOSPICE,50.62,,,,,,,17.0700,163.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,117.36,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $117.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,101.06,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $101.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,117.36,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $117.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,117.36,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $117.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CLINICAL PATH CONSULT LIMITED REVIEW,80503,CPT,310,RC,31000362,CDM,,,,outpatient,,,163.0000,107.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,97.80,,,,,,,17.0700,163.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $163.00 in Billed Charges for Rev 310 Proc 80503 = $97.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,AETNA,AETNA HSHS,1279.08,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,279.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,AETNA,AETNA MEDICARE,600.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,AETNA,ALL COMMERCIAL AETNA,1980.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,ANTHEM,ANTEHM MEDICAID,480.56,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81321 at $480.56 (Fee Schedule) = $480.56 (Total Line Payment) at 100% = $480.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,600.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,ANTHEM,ANTHEM POS/HMO,1980.00,,,,,,,480.5600,1980.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,100.00 from Fee Schedule WII28_25 for Rev 310 Proc 81321 Mod TC * Qty 1 = $2,100.00 at 100% = $2,100.00 (Limited to $1,980.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,ANTHEM,ANTHEM PPO,1980.00,,,,,,,480.5600,1980.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,100.00 from Fee Schedule WII28_25 for Rev 310 Proc 81321 Mod TC * Qty 1 = $2,100.00 at 100% = $2,100.00 (Limited to $1,980.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1980.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,CENPATICO,ALL MEDICAID CENPATICO,1980.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1683.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,683.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,CIGNA,ALL COMMERCIAL CIGNA,1386.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,386.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,COFINITY,COFINITY,1980.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,480.56,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81321 at $480.56 (Fee Schedule) = $480.56 (Total Line Payment) at 100% = $480.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,480.56,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81321 at $480.56 (Fee Schedule) = $480.56 (Total Line Payment) at 100% = $480.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1881.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,881.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,1663.20,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,663.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1405.80,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,405.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1445.40,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,445.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,962.28,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $962.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1683.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,683.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HUMANA,HUMANA CHOICE CARE HMO,1020.00,,,,,,,480.5600,1980.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,020.00 from Fee Schedule 005543_170 for Rev 310 Proc 81321 * Qty 1 = $1,020.00 at 100% = $1,020.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HUMANA,HUMANA CHOICE CARE PPO,1683.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,683.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,600.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,HUMANA,HUMANA NATIIONAL POS HMO,1020.00,,,,,,,480.5600,1980.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,020.00 from Fee Schedule 005543_170 for Rev 310 Proc 81321 * Qty 1 = $1,020.00 at 100% = $1,020.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1445.40,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,445.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1980.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,480.56,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81321 at $480.56 (Fee Schedule) = $480.56 (Total Line Payment) at 100% = $480.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,600.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,480.56,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81321 at $480.56 (Fee Schedule) = $480.56 (Total Line Payment) at 100% = $480.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,509.39,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81321 at $480.56 (Fee Schedule) = $480.56 (Total Line Payment) at 100% = $480.56... $480.56 at 106% = $509.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,600.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,990.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $990.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1663.20,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,663.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,1350.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1485.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,485.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1821.60,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,821.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,780.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,780.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,PREVEA HEALTH NETWORK,PREVEA360,780.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,780.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1263.83,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,263.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,606.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1425.60,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,425.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,TRIOLOGY,TRILOGY MEDICAID,509.39,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81321 at $480.56 (Fee Schedule) = $480.56 (Total Line Payment) at 106% = $509.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,720.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $720.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81321 * Qty 1 = $720.00 at 100% = $720.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,720.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $720.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81321 * Qty 1 = $720.00 at 100% = $720.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,600.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,720.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $720.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81321 * Qty 1 = $720.00 at 100% = $720.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,UNITY HEALTH PLAN,UNITY HOSPICE,600.00,,,,,,,480.5600,1980.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1425.60,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,425.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1227.60,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,227.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1425.60,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,425.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1425.60,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,425.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PTEN GENE ANALYSIS FULL SEQUENCE,81321,CPT,310,RC,31000365,CDM,,,,both,,,1980.0000,1306.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1188.00,,,,,,,480.5600,1980.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,980.00 in Billed Charges for Rev 310 Proc 81321 = $1,188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,AETNA,AETNA HSHS,158.27,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $158.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,AETNA,AETNA MEDICARE,74.33,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,AETNA,ALL COMMERCIAL AETNA,245.00,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $245.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,ANTHEM,ANTEHM MEDICAID,76.81,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81374 at $76.81 (Fee Schedule) = $76.81 (Total Line Payment) at 100% = $76.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,74.33,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,ANTHEM,ANTHEM POS/HMO,245.00,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $260.16 from Fee Schedule WII28_25 for Rev 310 Proc 81374 Mod TC * Qty 1 = $260.16 at 100% = $260.16 (Limited to $245.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,ANTHEM,ANTHEM PPO,245.00,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $260.16 from Fee Schedule WII28_25 for Rev 310 Proc 81374 Mod TC * Qty 1 = $260.16 at 100% = $260.16 (Limited to $245.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,245.00,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $245.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,CENPATICO,ALL MEDICAID CENPATICO,245.00,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $245.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,208.25,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $208.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,CIGNA,ALL COMMERCIAL CIGNA,171.50,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $171.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,COFINITY,COFINITY,245.00,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $245.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,76.81,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81374 at $76.81 (Fee Schedule) = $76.81 (Total Line Payment) at 100% = $76.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,76.81,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81374 at $76.81 (Fee Schedule) = $76.81 (Total Line Payment) at 100% = $76.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,232.75,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $232.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,205.80,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $205.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,173.95,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $173.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,178.85,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $178.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,119.07,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $119.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,208.25,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $208.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HUMANA,HUMANA CHOICE CARE HMO,126.36,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $126.36 from Fee Schedule 005543_170 for Rev 310 Proc 81374 * Qty 1 = $126.36 at 100% = $126.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HUMANA,HUMANA CHOICE CARE PPO,208.25,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $208.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,74.33,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,HUMANA,HUMANA NATIIONAL POS HMO,126.36,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $126.36 from Fee Schedule 005543_170 for Rev 310 Proc 81374 * Qty 1 = $126.36 at 100% = $126.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,178.85,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $178.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,245.00,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $245.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,76.81,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81374 at $76.81 (Fee Schedule) = $76.81 (Total Line Payment) at 100% = $76.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,74.33,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,76.81,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81374 at $76.81 (Fee Schedule) = $76.81 (Total Line Payment) at 100% = $76.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,81.42,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81374 at $76.81 (Fee Schedule) = $76.81 (Total Line Payment) at 100% = $76.81... $76.81 at 106% = $81.42 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,74.33,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,122.50,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $122.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,205.80,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $205.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,167.24,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,183.75,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $183.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,225.40,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $225.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,96.63,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,96.63,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,PREVEA HEALTH NETWORK,PREVEA360,96.63,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,96.63,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,156.38,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $156.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,75.07,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,176.40,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,TRIOLOGY,TRILOGY MEDICAID,81.42,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81374 at $76.81 (Fee Schedule) = $76.81 (Total Line Payment) at 106% = $81.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,89.20,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $89.20 from Fee Schedule UHC_98227C for Rev 310 Proc 81374 * Qty 1 = $89.20 at 100% = $89.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,89.20,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $89.20 from Fee Schedule UHC_98227C for Rev 310 Proc 81374 * Qty 1 = $89.20 at 100% = $89.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,74.33,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,89.20,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $89.20 from Fee Schedule UHC_98227C for Rev 310 Proc 81374 * Qty 1 = $89.20 at 100% = $89.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,UNITY HEALTH PLAN,UNITY HOSPICE,74.33,,,,,,,74.3300,245.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,176.40,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,151.90,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $151.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,176.40,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,176.40,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $176.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLS I TYPNG LW ANTGN EA,81374,CPT,310,RC,31000368,CDM,,,,both,,,245.0000,161.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,147.00,,,,,,,74.3300,245.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $245.00 in Billed Charges for Rev 310 Proc 81374 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,AETNA,AETNA HSHS,427.65,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $427.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,AETNA,AETNA MEDICARE,220.74,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,AETNA,ALL COMMERCIAL AETNA,662.00,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,ANTHEM,ANTEHM MEDICAID,228.09,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81375 at $228.09 (Fee Schedule) = $228.09 (Total Line Payment) at 100% = $228.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,220.74,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,ANTHEM,ANTHEM POS/HMO,662.00,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $772.59 from Fee Schedule WII28_25 for Rev 310 Proc 81375 Mod TC * Qty 1 = $772.59 at 100% = $772.59 (Limited to $662.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,ANTHEM,ANTHEM PPO,662.00,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $772.59 from Fee Schedule WII28_25 for Rev 310 Proc 81375 Mod TC * Qty 1 = $772.59 at 100% = $772.59 (Limited to $662.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,662.00,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,CENPATICO,ALL MEDICAID CENPATICO,662.00,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,562.70,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $562.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,CIGNA,ALL COMMERCIAL CIGNA,463.40,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $463.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,COFINITY,COFINITY,662.00,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,228.09,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81375 at $228.09 (Fee Schedule) = $228.09 (Total Line Payment) at 100% = $228.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,228.09,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81375 at $228.09 (Fee Schedule) = $228.09 (Total Line Payment) at 100% = $228.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,628.90,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $628.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,556.08,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $556.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,470.02,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $470.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,483.26,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $483.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,321.73,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $321.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,562.70,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $562.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HUMANA,HUMANA CHOICE CARE HMO,375.26,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $375.26 from Fee Schedule 005543_170 for Rev 310 Proc 81375 * Qty 1 = $375.26 at 100% = $375.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HUMANA,HUMANA CHOICE CARE PPO,562.70,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $562.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,220.74,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,HUMANA,HUMANA NATIIONAL POS HMO,375.26,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $375.26 from Fee Schedule 005543_170 for Rev 310 Proc 81375 * Qty 1 = $375.26 at 100% = $375.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,483.26,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $483.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,662.00,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,228.09,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81375 at $228.09 (Fee Schedule) = $228.09 (Total Line Payment) at 100% = $228.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,220.74,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,228.09,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81375 at $228.09 (Fee Schedule) = $228.09 (Total Line Payment) at 100% = $228.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,241.78,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81375 at $228.09 (Fee Schedule) = $228.09 (Total Line Payment) at 100% = $228.09... $228.09 at 106% = $241.78 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,220.74,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,331.00,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $331.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,556.08,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $556.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,496.67,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,496.50,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $496.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,609.04,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $609.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,286.96,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,286.96,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,PREVEA HEALTH NETWORK,PREVEA360,286.96,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,286.96,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,422.55,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $422.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,222.95,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,476.64,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $476.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,TRIOLOGY,TRILOGY MEDICAID,241.78,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81375 at $228.09 (Fee Schedule) = $228.09 (Total Line Payment) at 106% = $241.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,264.89,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $264.89 from Fee Schedule UHC_98227C for Rev 310 Proc 81375 * Qty 1 = $264.89 at 100% = $264.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,264.89,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $264.89 from Fee Schedule UHC_98227C for Rev 310 Proc 81375 * Qty 1 = $264.89 at 100% = $264.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,220.74,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,264.89,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $264.89 from Fee Schedule UHC_98227C for Rev 310 Proc 81375 * Qty 1 = $264.89 at 100% = $264.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,UNITY HEALTH PLAN,UNITY HOSPICE,220.74,,,,,,,220.7400,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,476.64,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $476.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,410.44,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $410.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,476.64,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $476.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,476.64,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $476.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS II TYPING LOW RESOLUTION,81375,CPT,310,RC,31000370,CDM,,,,both,,,662.0000,436.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,397.20,,,,,,,220.7400,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $662.00 in Billed Charges for Rev 310 Proc 81375 = $397.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,AETNA,AETNA HSHS,2645.37,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,645.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,AETNA,AETNA MEDICARE,896.87,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,AETNA,ALL COMMERCIAL AETNA,4095.00,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $4,095.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,ANTHEM,ANTEHM MEDICAID,133.58,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,896.87,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,ANTHEM,ANTHEM POS/HMO,2784.60,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81457 $4,095.00 in Billed Charges at 68% = $2,784.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,ANTHEM,ANTHEM PPO,2784.60,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81457 $4,095.00 in Billed Charges at 68% = $2,784.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4095.00,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $4,095.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,CENPATICO,ALL MEDICAID CENPATICO,4095.00,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $4,095.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3480.75,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $3,480.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,CIGNA,ALL COMMERCIAL CIGNA,2866.50,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,866.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,COFINITY,COFINITY,4095.00,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $4,095.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,133.58,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,133.58,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3890.25,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $3,890.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,3439.80,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $3,439.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2907.45,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,907.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2989.35,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,989.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,1990.17,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $1,990.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3480.75,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $3,480.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,HUMANA,HUMANA CHOICE CARE PPO,3480.75,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $3,480.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,896.87,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2989.35,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,989.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,4095.00,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $4,095.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,133.58,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,896.87,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,133.58,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,141.59,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58... $133.58 at 106% = $141.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,896.87,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2047.50,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,047.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3439.80,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $3,439.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,2017.96,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3071.25,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $3,071.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3767.40,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $3,767.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1165.93,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1165.93,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,PREVEA HEALTH NETWORK,PREVEA360,1165.93,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1165.93,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2613.84,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,613.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,905.84,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2948.40,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,948.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,TRIOLOGY,TRILOGY MEDICAID,141.59,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 106% = $141.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1076.24,,,,,,,133.5800,4095.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,1076.24,,,,,,,133.5800,4095.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,896.87,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,1076.24,,,,,,,133.5800,4095.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,UNITY HEALTH PLAN,UNITY HOSPICE,896.87,,,,,,,133.5800,4095.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2948.40,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,948.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2538.90,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,538.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2948.40,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,948.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2948.40,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,948.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO NEO GSAP DNA MCRSTL INS,81457,CPT,310,RC,31000371,CDM,,,,both,,,4095.0000,2702.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2457.00,,,,,,,133.5800,4095.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,095.00 in Billed Charges for Rev 310 Proc 81457 = $2,457.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,AETNA,AETNA HSHS,374.68,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $374.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,AETNA,AETNA MEDICARE,165.49,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,AETNA,ALL COMMERCIAL AETNA,580.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $580.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,ANTHEM,ANTEHM MEDICAID,67.75,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88120 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,165.49,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,ANTHEM,ANTHEM POS/HMO,580.00,,,,,,,67.7500,580.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,884.03 from Fee Schedule WII28_25 for Rev 310 Proc 88120 Mod TC * Qty 1 = $1,884.03 at 100% = $1,884.03 (Limited to $580.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,ANTHEM,ANTHEM PPO,580.00,,,,,,,67.7500,580.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,884.03 from Fee Schedule WII28_25 for Rev 310 Proc 88120 Mod TC * Qty 1 = $1,884.03 at 100% = $1,884.03 (Limited to $580.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,580.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $580.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,CENPATICO,ALL MEDICAID CENPATICO,580.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $580.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,493.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $493.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,CIGNA,ALL COMMERCIAL CIGNA,406.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $406.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,COFINITY,COFINITY,580.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $580.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,67.75,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88120 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,67.75,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88120 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,551.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,487.20,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,411.80,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $411.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,423.40,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $423.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,281.88,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $281.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,493.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $493.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HUMANA,HUMANA CHOICE CARE HMO,580.00,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $942.91 from Fee Schedule 005543_170 for Rev 310 Proc 88120 * Qty 1 = $942.91 at 100% = $942.91 (Limited to $580.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HUMANA,HUMANA CHOICE CARE PPO,493.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $493.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,165.49,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,HUMANA,HUMANA NATIIONAL POS HMO,580.00,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $942.91 from Fee Schedule 005543_170 for Rev 310 Proc 88120 * Qty 1 = $942.91 at 100% = $942.91 (Limited to $580.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,423.40,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $423.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,580.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $580.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,67.75,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88120 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,165.49,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,67.75,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88120 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,71.82,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88120 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75... $67.75 at 106% = $71.82 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,165.49,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,290.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $290.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,487.20,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $487.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,372.34,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,435.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $435.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,533.60,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $533.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,348.00,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,348.00,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,PREVEA HEALTH NETWORK,PREVEA360,348.00,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,348.00,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,370.21,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $370.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,167.14,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,417.60,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $417.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,TRIOLOGY,TRILOGY MEDICAID,71.81,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88120 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 106% = $71.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,188.70,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 310 Proc 88120 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,188.70,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 310 Proc 88120 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,165.49,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,188.70,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 310 Proc 88120 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,UNITY HEALTH PLAN,UNITY HOSPICE,165.49,,,,,,,67.7500,580.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,417.60,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $417.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,359.60,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $359.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,417.60,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $417.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,417.60,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $417.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IDH1 COMMON VARIANTS,88120,CPT,310,RC,31000373,CDM,,,,both,,,580.0000,382.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,348.00,,,,,,,67.7500,580.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $580.00 in Billed Charges for Rev 310 Proc 88120 = $348.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,AETNA,AETNA HSHS,886.31,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $886.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,AETNA,AETNA MEDICARE,780.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,AETNA,ALL COMMERCIAL AETNA,1372.00,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,ANTHEM,ANTEHM MEDICAID,599.94,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81201 at $599.94 (Fee Schedule) = $599.94 (Total Line Payment) at 100% = $599.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,780.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,ANTHEM,ANTHEM POS/HMO,1372.00,,,,,,,599.9400,1755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,730.00 from Fee Schedule WII28_25 for Rev 310 Proc 81201 Mod TC * Qty 1 = $2,730.00 at 100% = $2,730.00 (Limited to $1,372.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,ANTHEM,ANTHEM PPO,1372.00,,,,,,,599.9400,1755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,730.00 from Fee Schedule WII28_25 for Rev 310 Proc 81201 Mod TC * Qty 1 = $2,730.00 at 100% = $2,730.00 (Limited to $1,372.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1372.00,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,CENPATICO,ALL MEDICAID CENPATICO,1372.00,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1166.20,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,166.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,CIGNA,ALL COMMERCIAL CIGNA,960.40,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $960.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,COFINITY,COFINITY,1372.00,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,599.94,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81201 at $599.94 (Fee Schedule) = $599.94 (Total Line Payment) at 100% = $599.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,599.94,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81201 at $599.94 (Fee Schedule) = $599.94 (Total Line Payment) at 100% = $599.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1303.40,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,303.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,1152.48,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,152.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,974.12,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $974.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1001.56,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,001.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,666.79,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $666.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1166.20,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,166.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HUMANA,HUMANA CHOICE CARE HMO,1326.00,,,,,,,599.9400,1755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,326.00 from Fee Schedule 005543_170 for Rev 310 Proc 81201 * Qty 1 = $1,326.00 at 100% = $1,326.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HUMANA,HUMANA CHOICE CARE PPO,1166.20,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,166.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,780.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,HUMANA,HUMANA NATIIONAL POS HMO,1326.00,,,,,,,599.9400,1755.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,326.00 from Fee Schedule 005543_170 for Rev 310 Proc 81201 * Qty 1 = $1,326.00 at 100% = $1,326.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1001.56,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,001.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1372.00,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,599.94,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81201 at $599.94 (Fee Schedule) = $599.94 (Total Line Payment) at 100% = $599.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,780.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,599.94,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81201 at $599.94 (Fee Schedule) = $599.94 (Total Line Payment) at 100% = $599.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,635.94,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81201 at $599.94 (Fee Schedule) = $599.94 (Total Line Payment) at 100% = $599.94... $599.94 at 106% = $635.94 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,780.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,686.00,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $686.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1152.48,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,152.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,1755.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1029.00,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,029.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1262.24,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $1,262.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1014.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1014.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,PREVEA HEALTH NETWORK,PREVEA360,1014.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1014.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,875.75,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $875.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,787.80,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,987.84,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $987.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,TRIOLOGY,TRILOGY MEDICAID,635.94,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81201 at $599.94 (Fee Schedule) = $599.94 (Total Line Payment) at 106% = $635.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,936.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $936.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81201 * Qty 1 = $936.00 at 100% = $936.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,936.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $936.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81201 * Qty 1 = $936.00 at 100% = $936.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,780.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,936.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $936.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81201 * Qty 1 = $936.00 at 100% = $936.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,UNITY HEALTH PLAN,UNITY HOSPICE,780.00,,,,,,,599.9400,1755.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,987.84,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $987.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,850.64,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $850.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,987.84,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $987.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,987.84,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $987.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS FULL SEQUENCE,81201,CPT,310,RC,31000376,CDM,,,,both,,,1372.0000,905.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,823.20,,,,,,,599.9400,1755.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,372.00 in Billed Charges for Rev 310 Proc 81201 = $823.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,AETNA,AETNA HSHS,886.31,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $886.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,AETNA,AETNA MEDICARE,200.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,AETNA,ALL COMMERCIAL AETNA,1372.00,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,ANTHEM,ANTEHM MEDICAID,206.66,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81203 at $206.66 (Fee Schedule) = $206.66 (Total Line Payment) at 100% = $206.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,200.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,ANTHEM,ANTHEM POS/HMO,700.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $700.00 from Fee Schedule WII28_25 for Rev 310 Proc 81203 Mod TC * Qty 1 = $700.00 at 100% = $700.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,ANTHEM,ANTHEM PPO,700.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $700.00 from Fee Schedule WII28_25 for Rev 310 Proc 81203 Mod TC * Qty 1 = $700.00 at 100% = $700.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1372.00,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,CENPATICO,ALL MEDICAID CENPATICO,1372.00,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1166.20,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,166.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,CIGNA,ALL COMMERCIAL CIGNA,960.40,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $960.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,COFINITY,COFINITY,1372.00,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,206.66,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81203 at $206.66 (Fee Schedule) = $206.66 (Total Line Payment) at 100% = $206.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,206.66,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81203 at $206.66 (Fee Schedule) = $206.66 (Total Line Payment) at 100% = $206.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1303.40,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,303.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,1152.48,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,152.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,974.12,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $974.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1001.56,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,001.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,666.79,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $666.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1166.20,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,166.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HUMANA,HUMANA CHOICE CARE HMO,340.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $340.00 from Fee Schedule 005543_170 for Rev 310 Proc 81203 * Qty 1 = $340.00 at 100% = $340.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HUMANA,HUMANA CHOICE CARE PPO,1166.20,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,166.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,200.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,HUMANA,HUMANA NATIIONAL POS HMO,340.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $340.00 from Fee Schedule 005543_170 for Rev 310 Proc 81203 * Qty 1 = $340.00 at 100% = $340.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1001.56,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,001.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1372.00,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,206.66,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81203 at $206.66 (Fee Schedule) = $206.66 (Total Line Payment) at 100% = $206.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,200.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,206.66,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81203 at $206.66 (Fee Schedule) = $206.66 (Total Line Payment) at 100% = $206.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,219.06,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81203 at $206.66 (Fee Schedule) = $206.66 (Total Line Payment) at 100% = $206.66... $206.66 at 106% = $219.06 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,200.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,686.00,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $686.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1152.48,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,152.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,450.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1029.00,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,029.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1262.24,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $1,262.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,260.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,260.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,PREVEA HEALTH NETWORK,PREVEA360,260.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,260.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,875.75,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $875.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,202.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,987.84,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $987.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,TRIOLOGY,TRILOGY MEDICAID,219.06,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81203 at $206.66 (Fee Schedule) = $206.66 (Total Line Payment) at 106% = $219.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,240.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $240.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81203 * Qty 1 = $240.00 at 100% = $240.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,240.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $240.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81203 * Qty 1 = $240.00 at 100% = $240.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,200.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,240.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $240.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81203 * Qty 1 = $240.00 at 100% = $240.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,UNITY HEALTH PLAN,UNITY HOSPICE,200.00,,,,,,,200.0000,1372.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,987.84,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $987.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,850.64,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $850.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,987.84,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $987.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,987.84,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $987.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APC GENE ANALYSIS DUPLICATE/DELETION VARIANTS,81203,CPT,310,RC,31000377,CDM,,,,both,,,1372.0000,905.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,823.20,,,,,,,200.0000,1372.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,372.00 in Billed Charges for Rev 310 Proc 81203 = $823.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,AETNA,AETNA HSHS,3023.28,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,023.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,AETNA,AETNA MEDICARE,608.17,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,AETNA,ALL COMMERCIAL AETNA,4680.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $4,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,ANTHEM,ANTEHM MEDICAID,17.32,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0272U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,608.17,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,ANTHEM,ANTHEM POS/HMO,2128.60,,,,,,,17.3200,4680.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,128.60 from Fee Schedule WII28_25 for Rev 310 Proc 0272U Mod TC * Qty 1 = $2,128.60 at 100% = $2,128.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,ANTHEM,ANTHEM PPO,2128.60,,,,,,,17.3200,4680.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,128.60 from Fee Schedule WII28_25 for Rev 310 Proc 0272U Mod TC * Qty 1 = $2,128.60 at 100% = $2,128.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4680.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $4,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,CENPATICO,ALL MEDICAID CENPATICO,4680.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $4,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3978.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,978.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,CIGNA,ALL COMMERCIAL CIGNA,3276.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,276.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,COFINITY,COFINITY,4680.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $4,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.32,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0272U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.32,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0272U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4446.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $4,446.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,3931.20,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,931.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3322.80,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,322.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3416.40,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,416.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,2274.48,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $2,274.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3978.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,978.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HUMANA,HUMANA CHOICE CARE HMO,1033.89,,,,,,,17.3200,4680.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,033.89 from Fee Schedule 005543_170 for Rev 310 Proc 0272U * Qty 1 = $1,033.89 at 100% = $1,033.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HUMANA,HUMANA CHOICE CARE PPO,3978.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,978.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,608.17,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,HUMANA,HUMANA NATIIONAL POS HMO,1033.89,,,,,,,17.3200,4680.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,033.89 from Fee Schedule 005543_170 for Rev 310 Proc 0272U * Qty 1 = $1,033.89 at 100% = $1,033.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3416.40,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,416.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,4680.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $4,680.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.32,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0272U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,608.17,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.32,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0272U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,18.36,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0272U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32... $17.32 at 106% = $18.36 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,608.17,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2340.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $2,340.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3931.20,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,931.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,1368.38,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3510.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4305.60,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $4,305.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,790.62,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,790.62,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,PREVEA HEALTH NETWORK,PREVEA360,790.62,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,790.62,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2987.24,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $2,987.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,614.25,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3369.60,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,369.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,TRIOLOGY,TRILOGY MEDICAID,18.36,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0272U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 106% = $18.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,729.80,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $729.80 from Fee Schedule UHC_98227C for Rev 310 Proc 0272U * Qty 1 = $729.80 at 100% = $729.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,729.80,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $729.80 from Fee Schedule UHC_98227C for Rev 310 Proc 0272U * Qty 1 = $729.80 at 100% = $729.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,608.17,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,729.80,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $729.80 from Fee Schedule UHC_98227C for Rev 310 Proc 0272U * Qty 1 = $729.80 at 100% = $729.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,UNITY HEALTH PLAN,UNITY HOSPICE,608.17,,,,,,,17.3200,4680.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3369.60,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,369.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2901.60,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $2,901.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3369.60,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,369.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3369.60,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $3,369.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEM GENETIC BLD DO 60 GENES,0272U,CPT,310,RC,31000385,CDM,,,,both,,,4680.0000,3088.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2808.00,,,,,,,17.3200,4680.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,680.00 in Billed Charges for Rev 310 Proc 0272U = $2,808.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,AETNA,AETNA HSHS,458.01,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $458.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,AETNA,AETNA MEDICARE,121.91,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,AETNA,ALL COMMERCIAL AETNA,709.00,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $709.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,ANTHEM,ANTEHM MEDICAID,17.32,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0027U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,121.91,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,ANTHEM,ANTHEM POS/HMO,426.69,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $426.69 from Fee Schedule WII28_25 for Rev 310 Proc 0027U Mod TC * Qty 1 = $426.69 at 100% = $426.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,ANTHEM,ANTHEM PPO,426.69,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $426.69 from Fee Schedule WII28_25 for Rev 310 Proc 0027U Mod TC * Qty 1 = $426.69 at 100% = $426.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,709.00,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $709.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,CENPATICO,ALL MEDICAID CENPATICO,709.00,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $709.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,602.65,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $602.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,CIGNA,ALL COMMERCIAL CIGNA,496.30,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $496.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,COFINITY,COFINITY,709.00,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $709.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.32,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0027U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.32,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0027U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,673.55,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $673.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,595.56,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $595.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,503.39,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $503.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,517.57,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $517.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,344.57,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $344.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,602.65,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $602.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HUMANA,HUMANA CHOICE CARE HMO,207.25,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.25 from Fee Schedule 005543_170 for Rev 310 Proc 0027U * Qty 1 = $207.25 at 100% = $207.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HUMANA,HUMANA CHOICE CARE PPO,602.65,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $602.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,121.91,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,HUMANA,HUMANA NATIIONAL POS HMO,207.25,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.25 from Fee Schedule 005543_170 for Rev 310 Proc 0027U * Qty 1 = $207.25 at 100% = $207.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,517.57,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $517.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,709.00,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $709.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.32,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0027U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,121.91,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.32,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0027U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,18.36,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0027U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32... $17.32 at 106% = $18.36 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,121.91,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,354.50,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $354.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,595.56,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $595.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,274.30,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,531.75,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $531.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,652.28,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $652.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.48,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.48,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,PREVEA HEALTH NETWORK,PREVEA360,158.48,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.48,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,452.55,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $452.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.13,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,510.48,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $510.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,TRIOLOGY,TRILOGY MEDICAID,18.36,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 0027U at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 106% = $18.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.29,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.29 from Fee Schedule UHC_98227C for Rev 310 Proc 0027U * Qty 1 = $146.29 at 100% = $146.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,146.29,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.29 from Fee Schedule UHC_98227C for Rev 310 Proc 0027U * Qty 1 = $146.29 at 100% = $146.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,121.91,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,146.29,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.29 from Fee Schedule UHC_98227C for Rev 310 Proc 0027U * Qty 1 = $146.29 at 100% = $146.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,UNITY HEALTH PLAN,UNITY HOSPICE,121.91,,,,,,,17.3200,709.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,510.48,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $510.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,439.58,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $439.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,510.48,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $510.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,510.48,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $510.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE TRGT SEQ ALYS,0027U,CPT,310,RC,31000386,CDM,,,,both,,,709.0000,467.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,425.40,,,,,,,17.3200,709.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $709.00 in Billed Charges for Rev 310 Proc 0027U = $425.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,AETNA,AETNA HSHS,562.67,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $562.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,AETNA,AETNA MEDICARE,175.40,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,AETNA,ALL COMMERCIAL AETNA,871.00,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $871.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,ANTHEM,ANTEHM MEDICAID,140.32,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81233 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,175.40,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,ANTHEM,ANTHEM POS/HMO,613.90,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $613.90 from Fee Schedule WII28_25 for Rev 310 Proc 81233 Mod TC * Qty 1 = $613.90 at 100% = $613.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,ANTHEM,ANTHEM PPO,613.90,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $613.90 from Fee Schedule WII28_25 for Rev 310 Proc 81233 Mod TC * Qty 1 = $613.90 at 100% = $613.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,871.00,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $871.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,CENPATICO,ALL MEDICAID CENPATICO,871.00,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $871.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,740.35,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $740.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,CIGNA,ALL COMMERCIAL CIGNA,609.70,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $609.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,COFINITY,COFINITY,871.00,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $871.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,140.32,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81233 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,140.32,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81233 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,827.45,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $827.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,731.64,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $731.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,618.41,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $618.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,635.83,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $635.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,423.31,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $423.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,740.35,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $740.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HUMANA,HUMANA CHOICE CARE HMO,298.18,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $298.18 from Fee Schedule 005543_170 for Rev 310 Proc 81233 * Qty 1 = $298.18 at 100% = $298.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HUMANA,HUMANA CHOICE CARE PPO,740.35,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $740.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,175.40,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,HUMANA,HUMANA NATIIONAL POS HMO,298.18,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $298.18 from Fee Schedule 005543_170 for Rev 310 Proc 81233 * Qty 1 = $298.18 at 100% = $298.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,635.83,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $635.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,871.00,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $871.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,140.32,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81233 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,175.40,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,140.32,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81233 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,148.74,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81233 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 100% = $140.32... $140.32 at 106% = $148.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,175.40,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,435.50,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $435.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,731.64,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $731.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,394.65,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,653.25,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $653.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,801.32,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $801.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,228.02,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,228.02,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,PREVEA HEALTH NETWORK,PREVEA360,228.02,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,228.02,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,555.96,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $555.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,177.15,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,627.12,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $627.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,TRIOLOGY,TRILOGY MEDICAID,148.74,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81233 at $140.32 (Fee Schedule) = $140.32 (Total Line Payment) at 106% = $148.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,210.48,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81233 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,210.48,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81233 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,175.40,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,210.48,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.48 from Fee Schedule UHC_98227C for Rev 310 Proc 81233 * Qty 1 = $210.48 at 100% = $210.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,UNITY HEALTH PLAN,UNITY HOSPICE,175.40,,,,,,,140.3200,871.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,627.12,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $627.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,540.02,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $540.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,627.12,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $627.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,627.12,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $627.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BTK GENE COMMON VARIANTS,81233,CPT,310,RC,31000387,CDM,,,,both,,,871.0000,574.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,522.60,,,,,,,140.3200,871.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $871.00 in Billed Charges for Rev 310 Proc 81233 = $522.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,AETNA,AETNA HSHS,1313.96,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,313.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,AETNA,AETNA MEDICARE,518.28,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,AETNA,ALL COMMERCIAL AETNA,2034.00,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $2,034.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,ANTHEM,ANTEHM MEDICAID,414.62,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81194 at $414.62 (Fee Schedule) = $414.62 (Total Line Payment) at 100% = $414.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,518.28,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,ANTHEM,ANTHEM POS/HMO,1813.98,,,,,,,414.6200,2034.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,813.98 from Fee Schedule WII28_25 for Rev 310 Proc 81194 Mod TC * Qty 1 = $1,813.98 at 100% = $1,813.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,ANTHEM,ANTHEM PPO,1813.98,,,,,,,414.6200,2034.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,813.98 from Fee Schedule WII28_25 for Rev 310 Proc 81194 Mod TC * Qty 1 = $1,813.98 at 100% = $1,813.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2034.00,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $2,034.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,CENPATICO,ALL MEDICAID CENPATICO,2034.00,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $2,034.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1728.90,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,728.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,CIGNA,ALL COMMERCIAL CIGNA,1423.80,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,423.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,COFINITY,COFINITY,2034.00,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $2,034.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,414.62,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81194 at $414.62 (Fee Schedule) = $414.62 (Total Line Payment) at 100% = $414.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,414.62,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81194 at $414.62 (Fee Schedule) = $414.62 (Total Line Payment) at 100% = $414.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1932.30,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,932.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,1708.56,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,708.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1444.14,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,444.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1484.82,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,484.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,988.52,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $988.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1728.90,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,728.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HUMANA,HUMANA CHOICE CARE HMO,881.08,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $881.08 from Fee Schedule 005543_170 for Rev 310 Proc 81194 * Qty 1 = $881.08 at 100% = $881.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HUMANA,HUMANA CHOICE CARE PPO,1728.90,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,728.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,518.28,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,HUMANA,HUMANA NATIIONAL POS HMO,881.08,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $881.08 from Fee Schedule 005543_170 for Rev 310 Proc 81194 * Qty 1 = $881.08 at 100% = $881.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1484.82,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,484.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2034.00,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $2,034.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,414.62,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81194 at $414.62 (Fee Schedule) = $414.62 (Total Line Payment) at 100% = $414.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,518.28,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,414.62,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81194 at $414.62 (Fee Schedule) = $414.62 (Total Line Payment) at 100% = $414.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,439.50,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81194 at $414.62 (Fee Schedule) = $414.62 (Total Line Payment) at 100% = $414.62... $414.62 at 106% = $439.50 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,518.28,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1017.00,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,017.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1708.56,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,708.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,1166.13,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1525.50,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,525.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1871.28,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,871.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,673.76,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,673.76,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,PREVEA HEALTH NETWORK,PREVEA360,673.76,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,673.76,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1298.30,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,298.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,523.46,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1464.48,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,464.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,TRIOLOGY,TRILOGY MEDICAID,439.50,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81194 at $414.62 (Fee Schedule) = $414.62 (Total Line Payment) at 106% = $439.50. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,621.94,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $621.94 from Fee Schedule UHC_98227C for Rev 310 Proc 81194 * Qty 1 = $621.94 at 100% = $621.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,621.94,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $621.94 from Fee Schedule UHC_98227C for Rev 310 Proc 81194 * Qty 1 = $621.94 at 100% = $621.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,518.28,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,621.94,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $621.94 from Fee Schedule UHC_98227C for Rev 310 Proc 81194 * Qty 1 = $621.94 at 100% = $621.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,UNITY HEALTH PLAN,UNITY HOSPICE,518.28,,,,,,,414.6200,2034.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1464.48,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,464.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1261.08,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,261.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1464.48,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,464.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1464.48,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,464.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NTRK TRANSLOCATION ANALYSIS,81194,CPT,310,RC,31000390,CDM,,,,both,,,2034.0000,1342.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1220.40,,,,,,,414.6200,2034.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,034.00 in Billed Charges for Rev 310 Proc 81194 = $1,220.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,AETNA,AETNA HSHS,1060.73,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,060.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,AETNA,AETNA MEDICARE,641.85,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,AETNA,ALL COMMERCIAL AETNA,1642.00,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,642.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,ANTHEM,ANTEHM MEDICAID,513.48,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81351 at $513.48 (Fee Schedule) = $513.48 (Total Line Payment) at 100% = $513.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,641.85,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,ANTHEM,ANTHEM POS/HMO,1642.00,,,,,,,513.4800,1642.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,246.48 from Fee Schedule WII28_25 for Rev 310 Proc 81351 Mod TC * Qty 1 = $2,246.48 at 100% = $2,246.48 (Limited to $1,642.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,ANTHEM,ANTHEM PPO,1642.00,,,,,,,513.4800,1642.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,246.48 from Fee Schedule WII28_25 for Rev 310 Proc 81351 Mod TC * Qty 1 = $2,246.48 at 100% = $2,246.48 (Limited to $1,642.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1642.00,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,642.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,CENPATICO,ALL MEDICAID CENPATICO,1642.00,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,642.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1395.70,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,395.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,CIGNA,ALL COMMERCIAL CIGNA,1149.40,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,149.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,COFINITY,COFINITY,1642.00,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,642.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,513.48,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81351 at $513.48 (Fee Schedule) = $513.48 (Total Line Payment) at 100% = $513.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,513.48,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81351 at $513.48 (Fee Schedule) = $513.48 (Total Line Payment) at 100% = $513.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1559.90,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,559.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,1379.28,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,379.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1165.82,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,165.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1198.66,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,198.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,798.01,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $798.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1395.70,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,395.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HUMANA,HUMANA CHOICE CARE HMO,1091.15,,,,,,,513.4800,1642.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,091.15 from Fee Schedule 005543_170 for Rev 310 Proc 81351 * Qty 1 = $1,091.15 at 100% = $1,091.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HUMANA,HUMANA CHOICE CARE PPO,1395.70,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,395.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,641.85,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,HUMANA,HUMANA NATIIONAL POS HMO,1091.15,,,,,,,513.4800,1642.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,091.15 from Fee Schedule 005543_170 for Rev 310 Proc 81351 * Qty 1 = $1,091.15 at 100% = $1,091.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1198.66,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,198.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1642.00,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,642.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,513.48,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81351 at $513.48 (Fee Schedule) = $513.48 (Total Line Payment) at 100% = $513.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,641.85,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,513.48,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81351 at $513.48 (Fee Schedule) = $513.48 (Total Line Payment) at 100% = $513.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,544.29,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81351 at $513.48 (Fee Schedule) = $513.48 (Total Line Payment) at 100% = $513.48... $513.48 at 106% = $544.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,641.85,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,821.00,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $821.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1379.28,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,379.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,1444.16,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1231.50,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,231.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1510.64,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,510.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,834.41,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,834.41,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,PREVEA HEALTH NETWORK,PREVEA360,834.41,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,834.41,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1048.09,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,048.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,648.27,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1182.24,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,182.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,TRIOLOGY,TRILOGY MEDICAID,544.29,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81351 at $513.48 (Fee Schedule) = $513.48 (Total Line Payment) at 106% = $544.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,770.22,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $770.22 from Fee Schedule UHC_98227C for Rev 310 Proc 81351 * Qty 1 = $770.22 at 100% = $770.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,770.22,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $770.22 from Fee Schedule UHC_98227C for Rev 310 Proc 81351 * Qty 1 = $770.22 at 100% = $770.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,641.85,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,770.22,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $770.22 from Fee Schedule UHC_98227C for Rev 310 Proc 81351 * Qty 1 = $770.22 at 100% = $770.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,UNITY HEALTH PLAN,UNITY HOSPICE,641.85,,,,,,,513.4800,1642.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1182.24,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,182.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1018.04,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,018.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1182.24,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,182.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1182.24,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $1,182.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TP52 GENE ANALYSIS FULL GENE SEQUENCE,81351,CPT,310,RC,31000392,CDM,,,,both,,,1642.0000,1083.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,985.20,,,,,,,513.4800,1642.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,642.00 in Billed Charges for Rev 310 Proc 81351 = $985.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,AETNA,AETNA HSHS,339.80,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $339.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,AETNA,AETNA MEDICARE,262.99,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,AETNA,ALL COMMERCIAL AETNA,526.00,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $526.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,262.99,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,ANTHEM,ANTHEM POS/HMO,357.68,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 306 Proc 81515 $526.00 in Billed Charges at 68% = $357.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,ANTHEM,ANTHEM PPO,357.68,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 306 Proc 81515 $526.00 in Billed Charges at 68% = $357.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,526.00,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $526.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,CENPATICO,ALL MEDICAID CENPATICO,526.00,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $526.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,447.10,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $447.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,CIGNA,ALL COMMERCIAL CIGNA,368.20,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $368.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,COFINITY,COFINITY,526.00,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $526.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,499.70,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $499.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,441.84,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $441.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,373.46,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $373.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,383.98,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $383.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,255.64,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $255.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,447.10,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $447.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,HUMANA,HUMANA CHOICE CARE PPO,447.10,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $447.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,262.99,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,383.98,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $383.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,526.00,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $526.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,262.99,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,262.99,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,263.00,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,441.84,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $441.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,591.73,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,394.50,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $394.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,483.92,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $483.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,341.89,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,341.89,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,PREVEA HEALTH NETWORK,PREVEA360,341.89,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,341.89,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,335.75,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $335.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,265.62,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,378.72,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $378.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,315.59,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 81515 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,315.59,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 81515 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,262.99,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,315.59,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 81515 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,UNITY HEALTH PLAN,UNITY HOSPICE,262.99,,,,,,,255.6400,591.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,378.72,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $378.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,326.12,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $326.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,378.72,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $378.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,378.72,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $378.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS,81515,CPT,306,RC,31000396,CDM,,,,both,,,526.0000,347.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,315.60,,,,,,,255.6400,591.7300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $526.00 in Billed Charges for Rev 306 Proc 81515 = $315.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,AETNA,AETNA HSHS,1153.76,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,153.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,AETNA,AETNA MEDICARE,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,AETNA,ALL COMMERCIAL AETNA,1786.00,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,786.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,ANTHEM,ANTEHM MEDICAID,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81345 at $185.20 (Fee Schedule) = $185.20 (Total Line Payment) at 100% = $185.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,ANTHEM,ANTHEM POS/HMO,648.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $648.20 from Fee Schedule WII28_25 for Rev 310 Proc 81345 Mod TC * Qty 1 = $648.20 at 100% = $648.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,ANTHEM,ANTHEM PPO,648.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $648.20 from Fee Schedule WII28_25 for Rev 310 Proc 81345 Mod TC * Qty 1 = $648.20 at 100% = $648.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1786.00,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,786.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,CENPATICO,ALL MEDICAID CENPATICO,1786.00,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,786.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1518.10,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,518.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,CIGNA,ALL COMMERCIAL CIGNA,1250.20,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,250.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,COFINITY,COFINITY,1786.00,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,786.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81345 at $185.20 (Fee Schedule) = $185.20 (Total Line Payment) at 100% = $185.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81345 at $185.20 (Fee Schedule) = $185.20 (Total Line Payment) at 100% = $185.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1696.70,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,696.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,1500.24,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,500.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1268.06,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,268.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1303.78,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,303.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,868.00,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $868.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1518.10,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,518.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HUMANA,HUMANA CHOICE CARE HMO,314.84,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $314.84 from Fee Schedule 005543_170 for Rev 310 Proc 81345 * Qty 1 = $314.84 at 100% = $314.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HUMANA,HUMANA CHOICE CARE PPO,1518.10,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,518.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,HUMANA,HUMANA NATIIONAL POS HMO,314.84,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $314.84 from Fee Schedule 005543_170 for Rev 310 Proc 81345 * Qty 1 = $314.84 at 100% = $314.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1303.78,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,303.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1786.00,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,786.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81345 at $185.20 (Fee Schedule) = $185.20 (Total Line Payment) at 100% = $185.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81345 at $185.20 (Fee Schedule) = $185.20 (Total Line Payment) at 100% = $185.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,196.31,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81345 at $185.20 (Fee Schedule) = $185.20 (Total Line Payment) at 100% = $185.20... $185.20 at 106% = $196.31 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,893.00,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $893.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1500.24,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,500.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,416.70,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1339.50,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,339.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1643.12,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,643.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,240.76,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,240.76,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,PREVEA HEALTH NETWORK,PREVEA360,240.76,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,240.76,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1140.00,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,140.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,187.05,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1285.92,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,285.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,TRIOLOGY,TRILOGY MEDICAID,196.31,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81345 at $185.20 (Fee Schedule) = $185.20 (Total Line Payment) at 106% = $196.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,222.24,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81345 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,222.24,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81345 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,222.24,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81345 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,UNITY HEALTH PLAN,UNITY HOSPICE,185.20,,,,,,,185.2000,1786.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1285.92,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,285.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1107.32,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,107.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1285.92,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,285.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1285.92,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,285.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TERT GENE TARGETED SEQ ALYS- 90,81345,CPT,310,RC,31040110,CDM,,,,both,,,1786.0000,1178.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1071.60,,,,,,,185.2000,1786.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,786.00 in Billed Charges for Rev 310 Proc 81345 = $1,071.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,AETNA,AETNA HSHS,145.35,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $145.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,AETNA,AETNA MEDICARE,36.28,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,AETNA,ALL COMMERCIAL AETNA,225.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88104 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,36.28,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTHEM POS/HMO,133.85,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $133.85 from Fee Schedule WII28_25 for Rev 311 Proc 88104 Mod TC * Qty 1 = $133.85 at 100% = $133.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTHEM PPO,133.85,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $133.85 from Fee Schedule WII28_25 for Rev 311 Proc 88104 Mod TC * Qty 1 = $133.85 at 100% = $133.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,225.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,CENPATICO,ALL MEDICAID CENPATICO,225.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,191.25,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,CIGNA,ALL COMMERCIAL CIGNA,157.50,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,COFINITY,COFINITY,225.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88104 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88104 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,213.75,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $213.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,189.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,159.75,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $159.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,164.25,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,109.35,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $109.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,191.25,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE HMO,123.23,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $123.23 from Fee Schedule 005543_170 for Rev 311 Proc 88104 * Qty 1 = $123.23 at 100% = $123.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE PPO,191.25,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,36.28,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA NATIIONAL POS HMO,123.23,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $123.23 from Fee Schedule 005543_170 for Rev 311 Proc 88104 * Qty 1 = $123.23 at 100% = $123.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,164.25,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,225.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88104 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,36.28,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88104 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88104 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,36.28,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,112.50,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,189.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,81.63,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,168.75,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,207.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,135.00,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,135.00,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA360,135.00,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,135.00,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,143.62,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $143.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,36.64,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,162.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88104 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,40.75,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.75 from Fee Schedule UHC_98227C for Rev 311 Proc 88104 * Qty 1 = $40.75 at 100% = $40.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,40.75,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.75 from Fee Schedule UHC_98227C for Rev 311 Proc 88104 * Qty 1 = $40.75 at 100% = $40.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,36.28,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,40.75,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.75 from Fee Schedule UHC_98227C for Rev 311 Proc 88104 * Qty 1 = $40.75 at 100% = $40.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,UNITY HEALTH PLAN,UNITY HOSPICE,36.28,,,,,,,12.2000,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,162.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,139.50,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $139.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,162.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,162.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH FLD SMEAR,88104,CPT,311,RC,31100101,CDM,,,,both,,,225.0000,148.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,135.00,,,,,,,12.2000,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $225.00 in Billed Charges for Rev 311 Proc 88104 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,AETNA,AETNA HSHS,164.73,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $164.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,AETNA,AETNA MEDICARE,50.62,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,AETNA,ALL COMMERCIAL AETNA,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88112 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,50.62,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,ANTHEM,ANTHEM POS/HMO,130.43,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $130.43 from Fee Schedule WII28_25 for Rev 311 Proc 88112 Mod TC * Qty 1 = $130.43 at 100% = $130.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,ANTHEM,ANTHEM PPO,130.43,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $130.43 from Fee Schedule WII28_25 for Rev 311 Proc 88112 Mod TC * Qty 1 = $130.43 at 100% = $130.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,CENPATICO,ALL MEDICAID CENPATICO,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,216.75,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $216.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,CIGNA,ALL COMMERCIAL CIGNA,178.50,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,COFINITY,COFINITY,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88112 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88112 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,242.25,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $242.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,214.20,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,181.05,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $181.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,186.15,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $186.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,123.93,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $123.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,216.75,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $216.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HUMANA,HUMANA CHOICE CARE HMO,111.13,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.13 from Fee Schedule 005543_170 for Rev 311 Proc 88112 * Qty 1 = $111.13 at 100% = $111.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HUMANA,HUMANA CHOICE CARE PPO,216.75,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $216.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,50.62,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,HUMANA,HUMANA NATIIONAL POS HMO,111.13,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.13 from Fee Schedule 005543_170 for Rev 311 Proc 88112 * Qty 1 = $111.13 at 100% = $111.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,186.15,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $186.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88112 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,50.62,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88112 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88112 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,50.62,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,127.50,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,214.20,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,113.89,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,191.25,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,234.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $234.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,153.00,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,153.00,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,PREVEA HEALTH NETWORK,PREVEA360,153.00,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,153.00,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,162.77,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $162.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.13,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,183.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88112 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.17,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88112 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,60.17,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88112 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,50.62,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,60.17,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88112 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,UNITY HEALTH PLAN,UNITY HOSPICE,50.62,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,183.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,158.10,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $158.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,183.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,183.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH CELL ENHANCE,88112,CPT,311,RC,31100104,CDM,,,,both,,,255.0000,168.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,153.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $255.00 in Billed Charges for Rev 311 Proc 88112 = $153.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,AETNA,AETNA HSHS,136.31,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $136.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,AETNA,AETNA MEDICARE,20.26,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,AETNA,ALL COMMERCIAL AETNA,211.00,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $211.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,ANTHEM,ANTEHM MEDICAID,20.93,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88142 at $20.93 (Fee Schedule) = $20.93 (Total Line Payment) at 100% = $20.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,20.26,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,ANTHEM,ANTHEM POS/HMO,70.91,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $70.91 from Fee Schedule WII28_25 for Rev 311 Proc 88142 Mod TC * Qty 1 = $70.91 at 100% = $70.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,ANTHEM,ANTHEM PPO,70.91,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $70.91 from Fee Schedule WII28_25 for Rev 311 Proc 88142 Mod TC * Qty 1 = $70.91 at 100% = $70.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,211.00,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $211.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,CENPATICO,ALL MEDICAID CENPATICO,211.00,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $211.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,179.35,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $179.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,CIGNA,ALL COMMERCIAL CIGNA,147.70,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $147.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,COFINITY,COFINITY,211.00,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $211.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,20.93,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88142 at $20.93 (Fee Schedule) = $20.93 (Total Line Payment) at 100% = $20.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,20.93,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88142 at $20.93 (Fee Schedule) = $20.93 (Total Line Payment) at 100% = $20.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,200.45,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $200.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,177.24,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $177.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,149.81,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $149.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,154.03,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $154.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,102.55,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $102.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,179.35,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $179.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HUMANA,HUMANA CHOICE CARE HMO,34.44,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.44 from Fee Schedule 005543_170 for Rev 311 Proc 88142 * Qty 1 = $34.44 at 100% = $34.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HUMANA,HUMANA CHOICE CARE PPO,179.35,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $179.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,20.26,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,HUMANA,HUMANA NATIIONAL POS HMO,34.44,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.44 from Fee Schedule 005543_170 for Rev 311 Proc 88142 * Qty 1 = $34.44 at 100% = $34.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,154.03,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $154.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,211.00,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $211.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,20.93,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88142 at $20.93 (Fee Schedule) = $20.93 (Total Line Payment) at 100% = $20.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,20.26,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,20.93,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88142 at $20.93 (Fee Schedule) = $20.93 (Total Line Payment) at 100% = $20.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,22.19,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88142 at $20.93 (Fee Schedule) = $20.93 (Total Line Payment) at 100% = $20.93... $20.93 at 106% = $22.19 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,20.26,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,105.50,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $105.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,177.24,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $177.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,45.59,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,158.25,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $158.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,194.12,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $194.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,26.34,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,26.34,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,PREVEA HEALTH NETWORK,PREVEA360,26.34,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,26.34,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,134.68,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $134.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,20.46,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,151.92,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $151.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,TRIOLOGY,TRILOGY MEDICAID,22.19,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88142 at $20.93 (Fee Schedule) = $20.93 (Total Line Payment) at 106% = $22.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,24.31,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.31 from Fee Schedule UHC_98227C for Rev 311 Proc 88142 * Qty 1 = $24.31 at 100% = $24.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,24.31,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.31 from Fee Schedule UHC_98227C for Rev 311 Proc 88142 * Qty 1 = $24.31 at 100% = $24.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,20.26,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,24.31,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.31 from Fee Schedule UHC_98227C for Rev 311 Proc 88142 * Qty 1 = $24.31 at 100% = $24.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,UNITY HEALTH PLAN,UNITY HOSPICE,20.26,,,,,,,20.2600,211.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,151.92,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $151.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,130.82,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $130.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,151.92,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $151.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,151.92,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $151.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THINPREP PAP,88142,CPT,311,RC,31100107,CDM,,,,both,,,211.0000,139.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,126.60,,,,,,,20.2600,211.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $211.00 in Billed Charges for Rev 311 Proc 88142 = $126.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,AETNA,AETNA HSHS,70.41,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $70.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,AETNA,AETNA MEDICARE,18.54,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,AETNA,ALL COMMERCIAL AETNA,109.00,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,ANTHEM,ANTEHM MEDICAID,14.86,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88150 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,18.54,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,ANTHEM,ANTHEM POS/HMO,55.72,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.72 from Fee Schedule WII28_25 for Rev 311 Proc 88150 Mod TC * Qty 1 = $55.72 at 100% = $55.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,ANTHEM,ANTHEM PPO,55.72,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.72 from Fee Schedule WII28_25 for Rev 311 Proc 88150 Mod TC * Qty 1 = $55.72 at 100% = $55.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,109.00,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,CENPATICO,ALL MEDICAID CENPATICO,109.00,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,92.65,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $92.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,CIGNA,ALL COMMERCIAL CIGNA,76.30,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $76.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,COFINITY,COFINITY,109.00,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.86,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88150 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.86,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88150 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,103.55,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $103.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,91.56,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $91.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,77.39,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $77.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,79.57,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $79.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,52.97,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $52.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,92.65,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $92.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HUMANA,HUMANA CHOICE CARE HMO,30.19,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.19 from Fee Schedule 005543_170 for Rev 311 Proc 88150 * Qty 1 = $30.19 at 100% = $30.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HUMANA,HUMANA CHOICE CARE PPO,92.65,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $92.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,18.54,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,HUMANA,HUMANA NATIIONAL POS HMO,30.19,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.19 from Fee Schedule 005543_170 for Rev 311 Proc 88150 * Qty 1 = $30.19 at 100% = $30.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,79.57,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $79.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,109.00,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.86,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88150 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,18.54,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.86,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88150 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,15.75,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88150 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86... $14.86 at 106% = $15.75 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,18.54,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,54.50,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $54.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,91.56,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $91.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,41.72,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,81.75,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $81.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,100.28,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $100.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,24.10,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,24.10,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,PREVEA HEALTH NETWORK,PREVEA360,24.10,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,24.10,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,69.57,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $69.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,18.73,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,78.48,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $78.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,TRIOLOGY,TRILOGY MEDICAID,15.75,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88150 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 106% = $15.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.77,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.77 from Fee Schedule UHC_98227C for Rev 311 Proc 88150 * Qty 1 = $20.77 at 100% = $20.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,20.77,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.77 from Fee Schedule UHC_98227C for Rev 311 Proc 88150 * Qty 1 = $20.77 at 100% = $20.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,18.54,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,20.77,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.77 from Fee Schedule UHC_98227C for Rev 311 Proc 88150 * Qty 1 = $20.77 at 100% = $20.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,UNITY HEALTH PLAN,UNITY HOSPICE,18.54,,,,,,,14.8600,109.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,78.48,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $78.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,67.58,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $67.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,78.48,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $78.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,78.48,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $78.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PAP SMEAR DIAG UP TO 3 SLIDES,88150,CPT,311,RC,31100108,CDM,,,,both,,,109.0000,71.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,65.40,,,,,,,14.8600,109.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $109.00 in Billed Charges for Rev 311 Proc 88150 = $65.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,AETNA,AETNA HSHS,193.80,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,AETNA,AETNA MEDICARE,165.49,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,AETNA,ALL COMMERCIAL AETNA,300.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTEHM MEDICAID,67.75,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88172 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,165.49,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM POS/HMO,64.25,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $64.25 from Fee Schedule WII28_25 for Rev 311 Proc 88172 Mod TC * Qty 1 = $64.25 at 100% = $64.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,ANTHEM,ANTHEM PPO,64.25,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $64.25 from Fee Schedule WII28_25 for Rev 311 Proc 88172 Mod TC * Qty 1 = $64.25 at 100% = $64.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,300.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,CENPATICO,ALL MEDICAID CENPATICO,300.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,255.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,CIGNA,ALL COMMERCIAL CIGNA,210.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,COFINITY,COFINITY,300.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,67.75,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88172 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,67.75,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88172 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,285.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $285.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,252.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,213.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $213.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,219.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,145.80,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $145.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,255.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA CHOICE CARE HMO,91.41,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $91.41 from Fee Schedule 005543_170 for Rev 311 Proc 88172 * Qty 1 = $91.41 at 100% = $91.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA CHOICE CARE PPO,255.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,165.49,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,HUMANA,HUMANA NATIIONAL POS HMO,91.41,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $91.41 from Fee Schedule 005543_170 for Rev 311 Proc 88172 * Qty 1 = $91.41 at 100% = $91.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,219.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,300.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,67.75,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88172 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,165.49,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,67.75,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88172 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,71.82,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88172 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75... $67.75 at 106% = $71.82 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,165.49,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,150.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,252.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,372.34,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,225.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,276.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $276.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,180.00,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,180.00,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA360,180.00,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,180.00,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,191.49,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $191.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,167.14,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,216.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,TRIOLOGY,TRILOGY MEDICAID,71.81,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88172 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 106% = $71.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,188.70,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 311 Proc 88172 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,188.70,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 311 Proc 88172 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,165.49,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,188.70,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). $188.70 from Fee Schedule UHC_98227C for Rev 311 Proc 88172 * Qty 1 = $188.70 at 100% = $188.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,UNITY HEALTH PLAN,UNITY HOSPICE,165.49,,,,,,,64.2500,372.3400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,216.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,186.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,216.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,216.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL,88172,CPT,311,RC,31100114,CDM,,,,both,,,300.0000,198.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,180.00,,,,,,,64.2500,372.3400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $300.00 in Billed Charges for Rev 311 Proc 88172 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,AETNA,AETNA HSHS,131.14,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $131.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,AETNA,AETNA MEDICARE,50.62,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,AETNA,ALL COMMERCIAL AETNA,203.00,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $203.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,50.62,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,ANTHEM,ANTHEM POS/HMO,203.00,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $361.98 from Fee Schedule WII28_25 for Rev 311 Proc 88182 Mod TC * Qty 1 = $361.98 at 100% = $361.98 (Limited to $203.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,ANTHEM,ANTHEM PPO,203.00,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $361.98 from Fee Schedule WII28_25 for Rev 311 Proc 88182 Mod TC * Qty 1 = $361.98 at 100% = $361.98 (Limited to $203.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,203.00,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $203.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,CENPATICO,ALL MEDICAID CENPATICO,203.00,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $203.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,172.55,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $172.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,CIGNA,ALL COMMERCIAL CIGNA,142.10,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $142.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,COFINITY,COFINITY,203.00,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $203.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,192.85,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $192.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,170.52,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $170.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,144.13,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $144.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,148.19,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $148.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,98.66,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $98.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,172.55,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $172.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HUMANA,HUMANA CHOICE CARE HMO,203.00,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $271.07 from Fee Schedule 005543_170 for Rev 311 Proc 88182 * Qty 1 = $271.07 at 100% = $271.07 (Limited to $203.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HUMANA,HUMANA CHOICE CARE PPO,172.55,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $172.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HUMANA,HUMANA MEDICARE ADVANTAGE,50.62,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,HUMANA,HUMANA NATIIONAL POS HMO,203.00,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $271.07 from Fee Schedule 005543_170 for Rev 311 Proc 88182 * Qty 1 = $271.07 at 100% = $271.07 (Limited to $203.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,148.19,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $148.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,203.00,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $203.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,50.62,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,MOLINA HEALTHCARE,MOLINA MEDICARE,50.62,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,101.50,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $101.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,170.52,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $170.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,NAPHCARE,ALL COMMERICAL NAPHCARE,113.89,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,152.25,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $152.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,186.76,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $186.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,121.80,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,121.80,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,PREVEA HEALTH NETWORK,PREVEA360,121.80,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,121.80,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,129.57,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $129.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.13,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,146.16,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $146.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.17,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88182 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,UNITED HEALTHCARE,UHC ONEIDA NATION,60.17,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88182 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,50.62,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,UNITED HEALTHCARE,UNITED HEALTHCARE,60.17,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88182 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,UNITY HEALTH PLAN,UNITY HOSPICE,50.62,,,,,,,12.2000,203.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,146.16,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $146.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,125.86,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $125.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,146.16,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $146.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,146.16,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $146.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT,88182,CPT,311,RC,31100117,CDM,,,,both,,,203.0000,133.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,121.80,,,,,,,12.2000,203.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $203.00 in Billed Charges for Rev 311 Proc 88182 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,AETNA,AETNA HSHS,406.98,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $406.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,AETNA,AETNA MEDICARE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,AETNA,ALL COMMERCIAL AETNA,630.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,ANTHEM,ANTEHM MEDICAID,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,ANTHEM,ANTHEM POS/HMO,226.63,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $226.63 from Fee Schedule WII28_25 for Rev 311 Proc 88184 Mod TC * Qty 1 = $226.63 at 100% = $226.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,ANTHEM,ANTHEM PPO,226.63,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $226.63 from Fee Schedule WII28_25 for Rev 311 Proc 88184 Mod TC * Qty 1 = $226.63 at 100% = $226.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,630.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,CENPATICO,ALL MEDICAID CENPATICO,630.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,535.50,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $535.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,CIGNA,ALL COMMERCIAL CIGNA,441.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $441.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,COFINITY,COFINITY,630.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,598.50,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $598.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,529.20,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $529.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,447.30,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $447.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,459.90,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $459.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,306.18,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $306.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,535.50,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $535.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HUMANA,HUMANA CHOICE CARE HMO,126.02,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $126.02 from Fee Schedule 005543_170 for Rev 311 Proc 88184 * Qty 1 = $126.02 at 100% = $126.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HUMANA,HUMANA CHOICE CARE PPO,535.50,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $535.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,HUMANA,HUMANA NATIIONAL POS HMO,126.02,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $126.02 from Fee Schedule 005543_170 for Rev 311 Proc 88184 * Qty 1 = $126.02 at 100% = $126.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,459.90,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $459.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,630.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,71.82,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75... $67.75 at 106% = $71.82 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,315.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,529.20,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $529.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,783.38,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,472.50,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $472.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,579.60,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,378.00,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,378.00,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,PREVEA HEALTH NETWORK,PREVEA360,378.00,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,378.00,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,402.13,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $402.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,351.65,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,453.60,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $453.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,TRIOLOGY,TRILOGY MEDICAID,71.81,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 106% = $71.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,388.93,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 311 Proc 88184 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,388.93,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 311 Proc 88184 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,388.93,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 311 Proc 88184 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,UNITY HEALTH PLAN,UNITY HOSPICE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,453.60,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $453.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,390.60,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $390.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,453.60,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $453.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,453.60,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $453.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100119,CDM,,,,both,,,630.0000,415.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,378.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $630.00 in Billed Charges for Rev 311 Proc 88184 = $378.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,AETNA,AETNA HSHS,252.59,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $252.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,AETNA,ALL COMMERCIAL AETNA,391.00,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88185 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,ANTHEM,ANTHEM POS/HMO,73.02,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $73.02 from Fee Schedule WII28_25 for Rev 311 Proc 88185 Mod TC * Qty 1 = $73.02 at 100% = $73.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,ANTHEM,ANTHEM PPO,73.02,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $73.02 from Fee Schedule WII28_25 for Rev 311 Proc 88185 Mod TC * Qty 1 = $73.02 at 100% = $73.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,391.00,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,CENPATICO,ALL MEDICAID CENPATICO,391.00,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,332.35,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $332.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,CIGNA,ALL COMMERCIAL CIGNA,273.70,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $273.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,COFINITY,COFINITY,391.00,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88185 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88185 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,371.45,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $371.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,328.44,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $328.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,277.61,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $277.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,285.43,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $285.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,190.03,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $190.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,332.35,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $332.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,HUMANA,HUMANA CHOICE CARE HMO,38.45,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $38.45 from Fee Schedule 005543_170 for Rev 311 Proc 88185 * Qty 1 = $38.45 at 100% = $38.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,HUMANA,HUMANA CHOICE CARE PPO,332.35,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $332.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,HUMANA,HUMANA NATIIONAL POS HMO,38.45,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $38.45 from Fee Schedule 005543_170 for Rev 311 Proc 88185 * Qty 1 = $38.45 at 100% = $38.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,285.43,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $285.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,391.00,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $391.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88185 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88185 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88185 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,195.50,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $195.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,328.44,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $328.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,293.25,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $293.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,359.72,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $359.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,234.60,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,234.60,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,PREVEA HEALTH NETWORK,PREVEA360,234.60,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,234.60,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,249.58,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $249.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,281.52,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $281.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88185 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,28.87,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.87 from Fee Schedule UHC_98227C for Rev 311 Proc 88185 * Qty 1 = $28.87 at 100% = $28.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,28.87,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.87 from Fee Schedule UHC_98227C for Rev 311 Proc 88185 * Qty 1 = $28.87 at 100% = $28.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,28.87,,,,,,,12.2000,391.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.87 from Fee Schedule UHC_98227C for Rev 311 Proc 88185 * Qty 1 = $28.87 at 100% = $28.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,281.52,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $281.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,242.42,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $242.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,281.52,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $281.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,281.52,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $281.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,311,RC,31100124,CDM,,,,both,,,391.0000,258.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,234.60,,,,,,,12.2000,391.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $391.00 in Billed Charges for Rev 311 Proc 88185 = $234.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,AETNA,AETNA HSHS,775.20,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,200.00 in Billed Charges for Rev 360 = $775.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,AETNA,ALL COMMERCIAL AETNA,1200.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,200.00 in Billed Charges for Rev 360 = $1,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1200.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,200.00 in Billed Charges for Rev 360 = $1,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,CENPATICO,ALL MEDICAID CENPATICO,1200.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,200.00 in Billed Charges for Rev 360 = $1,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1020.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,200.00 in Billed Charges for Rev 360 = $1,020.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,CIGNA,ALL COMMERCIAL CIGNA,840.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,200.00 in Billed Charges for Rev 360 = $840.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,COFINITY,COFINITY,1200.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,200.00 in Billed Charges for Rev 360 = $1,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1140.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,200.00 in Billed Charges for Rev 360 = $1,140.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,1008.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,200.00 in Billed Charges for Rev 360 = $1,008.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,852.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,200.00 in Billed Charges for Rev 360 = $852.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,876.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,200.00 in Billed Charges for Rev 360 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,583.20,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,200.00 in Billed Charges for Rev 360 = $583.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1020.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,200.00 in Billed Charges for Rev 360 = $1,020.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,HUMANA,HUMANA CHOICE CARE PPO,1020.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,200.00 in Billed Charges for Rev 360 = $1,020.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,876.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,200.00 in Billed Charges for Rev 360 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1200.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,200.00 in Billed Charges for Rev 360 = $1,200.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,600.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,200.00 in Billed Charges for Rev 360 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1008.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,200.00 in Billed Charges for Rev 360 = $1,008.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,900.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,200.00 in Billed Charges for Rev 360 = $900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1104.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,200.00 in Billed Charges for Rev 360 = $1,104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,720.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,200.00 in Billed Charges for Rev 360 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,720.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,200.00 in Billed Charges for Rev 360 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,PREVEA HEALTH NETWORK,PREVEA360,720.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,200.00 in Billed Charges for Rev 360 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,720.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,200.00 in Billed Charges for Rev 360 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,765.96,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,200.00 in Billed Charges for Rev 360 = $765.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,864.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,200.00 in Billed Charges for Rev 360 = $864.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,864.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,200.00 in Billed Charges for Rev 360 = $864.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,744.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,200.00 in Billed Charges for Rev 360 = $744.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,864.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,200.00 in Billed Charges for Rev 360 = $864.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,864.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,200.00 in Billed Charges for Rev 360 = $864.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MINOR TREATMENT ROOM LEVEL 1,360,RC,36010135,CDM,,,,,,both,,,1200.0000,792.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,720.00,,,,,,,583.2000,1200.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,200.00 in Billed Charges for Rev 360 = $720.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,AETNA,AETNA HSHS,5089.19,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,878.00 in Billed Charges for Rev 360 = $5,089.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,AETNA,ALL COMMERCIAL AETNA,7878.00,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,878.00 in Billed Charges for Rev 360 = $7,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7878.00,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,878.00 in Billed Charges for Rev 360 = $7,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,CENPATICO,ALL MEDICAID CENPATICO,7878.00,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,878.00 in Billed Charges for Rev 360 = $7,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6696.30,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,878.00 in Billed Charges for Rev 360 = $6,696.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,CIGNA,ALL COMMERCIAL CIGNA,5514.60,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,878.00 in Billed Charges for Rev 360 = $5,514.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,COFINITY,COFINITY,7878.00,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,878.00 in Billed Charges for Rev 360 = $7,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7484.10,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,878.00 in Billed Charges for Rev 360 = $7,484.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,6617.52,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,878.00 in Billed Charges for Rev 360 = $6,617.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5593.38,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,878.00 in Billed Charges for Rev 360 = $5,593.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5750.94,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,878.00 in Billed Charges for Rev 360 = $5,750.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,3828.71,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,878.00 in Billed Charges for Rev 360 = $3,828.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6696.30,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,878.00 in Billed Charges for Rev 360 = $6,696.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,HUMANA,HUMANA CHOICE CARE PPO,6696.30,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,878.00 in Billed Charges for Rev 360 = $6,696.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5750.94,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,878.00 in Billed Charges for Rev 360 = $5,750.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,7878.00,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,878.00 in Billed Charges for Rev 360 = $7,878.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3939.00,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,878.00 in Billed Charges for Rev 360 = $3,939.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6617.52,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,878.00 in Billed Charges for Rev 360 = $6,617.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5908.50,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,878.00 in Billed Charges for Rev 360 = $5,908.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7247.76,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,878.00 in Billed Charges for Rev 360 = $7,247.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4726.80,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,878.00 in Billed Charges for Rev 360 = $4,726.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4726.80,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,878.00 in Billed Charges for Rev 360 = $4,726.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,PREVEA HEALTH NETWORK,PREVEA360,4726.80,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,878.00 in Billed Charges for Rev 360 = $4,726.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4726.80,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,878.00 in Billed Charges for Rev 360 = $4,726.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5028.53,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,878.00 in Billed Charges for Rev 360 = $5,028.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5672.16,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,878.00 in Billed Charges for Rev 360 = $5,672.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5672.16,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,878.00 in Billed Charges for Rev 360 = $5,672.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4884.36,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,878.00 in Billed Charges for Rev 360 = $4,884.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5672.16,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,878.00 in Billed Charges for Rev 360 = $5,672.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5672.16,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,878.00 in Billed Charges for Rev 360 = $5,672.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 0-90 MIN ASC,360,RC,36030112,CDM,,,,,,both,,,7878.0000,5199.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4726.80,,,,,,,3828.7100,7878.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,878.00 in Billed Charges for Rev 360 = $4,726.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,AETNA,AETNA HSHS,969.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,500.00 in Billed Charges for Rev 360 = $969.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,AETNA,ALL COMMERCIAL AETNA,1500.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,500.00 in Billed Charges for Rev 360 = $1,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1500.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,500.00 in Billed Charges for Rev 360 = $1,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,CENPATICO,ALL MEDICAID CENPATICO,1500.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,500.00 in Billed Charges for Rev 360 = $1,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1275.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,500.00 in Billed Charges for Rev 360 = $1,275.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,CIGNA,ALL COMMERCIAL CIGNA,1050.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,500.00 in Billed Charges for Rev 360 = $1,050.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,COFINITY,COFINITY,1500.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,500.00 in Billed Charges for Rev 360 = $1,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1425.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,500.00 in Billed Charges for Rev 360 = $1,425.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,1260.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,500.00 in Billed Charges for Rev 360 = $1,260.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1065.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,500.00 in Billed Charges for Rev 360 = $1,065.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1095.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,500.00 in Billed Charges for Rev 360 = $1,095.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,729.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,500.00 in Billed Charges for Rev 360 = $729.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1275.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,500.00 in Billed Charges for Rev 360 = $1,275.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,HUMANA,HUMANA CHOICE CARE PPO,1275.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,500.00 in Billed Charges for Rev 360 = $1,275.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1095.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,500.00 in Billed Charges for Rev 360 = $1,095.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1500.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,500.00 in Billed Charges for Rev 360 = $1,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,750.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,500.00 in Billed Charges for Rev 360 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1260.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,500.00 in Billed Charges for Rev 360 = $1,260.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1125.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,500.00 in Billed Charges for Rev 360 = $1,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1380.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,500.00 in Billed Charges for Rev 360 = $1,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,900.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,500.00 in Billed Charges for Rev 360 = $900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,900.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,500.00 in Billed Charges for Rev 360 = $900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,PREVEA HEALTH NETWORK,PREVEA360,900.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,500.00 in Billed Charges for Rev 360 = $900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,900.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,500.00 in Billed Charges for Rev 360 = $900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,957.45,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,500.00 in Billed Charges for Rev 360 = $957.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1080.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,500.00 in Billed Charges for Rev 360 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1080.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,500.00 in Billed Charges for Rev 360 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,930.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,500.00 in Billed Charges for Rev 360 = $930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1080.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,500.00 in Billed Charges for Rev 360 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1080.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,500.00 in Billed Charges for Rev 360 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 91-150 MIN ASC,360,RC,36030113,CDM,,,,,,both,,,1500.0000,990.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,900.00,,,,,,,729.0000,1500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,500.00 in Billed Charges for Rev 360 = $900.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,AETNA,AETNA HSHS,1567.20,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,426.00 in Billed Charges for Rev 360 = $1,567.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,AETNA,ALL COMMERCIAL AETNA,2426.00,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,426.00 in Billed Charges for Rev 360 = $2,426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2426.00,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,426.00 in Billed Charges for Rev 360 = $2,426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,CENPATICO,ALL MEDICAID CENPATICO,2426.00,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,426.00 in Billed Charges for Rev 360 = $2,426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2062.10,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,426.00 in Billed Charges for Rev 360 = $2,062.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,CIGNA,ALL COMMERCIAL CIGNA,1698.20,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,426.00 in Billed Charges for Rev 360 = $1,698.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,COFINITY,COFINITY,2426.00,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,426.00 in Billed Charges for Rev 360 = $2,426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2304.70,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,426.00 in Billed Charges for Rev 360 = $2,304.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,2037.84,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,426.00 in Billed Charges for Rev 360 = $2,037.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1722.46,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,426.00 in Billed Charges for Rev 360 = $1,722.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1770.98,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,426.00 in Billed Charges for Rev 360 = $1,770.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,1179.04,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,426.00 in Billed Charges for Rev 360 = $1,179.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2062.10,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,426.00 in Billed Charges for Rev 360 = $2,062.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,HUMANA,HUMANA CHOICE CARE PPO,2062.10,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,426.00 in Billed Charges for Rev 360 = $2,062.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1770.98,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,426.00 in Billed Charges for Rev 360 = $1,770.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2426.00,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,426.00 in Billed Charges for Rev 360 = $2,426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1213.00,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,426.00 in Billed Charges for Rev 360 = $1,213.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2037.84,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,426.00 in Billed Charges for Rev 360 = $2,037.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1819.50,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,426.00 in Billed Charges for Rev 360 = $1,819.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2231.92,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,426.00 in Billed Charges for Rev 360 = $2,231.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1455.60,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,426.00 in Billed Charges for Rev 360 = $1,455.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1455.60,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,426.00 in Billed Charges for Rev 360 = $1,455.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,PREVEA HEALTH NETWORK,PREVEA360,1455.60,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,426.00 in Billed Charges for Rev 360 = $1,455.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1455.60,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,426.00 in Billed Charges for Rev 360 = $1,455.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1548.52,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,426.00 in Billed Charges for Rev 360 = $1,548.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1746.72,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,426.00 in Billed Charges for Rev 360 = $1,746.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1746.72,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,426.00 in Billed Charges for Rev 360 = $1,746.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1504.12,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,426.00 in Billed Charges for Rev 360 = $1,504.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1746.72,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,426.00 in Billed Charges for Rev 360 = $1,746.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1746.72,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,426.00 in Billed Charges for Rev 360 = $1,746.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MEDIUM,360,RC,36030121,CDM,,,,,,both,,,2426.0000,1601.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1455.60,,,,,,,1179.0400,2426.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,426.00 in Billed Charges for Rev 360 = $1,455.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,AETNA,AETNA HSHS,1803.63,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,792.00 in Billed Charges for Rev 360 = $1,803.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,AETNA,ALL COMMERCIAL AETNA,2792.00,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,792.00 in Billed Charges for Rev 360 = $2,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2792.00,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,792.00 in Billed Charges for Rev 360 = $2,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,CENPATICO,ALL MEDICAID CENPATICO,2792.00,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,792.00 in Billed Charges for Rev 360 = $2,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2373.20,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,792.00 in Billed Charges for Rev 360 = $2,373.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,CIGNA,ALL COMMERCIAL CIGNA,1954.40,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,792.00 in Billed Charges for Rev 360 = $1,954.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,COFINITY,COFINITY,2792.00,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,792.00 in Billed Charges for Rev 360 = $2,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2652.40,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,792.00 in Billed Charges for Rev 360 = $2,652.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,2345.28,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,792.00 in Billed Charges for Rev 360 = $2,345.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1982.32,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,792.00 in Billed Charges for Rev 360 = $1,982.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2038.16,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,792.00 in Billed Charges for Rev 360 = $2,038.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,1356.91,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,792.00 in Billed Charges for Rev 360 = $1,356.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2373.20,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,792.00 in Billed Charges for Rev 360 = $2,373.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,HUMANA,HUMANA CHOICE CARE PPO,2373.20,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,792.00 in Billed Charges for Rev 360 = $2,373.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2038.16,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,792.00 in Billed Charges for Rev 360 = $2,038.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2792.00,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,792.00 in Billed Charges for Rev 360 = $2,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1396.00,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,792.00 in Billed Charges for Rev 360 = $1,396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2345.28,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,792.00 in Billed Charges for Rev 360 = $2,345.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2094.00,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,792.00 in Billed Charges for Rev 360 = $2,094.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2568.64,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,792.00 in Billed Charges for Rev 360 = $2,568.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1675.20,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,792.00 in Billed Charges for Rev 360 = $1,675.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1675.20,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,792.00 in Billed Charges for Rev 360 = $1,675.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,PREVEA HEALTH NETWORK,PREVEA360,1675.20,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,792.00 in Billed Charges for Rev 360 = $1,675.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1675.20,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,792.00 in Billed Charges for Rev 360 = $1,675.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1782.13,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,792.00 in Billed Charges for Rev 360 = $1,782.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2010.24,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,792.00 in Billed Charges for Rev 360 = $2,010.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2010.24,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,792.00 in Billed Charges for Rev 360 = $2,010.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1731.04,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,792.00 in Billed Charges for Rev 360 = $1,731.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2010.24,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,792.00 in Billed Charges for Rev 360 = $2,010.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2010.24,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,792.00 in Billed Charges for Rev 360 = $2,010.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MEDIUM,360,RC,36030124,CDM,,,,,,both,,,2792.0000,1842.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1675.20,,,,,,,1356.9100,2792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,792.00 in Billed Charges for Rev 360 = $1,675.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,AETNA,AETNA HSHS,694.45,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,075.00 in Billed Charges for Rev 360 = $694.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,AETNA,ALL COMMERCIAL AETNA,1075.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,075.00 in Billed Charges for Rev 360 = $1,075.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1075.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,075.00 in Billed Charges for Rev 360 = $1,075.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,CENPATICO,ALL MEDICAID CENPATICO,1075.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,075.00 in Billed Charges for Rev 360 = $1,075.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,913.75,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,075.00 in Billed Charges for Rev 360 = $913.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,CIGNA,ALL COMMERCIAL CIGNA,752.50,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,075.00 in Billed Charges for Rev 360 = $752.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,COFINITY,COFINITY,1075.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,075.00 in Billed Charges for Rev 360 = $1,075.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1021.25,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,075.00 in Billed Charges for Rev 360 = $1,021.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,903.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,075.00 in Billed Charges for Rev 360 = $903.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,763.25,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,075.00 in Billed Charges for Rev 360 = $763.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,784.75,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,075.00 in Billed Charges for Rev 360 = $784.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,522.45,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,075.00 in Billed Charges for Rev 360 = $522.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,913.75,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,075.00 in Billed Charges for Rev 360 = $913.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,HUMANA,HUMANA CHOICE CARE PPO,913.75,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,075.00 in Billed Charges for Rev 360 = $913.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,784.75,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,075.00 in Billed Charges for Rev 360 = $784.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1075.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,075.00 in Billed Charges for Rev 360 = $1,075.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,537.50,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,075.00 in Billed Charges for Rev 360 = $537.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,903.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,075.00 in Billed Charges for Rev 360 = $903.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,806.25,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,075.00 in Billed Charges for Rev 360 = $806.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,989.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,075.00 in Billed Charges for Rev 360 = $989.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,645.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,075.00 in Billed Charges for Rev 360 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,645.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,075.00 in Billed Charges for Rev 360 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,PREVEA HEALTH NETWORK,PREVEA360,645.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,075.00 in Billed Charges for Rev 360 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,645.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,075.00 in Billed Charges for Rev 360 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,686.17,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,075.00 in Billed Charges for Rev 360 = $686.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,774.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,075.00 in Billed Charges for Rev 360 = $774.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,774.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,075.00 in Billed Charges for Rev 360 = $774.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,666.50,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,075.00 in Billed Charges for Rev 360 = $666.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,774.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,075.00 in Billed Charges for Rev 360 = $774.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,774.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,075.00 in Billed Charges for Rev 360 = $774.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONSPLASTY,360,RC,36030129,CDM,,,,,,both,,,1075.0000,709.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,645.00,,,,,,,522.4500,1075.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,075.00 in Billed Charges for Rev 360 = $645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,AETNA,AETNA HSHS,250.65,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $388.00 in Billed Charges for Rev 360 = $250.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,AETNA,ALL COMMERCIAL AETNA,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 360 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 360 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,CENPATICO,ALL MEDICAID CENPATICO,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 360 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,329.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $388.00 in Billed Charges for Rev 360 = $329.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,CIGNA,ALL COMMERCIAL CIGNA,271.60,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $388.00 in Billed Charges for Rev 360 = $271.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,COFINITY,COFINITY,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 360 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,368.60,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $388.00 in Billed Charges for Rev 360 = $368.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,325.92,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $388.00 in Billed Charges for Rev 360 = $325.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,275.48,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $388.00 in Billed Charges for Rev 360 = $275.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,283.24,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $388.00 in Billed Charges for Rev 360 = $283.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,188.57,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $388.00 in Billed Charges for Rev 360 = $188.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,329.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $388.00 in Billed Charges for Rev 360 = $329.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,HUMANA,HUMANA CHOICE CARE PPO,329.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $388.00 in Billed Charges for Rev 360 = $329.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,283.24,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $388.00 in Billed Charges for Rev 360 = $283.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 360 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,194.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $388.00 in Billed Charges for Rev 360 = $194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,325.92,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $388.00 in Billed Charges for Rev 360 = $325.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,291.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $388.00 in Billed Charges for Rev 360 = $291.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,356.96,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $388.00 in Billed Charges for Rev 360 = $356.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 360 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 360 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,PREVEA HEALTH NETWORK,PREVEA360,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 360 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 360 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,247.66,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $388.00 in Billed Charges for Rev 360 = $247.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,279.36,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $388.00 in Billed Charges for Rev 360 = $279.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,279.36,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $388.00 in Billed Charges for Rev 360 = $279.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,240.56,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $388.00 in Billed Charges for Rev 360 = $240.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,279.36,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $388.00 in Billed Charges for Rev 360 = $279.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,279.36,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $388.00 in Billed Charges for Rev 360 = $279.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURG/PACU MAJOR TREATMENT ROOM,360,RC,36040003,CDM,,,,,,both,,,388.0000,256.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 360 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,AETNA,AETNA HSHS,3461.91,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,359.00 in Billed Charges for Rev 360 = $3,461.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,AETNA,ALL COMMERCIAL AETNA,5359.00,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,359.00 in Billed Charges for Rev 360 = $5,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5359.00,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,359.00 in Billed Charges for Rev 360 = $5,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,CENPATICO,ALL MEDICAID CENPATICO,5359.00,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,359.00 in Billed Charges for Rev 360 = $5,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4555.15,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,359.00 in Billed Charges for Rev 360 = $4,555.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,CIGNA,ALL COMMERCIAL CIGNA,3751.30,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,359.00 in Billed Charges for Rev 360 = $3,751.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,COFINITY,COFINITY,5359.00,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,359.00 in Billed Charges for Rev 360 = $5,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5091.05,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,359.00 in Billed Charges for Rev 360 = $5,091.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,4501.56,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,359.00 in Billed Charges for Rev 360 = $4,501.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3804.89,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,359.00 in Billed Charges for Rev 360 = $3,804.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3912.07,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,359.00 in Billed Charges for Rev 360 = $3,912.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,2604.47,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,359.00 in Billed Charges for Rev 360 = $2,604.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4555.15,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,359.00 in Billed Charges for Rev 360 = $4,555.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,HUMANA,HUMANA CHOICE CARE PPO,4555.15,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,359.00 in Billed Charges for Rev 360 = $4,555.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3912.07,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,359.00 in Billed Charges for Rev 360 = $3,912.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,5359.00,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,359.00 in Billed Charges for Rev 360 = $5,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2679.50,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,359.00 in Billed Charges for Rev 360 = $2,679.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4501.56,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,359.00 in Billed Charges for Rev 360 = $4,501.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4019.25,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,359.00 in Billed Charges for Rev 360 = $4,019.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4930.28,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,359.00 in Billed Charges for Rev 360 = $4,930.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3215.40,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,359.00 in Billed Charges for Rev 360 = $3,215.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3215.40,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,359.00 in Billed Charges for Rev 360 = $3,215.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,PREVEA HEALTH NETWORK,PREVEA360,3215.40,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,359.00 in Billed Charges for Rev 360 = $3,215.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3215.40,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,359.00 in Billed Charges for Rev 360 = $3,215.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3420.65,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,359.00 in Billed Charges for Rev 360 = $3,420.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3858.48,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,359.00 in Billed Charges for Rev 360 = $3,858.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3858.48,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,359.00 in Billed Charges for Rev 360 = $3,858.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3322.58,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,359.00 in Billed Charges for Rev 360 = $3,322.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3858.48,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,359.00 in Billed Charges for Rev 360 = $3,858.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3858.48,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,359.00 in Billed Charges for Rev 360 = $3,858.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LITHOTRIPSY SHOCKWAVE,360,RC,36050178,CDM,,,,,,both,,,5359.0000,3536.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3215.40,,,,,,,2604.4700,5359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,359.00 in Billed Charges for Rev 360 = $3,215.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,AETNA,AETNA HSHS,549.10,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $850.00 in Billed Charges for Rev 360 = $549.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,AETNA,ALL COMMERCIAL AETNA,850.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.00 in Billed Charges for Rev 360 = $850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,850.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.00 in Billed Charges for Rev 360 = $850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,CENPATICO,ALL MEDICAID CENPATICO,850.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.00 in Billed Charges for Rev 360 = $850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,722.50,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $850.00 in Billed Charges for Rev 360 = $722.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,CIGNA,ALL COMMERCIAL CIGNA,595.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $850.00 in Billed Charges for Rev 360 = $595.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,COFINITY,COFINITY,850.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.00 in Billed Charges for Rev 360 = $850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,807.50,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $850.00 in Billed Charges for Rev 360 = $807.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,714.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $850.00 in Billed Charges for Rev 360 = $714.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,603.50,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $850.00 in Billed Charges for Rev 360 = $603.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,620.50,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $850.00 in Billed Charges for Rev 360 = $620.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,413.10,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $850.00 in Billed Charges for Rev 360 = $413.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,722.50,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $850.00 in Billed Charges for Rev 360 = $722.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,HUMANA,HUMANA CHOICE CARE PPO,722.50,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $850.00 in Billed Charges for Rev 360 = $722.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,620.50,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $850.00 in Billed Charges for Rev 360 = $620.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,850.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $850.00 in Billed Charges for Rev 360 = $850.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,425.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $850.00 in Billed Charges for Rev 360 = $425.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,714.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $850.00 in Billed Charges for Rev 360 = $714.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,637.50,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $850.00 in Billed Charges for Rev 360 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,782.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $850.00 in Billed Charges for Rev 360 = $782.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,510.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $850.00 in Billed Charges for Rev 360 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,510.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $850.00 in Billed Charges for Rev 360 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,PREVEA HEALTH NETWORK,PREVEA360,510.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $850.00 in Billed Charges for Rev 360 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,510.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $850.00 in Billed Charges for Rev 360 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,542.56,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $850.00 in Billed Charges for Rev 360 = $542.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,612.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $850.00 in Billed Charges for Rev 360 = $612.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,612.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $850.00 in Billed Charges for Rev 360 = $612.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,527.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $850.00 in Billed Charges for Rev 360 = $527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,612.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $850.00 in Billed Charges for Rev 360 = $612.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,612.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $850.00 in Billed Charges for Rev 360 = $612.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,70902954,CDM,,,,,,both,,,850.0000,561.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,510.00,,,,,,,413.1000,850.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $850.00 in Billed Charges for Rev 360 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,AETNA,AETNA HSHS,3344.34,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,177.00 in Billed Charges for Rev 360 = $3,344.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,AETNA,ALL COMMERCIAL AETNA,5177.00,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,177.00 in Billed Charges for Rev 360 = $5,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5177.00,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,177.00 in Billed Charges for Rev 360 = $5,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,CENPATICO,ALL MEDICAID CENPATICO,5177.00,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,177.00 in Billed Charges for Rev 360 = $5,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4400.45,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,177.00 in Billed Charges for Rev 360 = $4,400.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,CIGNA,ALL COMMERCIAL CIGNA,3623.90,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,177.00 in Billed Charges for Rev 360 = $3,623.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,COFINITY,COFINITY,5177.00,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,177.00 in Billed Charges for Rev 360 = $5,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4918.15,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,177.00 in Billed Charges for Rev 360 = $4,918.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,4348.68,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,177.00 in Billed Charges for Rev 360 = $4,348.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3675.67,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,177.00 in Billed Charges for Rev 360 = $3,675.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3779.21,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,177.00 in Billed Charges for Rev 360 = $3,779.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,2516.02,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,177.00 in Billed Charges for Rev 360 = $2,516.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4400.45,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,177.00 in Billed Charges for Rev 360 = $4,400.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,HUMANA,HUMANA CHOICE CARE PPO,4400.45,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,177.00 in Billed Charges for Rev 360 = $4,400.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3779.21,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,177.00 in Billed Charges for Rev 360 = $3,779.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,5177.00,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,177.00 in Billed Charges for Rev 360 = $5,177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2588.50,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,177.00 in Billed Charges for Rev 360 = $2,588.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4348.68,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,177.00 in Billed Charges for Rev 360 = $4,348.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3882.75,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,177.00 in Billed Charges for Rev 360 = $3,882.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4762.84,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,177.00 in Billed Charges for Rev 360 = $4,762.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3106.20,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,177.00 in Billed Charges for Rev 360 = $3,106.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3106.20,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,177.00 in Billed Charges for Rev 360 = $3,106.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,PREVEA HEALTH NETWORK,PREVEA360,3106.20,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,177.00 in Billed Charges for Rev 360 = $3,106.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3106.20,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,177.00 in Billed Charges for Rev 360 = $3,106.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3304.48,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,177.00 in Billed Charges for Rev 360 = $3,304.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3727.44,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,177.00 in Billed Charges for Rev 360 = $3,727.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3727.44,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,177.00 in Billed Charges for Rev 360 = $3,727.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3209.74,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,177.00 in Billed Charges for Rev 360 = $3,209.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3727.44,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,177.00 in Billed Charges for Rev 360 = $3,727.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3727.44,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,177.00 in Billed Charges for Rev 360 = $3,727.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 BASE,360,RC,36060001,CDM,,,,,,both,,,5177.0000,3416.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3106.20,,,,,,,2516.0200,5177.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,177.00 in Billed Charges for Rev 360 = $3,106.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,AETNA,AETNA HSHS,4830.14,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,477.00 in Billed Charges for Rev 360 = $4,830.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,AETNA,ALL COMMERCIAL AETNA,7477.00,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,477.00 in Billed Charges for Rev 360 = $7,477.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7477.00,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,477.00 in Billed Charges for Rev 360 = $7,477.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,CENPATICO,ALL MEDICAID CENPATICO,7477.00,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,477.00 in Billed Charges for Rev 360 = $7,477.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6355.45,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,477.00 in Billed Charges for Rev 360 = $6,355.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,CIGNA,ALL COMMERCIAL CIGNA,5233.90,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,477.00 in Billed Charges for Rev 360 = $5,233.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,COFINITY,COFINITY,7477.00,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,477.00 in Billed Charges for Rev 360 = $7,477.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7103.15,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,477.00 in Billed Charges for Rev 360 = $7,103.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,6280.68,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,477.00 in Billed Charges for Rev 360 = $6,280.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5308.67,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,477.00 in Billed Charges for Rev 360 = $5,308.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5458.21,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,477.00 in Billed Charges for Rev 360 = $5,458.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,3633.82,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,477.00 in Billed Charges for Rev 360 = $3,633.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6355.45,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,477.00 in Billed Charges for Rev 360 = $6,355.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,HUMANA,HUMANA CHOICE CARE PPO,6355.45,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,477.00 in Billed Charges for Rev 360 = $6,355.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5458.21,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,477.00 in Billed Charges for Rev 360 = $5,458.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,7477.00,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,477.00 in Billed Charges for Rev 360 = $7,477.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3738.50,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,477.00 in Billed Charges for Rev 360 = $3,738.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6280.68,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,477.00 in Billed Charges for Rev 360 = $6,280.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5607.75,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,477.00 in Billed Charges for Rev 360 = $5,607.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6878.84,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,477.00 in Billed Charges for Rev 360 = $6,878.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4486.20,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,477.00 in Billed Charges for Rev 360 = $4,486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4486.20,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,477.00 in Billed Charges for Rev 360 = $4,486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,PREVEA HEALTH NETWORK,PREVEA360,4486.20,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,477.00 in Billed Charges for Rev 360 = $4,486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4486.20,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,477.00 in Billed Charges for Rev 360 = $4,486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4772.57,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,477.00 in Billed Charges for Rev 360 = $4,772.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5383.44,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,477.00 in Billed Charges for Rev 360 = $5,383.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5383.44,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,477.00 in Billed Charges for Rev 360 = $5,383.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4635.74,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,477.00 in Billed Charges for Rev 360 = $4,635.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5383.44,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,477.00 in Billed Charges for Rev 360 = $5,383.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5383.44,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,477.00 in Billed Charges for Rev 360 = $5,383.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 BASE,360,RC,36060002,CDM,,,,,,both,,,7477.0000,4934.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4486.20,,,,,,,3633.8200,7477.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,477.00 in Billed Charges for Rev 360 = $4,486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,AETNA,AETNA HSHS,10219.07,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $15,819.00 in Billed Charges for Rev 360 = $10,219.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,AETNA,ALL COMMERCIAL AETNA,15819.00,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,819.00 in Billed Charges for Rev 360 = $15,819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15819.00,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,819.00 in Billed Charges for Rev 360 = $15,819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,CENPATICO,ALL MEDICAID CENPATICO,15819.00,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,819.00 in Billed Charges for Rev 360 = $15,819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13446.15,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $15,819.00 in Billed Charges for Rev 360 = $13,446.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,CIGNA,ALL COMMERCIAL CIGNA,11073.30,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $15,819.00 in Billed Charges for Rev 360 = $11,073.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,COFINITY,COFINITY,15819.00,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,819.00 in Billed Charges for Rev 360 = $15,819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15028.05,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $15,819.00 in Billed Charges for Rev 360 = $15,028.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,13287.96,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $15,819.00 in Billed Charges for Rev 360 = $13,287.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11231.49,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $15,819.00 in Billed Charges for Rev 360 = $11,231.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11547.87,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $15,819.00 in Billed Charges for Rev 360 = $11,547.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,7688.03,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $15,819.00 in Billed Charges for Rev 360 = $7,688.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13446.15,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $15,819.00 in Billed Charges for Rev 360 = $13,446.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,HUMANA,HUMANA CHOICE CARE PPO,13446.15,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $15,819.00 in Billed Charges for Rev 360 = $13,446.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11547.87,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $15,819.00 in Billed Charges for Rev 360 = $11,547.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,15819.00,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,819.00 in Billed Charges for Rev 360 = $15,819.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7909.50,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $15,819.00 in Billed Charges for Rev 360 = $7,909.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13287.96,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $15,819.00 in Billed Charges for Rev 360 = $13,287.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11864.25,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $15,819.00 in Billed Charges for Rev 360 = $11,864.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,14553.48,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $15,819.00 in Billed Charges for Rev 360 = $14,553.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9491.40,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $15,819.00 in Billed Charges for Rev 360 = $9,491.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9491.40,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $15,819.00 in Billed Charges for Rev 360 = $9,491.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,PREVEA HEALTH NETWORK,PREVEA360,9491.40,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $15,819.00 in Billed Charges for Rev 360 = $9,491.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9491.40,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $15,819.00 in Billed Charges for Rev 360 = $9,491.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10097.27,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $15,819.00 in Billed Charges for Rev 360 = $10,097.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11389.68,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $15,819.00 in Billed Charges for Rev 360 = $11,389.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11389.68,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $15,819.00 in Billed Charges for Rev 360 = $11,389.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9807.78,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $15,819.00 in Billed Charges for Rev 360 = $9,807.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11389.68,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $15,819.00 in Billed Charges for Rev 360 = $11,389.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11389.68,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $15,819.00 in Billed Charges for Rev 360 = $11,389.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 5 BASE,360,RC,36060005,CDM,,,,,,both,,,15819.0000,10440.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9491.40,,,,,,,7688.0300,15819.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $15,819.00 in Billed Charges for Rev 360 = $9,491.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,AETNA,AETNA HSHS,13005.92,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $20,133.00 in Billed Charges for Rev 360 = $13,005.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,AETNA,ALL COMMERCIAL AETNA,20133.00,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,133.00 in Billed Charges for Rev 360 = $20,133.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20133.00,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,133.00 in Billed Charges for Rev 360 = $20,133.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,CENPATICO,ALL MEDICAID CENPATICO,20133.00,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,133.00 in Billed Charges for Rev 360 = $20,133.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17113.05,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $20,133.00 in Billed Charges for Rev 360 = $17,113.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,CIGNA,ALL COMMERCIAL CIGNA,14093.10,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $20,133.00 in Billed Charges for Rev 360 = $14,093.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,COFINITY,COFINITY,20133.00,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,133.00 in Billed Charges for Rev 360 = $20,133.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19126.35,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $20,133.00 in Billed Charges for Rev 360 = $19,126.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,16911.72,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $20,133.00 in Billed Charges for Rev 360 = $16,911.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14294.43,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $20,133.00 in Billed Charges for Rev 360 = $14,294.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14697.09,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $20,133.00 in Billed Charges for Rev 360 = $14,697.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,9784.64,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $20,133.00 in Billed Charges for Rev 360 = $9,784.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17113.05,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $20,133.00 in Billed Charges for Rev 360 = $17,113.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,HUMANA,HUMANA CHOICE CARE PPO,17113.05,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $20,133.00 in Billed Charges for Rev 360 = $17,113.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14697.09,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $20,133.00 in Billed Charges for Rev 360 = $14,697.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,20133.00,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $20,133.00 in Billed Charges for Rev 360 = $20,133.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10066.50,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $20,133.00 in Billed Charges for Rev 360 = $10,066.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,16911.72,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $20,133.00 in Billed Charges for Rev 360 = $16,911.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15099.75,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $20,133.00 in Billed Charges for Rev 360 = $15,099.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18522.36,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $20,133.00 in Billed Charges for Rev 360 = $18,522.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12079.80,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $20,133.00 in Billed Charges for Rev 360 = $12,079.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12079.80,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $20,133.00 in Billed Charges for Rev 360 = $12,079.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,PREVEA HEALTH NETWORK,PREVEA360,12079.80,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $20,133.00 in Billed Charges for Rev 360 = $12,079.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12079.80,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $20,133.00 in Billed Charges for Rev 360 = $12,079.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12850.89,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $20,133.00 in Billed Charges for Rev 360 = $12,850.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14495.76,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $20,133.00 in Billed Charges for Rev 360 = $14,495.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14495.76,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $20,133.00 in Billed Charges for Rev 360 = $14,495.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12482.46,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $20,133.00 in Billed Charges for Rev 360 = $12,482.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14495.76,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $20,133.00 in Billed Charges for Rev 360 = $14,495.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14495.76,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $20,133.00 in Billed Charges for Rev 360 = $14,495.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 6 BASE,360,RC,36060006,CDM,,,,,,both,,,20133.0000,13287.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12079.80,,,,,,,9784.6400,20133.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $20,133.00 in Billed Charges for Rev 360 = $12,079.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,AETNA,AETNA HSHS,14.21,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $22.00 in Billed Charges for Rev 360 = $14.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,AETNA,ALL COMMERCIAL AETNA,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 360 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 360 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,CENPATICO,ALL MEDICAID CENPATICO,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 360 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 360 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,CIGNA,ALL COMMERCIAL CIGNA,15.40,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $22.00 in Billed Charges for Rev 360 = $15.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,COFINITY,COFINITY,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 360 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,20.90,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $22.00 in Billed Charges for Rev 360 = $20.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,18.48,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.00 in Billed Charges for Rev 360 = $18.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15.62,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $22.00 in Billed Charges for Rev 360 = $15.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16.06,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.00 in Billed Charges for Rev 360 = $16.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,10.69,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $22.00 in Billed Charges for Rev 360 = $10.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 360 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,HUMANA,HUMANA CHOICE CARE PPO,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 360 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16.06,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.00 in Billed Charges for Rev 360 = $16.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 360 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $22.00 in Billed Charges for Rev 360 = $11.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18.48,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.00 in Billed Charges for Rev 360 = $18.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16.50,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $22.00 in Billed Charges for Rev 360 = $16.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,20.24,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $22.00 in Billed Charges for Rev 360 = $20.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.00 in Billed Charges for Rev 360 = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.00 in Billed Charges for Rev 360 = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA360,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.00 in Billed Charges for Rev 360 = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.00 in Billed Charges for Rev 360 = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14.04,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $22.00 in Billed Charges for Rev 360 = $14.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 360 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 360 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13.64,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $22.00 in Billed Charges for Rev 360 = $13.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 360 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 360 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 1 PER MIN,360,RC,36060007,CDM,,,,,,both,,,22.0000,14.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.00 in Billed Charges for Rev 360 = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,13.10,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,13.54,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87807 at $13.54 (Fee Schedule) = $13.54 (Total Line Payment) at 100% = $13.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.10,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,45.85,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $45.85 from Fee Schedule WII28_25 for Rev 306 Proc 87807 Mod TC * Qty 1 = $45.85 at 100% = $45.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,45.85,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $45.85 from Fee Schedule WII28_25 for Rev 306 Proc 87807 Mod TC * Qty 1 = $45.85 at 100% = $45.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,13.54,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87807 at $13.54 (Fee Schedule) = $13.54 (Total Line Payment) at 100% = $13.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,13.54,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87807 at $13.54 (Fee Schedule) = $13.54 (Total Line Payment) at 100% = $13.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,22.27,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.27 from Fee Schedule 005543_170 for Rev 306 Proc 87807 * Qty 1 = $22.27 at 100% = $22.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,13.10,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,22.27,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.27 from Fee Schedule 005543_170 for Rev 306 Proc 87807 * Qty 1 = $22.27 at 100% = $22.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,13.54,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87807 at $13.54 (Fee Schedule) = $13.54 (Total Line Payment) at 100% = $13.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.10,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,13.54,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87807 at $13.54 (Fee Schedule) = $13.54 (Total Line Payment) at 100% = $13.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,14.35,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87807 at $13.54 (Fee Schedule) = $13.54 (Total Line Payment) at 100% = $13.54... $13.54 at 106% = $14.35 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,13.10,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,29.48,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.03,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.03,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,17.03,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.03,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.23,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,14.35,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87807 at $13.54 (Fee Schedule) = $13.54 (Total Line Payment) at 106% = $14.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.72,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87807 * Qty 1 = $15.72 at 100% = $15.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,15.72,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87807 * Qty 1 = $15.72 at 100% = $15.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.10,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,15.72,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.72 from Fee Schedule UHC_98227C for Rev 306 Proc 87807 * Qty 1 = $15.72 at 100% = $15.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,13.10,,,,,,,13.1000,150.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL RSV,87807,CPT,306,RC,30600269,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,13.1000,150.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 306 Proc 87807 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,AETNA,AETNA HSHS,78.17,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $78.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,AETNA,AETNA MEDICARE,16.53,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,AETNA,ALL COMMERCIAL AETNA,121.00,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTEHM MEDICAID,16.86,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87880 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.53,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM POS/HMO,57.86,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.86 from Fee Schedule WII28_25 for Rev 306 Proc 87880 Mod TC * Qty 1 = $57.86 at 100% = $57.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,ANTHEM,ANTHEM PPO,57.86,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.86 from Fee Schedule WII28_25 for Rev 306 Proc 87880 Mod TC * Qty 1 = $57.86 at 100% = $57.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,121.00,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,CENPATICO,ALL MEDICAID CENPATICO,121.00,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,102.85,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,CIGNA,ALL COMMERCIAL CIGNA,84.70,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $84.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,COFINITY,COFINITY,121.00,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.86,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87880 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.86,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87880 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,114.95,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $114.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,101.64,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $101.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,85.91,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $85.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,88.33,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $88.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,58.81,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $58.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,102.85,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA CHOICE CARE HMO,28.10,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.10 from Fee Schedule 005543_170 for Rev 306 Proc 87880 * Qty 1 = $28.10 at 100% = $28.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA CHOICE CARE PPO,102.85,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $102.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,16.53,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,HUMANA,HUMANA NATIIONAL POS HMO,28.10,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.10 from Fee Schedule 005543_170 for Rev 306 Proc 87880 * Qty 1 = $28.10 at 100% = $28.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,88.33,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $88.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,121.00,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.86,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87880 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.53,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.86,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87880 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,17.87,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87880 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86... $16.86 at 106% = $17.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,16.53,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,60.50,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $60.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,101.64,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $101.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,37.19,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,90.75,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $90.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,111.32,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $111.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.49,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.49,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA360,21.49,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.49,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.23,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $77.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.70,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.12,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,TRIOLOGY,TRILOGY MEDICAID,17.87,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87880 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 106% = $17.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.84,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.84 from Fee Schedule UHC_98227C for Rev 306 Proc 87880 * Qty 1 = $19.84 at 100% = $19.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,19.84,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.84 from Fee Schedule UHC_98227C for Rev 306 Proc 87880 * Qty 1 = $19.84 at 100% = $19.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.53,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,19.84,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.84 from Fee Schedule UHC_98227C for Rev 306 Proc 87880 * Qty 1 = $19.84 at 100% = $19.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,UNITY HEALTH PLAN,UNITY HOSPICE,16.53,,,,,,,16.5300,121.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.12,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.02,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $75.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.12,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.12,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $87.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTICAL STREP,87880,CPT,306,RC,30600270,CDM,,,,both,,,121.0000,79.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,72.60,,,,,,,16.5300,121.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $121.00 in Billed Charges for Rev 306 Proc 87880 = $72.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA HSHS,67.18,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,AETNA,AETNA MEDICARE,16.07,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,AETNA,ALL COMMERCIAL AETNA,104.00,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTEHM MEDICAID,16.61,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87899 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.07,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM POS/HMO,56.25,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $56.25 from Fee Schedule WII28_25 for Rev 306 Proc 87899 Mod TC * Qty 1 = $56.25 at 100% = $56.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,ANTHEM,ANTHEM PPO,56.25,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $56.25 from Fee Schedule WII28_25 for Rev 306 Proc 87899 Mod TC * Qty 1 = $56.25 at 100% = $56.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,104.00,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,CENPATICO,ALL MEDICAID CENPATICO,104.00,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,88.40,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,CIGNA,ALL COMMERCIAL CIGNA,72.80,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,COFINITY,COFINITY,104.00,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.61,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87899 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.61,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87899 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,98.80,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $98.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,87.36,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,73.84,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $73.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,75.92,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,50.54,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,88.40,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE HMO,27.32,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.32 from Fee Schedule 005543_170 for Rev 306 Proc 87899 * Qty 1 = $27.32 at 100% = $27.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA CHOICE CARE PPO,88.40,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,16.07,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,HUMANA,HUMANA NATIIONAL POS HMO,27.32,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.32 from Fee Schedule 005543_170 for Rev 306 Proc 87899 * Qty 1 = $27.32 at 100% = $27.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,75.92,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $75.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,104.00,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $104.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.61,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87899 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.07,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.61,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87899 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,17.61,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87899 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 100% = $16.61... $16.61 at 106% = $17.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,16.07,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,52.00,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,87.36,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $87.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,36.16,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,78.00,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,95.68,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $95.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,20.89,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,20.89,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360,20.89,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,20.89,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,66.38,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $66.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.23,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,74.88,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,TRIOLOGY,TRILOGY MEDICAID,17.61,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87899 at $16.61 (Fee Schedule) = $16.61 (Total Line Payment) at 106% = $17.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.28,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87899 * Qty 1 = $19.28 at 100% = $19.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,19.28,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87899 * Qty 1 = $19.28 at 100% = $19.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.07,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,19.28,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.28 from Fee Schedule UHC_98227C for Rev 306 Proc 87899 * Qty 1 = $19.28 at 100% = $19.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,UNITY HEALTH PLAN,UNITY HOSPICE,16.07,,,,,,,16.0700,104.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,74.88,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,64.48,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $64.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,74.88,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,74.88,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AGENT NOS ASSAY W/OPTIC,87899,CPT,306,RC,30600271,CDM,,,,both,,,104.0000,68.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,62.40,,,,,,,16.0700,104.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.00 in Billed Charges for Rev 306 Proc 87899 = $62.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,AETNA,AETNA HSHS,1357.89,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,357.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,AETNA,AETNA MEDICARE,257.45,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,AETNA,ALL COMMERCIAL AETNA,2102.00,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,ANTHEM,ANTEHM MEDICAID,266.02,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87902 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,257.45,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,ANTHEM,ANTHEM POS/HMO,901.08,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $901.08 from Fee Schedule WII28_25 for Rev 306 Proc 87902 Mod TC * Qty 1 = $901.08 at 100% = $901.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,ANTHEM,ANTHEM PPO,901.08,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $901.08 from Fee Schedule WII28_25 for Rev 306 Proc 87902 Mod TC * Qty 1 = $901.08 at 100% = $901.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2102.00,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,CENPATICO,ALL MEDICAID CENPATICO,2102.00,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1786.70,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,786.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,CIGNA,ALL COMMERCIAL CIGNA,1471.40,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,471.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,COFINITY,COFINITY,2102.00,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,266.02,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87902 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,266.02,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87902 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1996.90,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,996.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,1765.68,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1492.42,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,492.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1534.46,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,534.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,1021.57,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,021.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1786.70,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,786.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,HUMANA CHOICE CARE HMO,437.67,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $437.67 from Fee Schedule 005543_170 for Rev 306 Proc 87902 * Qty 1 = $437.67 at 100% = $437.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,HUMANA CHOICE CARE PPO,1786.70,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,786.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,257.45,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,HUMANA NATIIONAL POS HMO,437.67,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $437.67 from Fee Schedule 005543_170 for Rev 306 Proc 87902 * Qty 1 = $437.67 at 100% = $437.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1534.46,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,534.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2102.00,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,266.02,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87902 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,257.45,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,266.02,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87902 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,281.98,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87902 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 100% = $266.02... $266.02 at 106% = $281.98 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,257.45,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1051.00,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,051.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1765.68,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,579.26,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1576.50,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,576.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1933.84,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,933.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,334.69,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,334.69,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,PREVEA HEALTH NETWORK,PREVEA360,334.69,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,334.69,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1341.71,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,341.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,260.02,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1513.44,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,513.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,TRIOLOGY,TRILOGY MEDICAID,281.98,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 87902 at $266.02 (Fee Schedule) = $266.02 (Total Line Payment) at 106% = $281.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,308.94,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $308.94 from Fee Schedule UHC_98227C for Rev 306 Proc 87902 * Qty 1 = $308.94 at 100% = $308.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,308.94,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $308.94 from Fee Schedule UHC_98227C for Rev 306 Proc 87902 * Qty 1 = $308.94 at 100% = $308.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,257.45,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,308.94,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $308.94 from Fee Schedule UHC_98227C for Rev 306 Proc 87902 * Qty 1 = $308.94 at 100% = $308.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,UNITY HEALTH PLAN,UNITY HOSPICE,257.45,,,,,,,257.4500,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1513.44,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,513.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1303.24,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,303.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1513.44,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,513.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1513.44,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,513.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENTOYPE HEP C,87902,CPT,306,RC,30600272,CDM,,,,both,,,2102.0000,1387.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1261.20,,,,,,,257.4500,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,102.00 in Billed Charges for Rev 306 Proc 87902 = $1,261.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,AETNA,AETNA HSHS,212.53,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $212.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,AETNA,ALL COMMERCIAL AETNA,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87591 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87591 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,CENPATICO,ALL MEDICAID CENPATICO,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,279.65,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $279.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,CIGNA,ALL COMMERCIAL CIGNA,230.30,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $230.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,COFINITY,COFINITY,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,312.55,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $312.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,276.36,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $276.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,233.59,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $233.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,240.17,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $240.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,159.89,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $159.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,279.65,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $279.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87591 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HUMANA,HUMANA CHOICE CARE PPO,279.65,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $279.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87591 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,240.17,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $240.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,329.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,164.50,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $164.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,276.36,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $276.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,246.75,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $246.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,302.68,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $302.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,210.00,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,236.88,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $236.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87591 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87591 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87591 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87591 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,329.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,236.88,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $236.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,203.98,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $203.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,236.88,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $236.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,236.88,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $236.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
N.GONORRHOEAE DNA AMP PROB,87591,CPT,306,RC,30600281,CDM,,,,both,,,329.0000,217.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,197.40,,,,,,,35.0900,329.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $329.00 in Billed Charges for Rev 306 Proc 87591 = $197.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,AETNA,AETNA HSHS,83.33,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $83.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,AETNA,AETNA MEDICARE,16.55,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,AETNA,ALL COMMERCIAL AETNA,129.00,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $129.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,ANTHEM,ANTEHM MEDICAID,16.86,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87804 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,16.55,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,ANTHEM,ANTHEM POS/HMO,57.93,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.93 from Fee Schedule WII28_25 for Rev 306 Proc 87804 Mod TC * Qty 1 = $57.93 at 100% = $57.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,ANTHEM,ANTHEM PPO,57.93,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.93 from Fee Schedule WII28_25 for Rev 306 Proc 87804 Mod TC * Qty 1 = $57.93 at 100% = $57.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,129.00,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $129.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,CENPATICO,ALL MEDICAID CENPATICO,129.00,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $129.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,109.65,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $109.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,CIGNA,ALL COMMERCIAL CIGNA,90.30,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $90.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,COFINITY,COFINITY,129.00,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $129.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.86,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87804 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.86,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87804 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,122.55,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $122.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,108.36,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $108.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,91.59,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $91.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,94.17,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $94.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,62.69,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $62.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,109.65,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $109.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HUMANA,HUMANA CHOICE CARE HMO,28.14,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.14 from Fee Schedule 005543_170 for Rev 306 Proc 87804 * Qty 1 = $28.14 at 100% = $28.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HUMANA,HUMANA CHOICE CARE PPO,109.65,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $109.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,16.55,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,HUMANA,HUMANA NATIIONAL POS HMO,28.14,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.14 from Fee Schedule 005543_170 for Rev 306 Proc 87804 * Qty 1 = $28.14 at 100% = $28.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,94.17,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $94.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,129.00,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $129.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.86,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87804 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.55,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.86,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87804 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,17.87,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87804 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 100% = $16.86... $16.86 at 106% = $17.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,16.55,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,64.50,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $64.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,108.36,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $108.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,37.24,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,96.75,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $96.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,118.68,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $118.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.52,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.52,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,PREVEA HEALTH NETWORK,PREVEA360,21.52,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.52,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,82.34,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $82.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,16.72,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,92.88,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $92.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,TRIOLOGY,TRILOGY MEDICAID,17.87,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87804 at $16.86 (Fee Schedule) = $16.86 (Total Line Payment) at 106% = $17.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.86,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.86 from Fee Schedule UHC_98227C for Rev 306 Proc 87804 * Qty 1 = $19.86 at 100% = $19.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,19.86,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.86 from Fee Schedule UHC_98227C for Rev 306 Proc 87804 * Qty 1 = $19.86 at 100% = $19.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,16.55,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,19.86,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.86 from Fee Schedule UHC_98227C for Rev 306 Proc 87804 * Qty 1 = $19.86 at 100% = $19.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,UNITY HEALTH PLAN,UNITY HOSPICE,16.55,,,,,,,16.5500,129.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,92.88,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $92.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,79.98,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $79.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,92.88,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $92.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,92.88,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $92.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QL INFLUENZA A/B,87804,CPT,306,RC,30600283,CDM,,,,both,,,129.0000,85.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,77.40,,,,,,,16.5500,129.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $129.00 in Billed Charges for Rev 306 Proc 87804 = $77.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,AETNA,AETNA HSHS,194.45,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $194.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,AETNA,ALL COMMERCIAL AETNA,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87581 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87581 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87581 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,CENPATICO,ALL MEDICAID CENPATICO,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,255.85,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $255.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,CIGNA,ALL COMMERCIAL CIGNA,210.70,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $210.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,COFINITY,COFINITY,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87581 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87581 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,285.95,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $285.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,252.84,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $252.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,213.71,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $213.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,219.73,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $219.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,146.29,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $146.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,255.85,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $255.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87581 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HUMANA,HUMANA CHOICE CARE PPO,255.85,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $255.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87581 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,219.73,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $219.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,301.00,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $301.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87581 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87581 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87581 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,150.50,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $150.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,252.84,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $252.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,225.75,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $225.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,276.92,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $276.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,192.13,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $192.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,216.72,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $216.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87581 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87581 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87581 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87581 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,301.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,216.72,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $216.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,186.62,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $186.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,216.72,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $216.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,216.72,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $216.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC M PNEUMONIAS AP-TECH,87581,CPT,306,RC,30600291,CDM,,,,both,,,301.0000,198.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,180.60,,,,,,,35.0900,301.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $301.00 in Billed Charges for Rev 306 Proc 87581 = $180.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,AETNA,AETNA HSHS,136.95,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $136.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,AETNA,ALL COMMERCIAL AETNA,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87496 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87496 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87496 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,CENPATICO,ALL MEDICAID CENPATICO,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,180.20,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,CIGNA,ALL COMMERCIAL CIGNA,148.40,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $148.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,COFINITY,COFINITY,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87496 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87496 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,201.40,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $201.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,178.08,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $178.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,150.52,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $150.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,154.76,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $154.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,103.03,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $103.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,180.20,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87496 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA CHOICE CARE PPO,180.20,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $180.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87496 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,154.76,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $154.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,212.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $212.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87496 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87496 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87496 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,106.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,178.08,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $178.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,159.00,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,195.04,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $195.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,135.32,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $135.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,152.64,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87496 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87496 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87496 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87496 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,212.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,152.64,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,131.44,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $131.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,152.64,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,152.64,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $152.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (CMV) MENI,87496,CPT,306,RC,30600294,CDM,,,,both,,,212.0000,139.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,127.20,,,,,,,35.0900,212.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $212.00 in Billed Charges for Rev 306 Proc 87496 = $127.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,AETNA,AETNA HSHS,63.95,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $63.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,AETNA,AETNA MEDICARE,5.99,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,AETNA,ALL COMMERCIAL AETNA,99.00,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,ANTHEM,ANTEHM MEDICAID,6.19,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87207 at $6.19 (Fee Schedule) = $6.19 (Total Line Payment) at 100% = $6.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5.99,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,ANTHEM,ANTHEM POS/HMO,20.97,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.97 from Fee Schedule WII28_25 for Rev 306 Proc 87207 Mod TC * Qty 1 = $20.97 at 100% = $20.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,ANTHEM,ANTHEM PPO,20.97,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.97 from Fee Schedule WII28_25 for Rev 306 Proc 87207 Mod TC * Qty 1 = $20.97 at 100% = $20.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,99.00,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,CENPATICO,ALL MEDICAID CENPATICO,99.00,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,84.15,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $84.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,CIGNA,ALL COMMERCIAL CIGNA,69.30,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $69.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,COFINITY,COFINITY,99.00,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.19,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87207 at $6.19 (Fee Schedule) = $6.19 (Total Line Payment) at 100% = $6.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.19,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87207 at $6.19 (Fee Schedule) = $6.19 (Total Line Payment) at 100% = $6.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,94.05,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $94.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,83.16,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $83.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,70.29,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $70.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,72.27,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $72.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,48.11,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $48.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,84.15,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $84.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HUMANA,HUMANA CHOICE CARE HMO,10.18,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.18 from Fee Schedule 005543_170 for Rev 306 Proc 87207 * Qty 1 = $10.18 at 100% = $10.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HUMANA,HUMANA CHOICE CARE PPO,84.15,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $84.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HUMANA,HUMANA MEDICARE ADVANTAGE,5.99,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,HUMANA,HUMANA NATIIONAL POS HMO,10.18,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.18 from Fee Schedule 005543_170 for Rev 306 Proc 87207 * Qty 1 = $10.18 at 100% = $10.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,72.27,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $72.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,99.00,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.19,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87207 at $6.19 (Fee Schedule) = $6.19 (Total Line Payment) at 100% = $6.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5.99,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.19,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87207 at $6.19 (Fee Schedule) = $6.19 (Total Line Payment) at 100% = $6.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,MOLINA HEALTHCARE,MOLINA MEDICAID,6.56,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87207 at $6.19 (Fee Schedule) = $6.19 (Total Line Payment) at 100% = $6.19... $6.19 at 106% = $6.56 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,MOLINA HEALTHCARE,MOLINA MEDICARE,5.99,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,49.50,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $49.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,83.16,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $83.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,NAPHCARE,ALL COMMERICAL NAPHCARE,13.48,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,74.25,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $74.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,91.08,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $91.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.79,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.79,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,PREVEA HEALTH NETWORK,PREVEA360,7.79,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.79,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,63.19,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $63.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,6.05,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,71.28,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $71.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,TRIOLOGY,TRILOGY MEDICAID,6.56,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87207 at $6.19 (Fee Schedule) = $6.19 (Total Line Payment) at 106% = $6.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.19,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.19 from Fee Schedule UHC_98227C for Rev 306 Proc 87207 * Qty 1 = $7.19 at 100% = $7.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,7.19,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.19 from Fee Schedule UHC_98227C for Rev 306 Proc 87207 * Qty 1 = $7.19 at 100% = $7.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5.99,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,7.19,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.19 from Fee Schedule UHC_98227C for Rev 306 Proc 87207 * Qty 1 = $7.19 at 100% = $7.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,UNITY HEALTH PLAN,UNITY HOSPICE,5.99,,,,,,,5.9900,99.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,71.28,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $71.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,61.38,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $61.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,71.28,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $71.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,71.28,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $71.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SMEAR SPECIAL STAIN,87207,CPT,306,RC,30600306,CDM,,,,both,,,99.0000,65.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,59.40,,,,,,,5.9900,99.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $99.00 in Billed Charges for Rev 306 Proc 87207 = $59.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,AETNA,AETNA HSHS,214.47,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $214.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,AETNA,ALL COMMERCIAL AETNA,332.00,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $332.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87651 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87651 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87651 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,332.00,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $332.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,CENPATICO,ALL MEDICAID CENPATICO,332.00,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $332.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,282.20,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $282.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,CIGNA,ALL COMMERCIAL CIGNA,232.40,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $232.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,COFINITY,COFINITY,332.00,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $332.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87651 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87651 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,315.40,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $315.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,278.88,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $278.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,235.72,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $235.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,242.36,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $242.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,161.35,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $161.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,282.20,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $282.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87651 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HUMANA,HUMANA CHOICE CARE PPO,282.20,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $282.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87651 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,242.36,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $242.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,332.00,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $332.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87651 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87651 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87651 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,166.00,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,278.88,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $278.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,249.00,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $249.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,305.44,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $305.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,211.92,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $211.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,239.04,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $239.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87651 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87651 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87651 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87651 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,332.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,239.04,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $239.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,205.84,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $205.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,239.04,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $239.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,239.04,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $239.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (GRP A STREP),87651,CPT,306,RC,30600332,CDM,,,,both,,,332.0000,219.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,199.20,,,,,,,35.0900,332.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $332.00 in Billed Charges for Rev 306 Proc 87651 = $199.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,AETNA,AETNA HSHS,175.07,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $175.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,AETNA,AETNA MEDICARE,42.84,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,AETNA,ALL COMMERCIAL AETNA,271.00,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,ANTHEM,ANTEHM MEDICAID,44.27,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87530 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,42.84,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,ANTHEM,ANTHEM POS/HMO,149.94,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87530 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,ANTHEM,ANTHEM PPO,149.94,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.94 from Fee Schedule WII28_25 for Rev 306 Proc 87530 Mod TC * Qty 1 = $149.94 at 100% = $149.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,271.00,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,CENPATICO,ALL MEDICAID CENPATICO,271.00,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,230.35,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $230.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,CIGNA,ALL COMMERCIAL CIGNA,189.70,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $189.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,COFINITY,COFINITY,271.00,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,44.27,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87530 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,44.27,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87530 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,257.45,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $257.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,227.64,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $227.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,192.41,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $192.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,197.83,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $197.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,131.71,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $131.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,230.35,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $230.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HUMANA,HUMANA CHOICE CARE HMO,72.83,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87530 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HUMANA,HUMANA CHOICE CARE PPO,230.35,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $230.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,42.84,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,HUMANA,HUMANA NATIIONAL POS HMO,72.83,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $72.83 from Fee Schedule 005543_170 for Rev 306 Proc 87530 * Qty 1 = $72.83 at 100% = $72.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,197.83,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $197.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,271.00,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,44.27,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87530 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,42.84,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,44.27,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87530 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,46.93,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87530 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 100% = $44.27... $44.27 at 106% = $46.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,42.84,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,135.50,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $135.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,227.64,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $227.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,96.39,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,203.25,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $203.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,249.32,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $249.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,55.69,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,55.69,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,PREVEA HEALTH NETWORK,PREVEA360,55.69,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,55.69,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,172.98,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $172.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,43.27,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,195.12,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $195.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,TRIOLOGY,TRILOGY MEDICAID,46.93,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87530 at $44.27 (Fee Schedule) = $44.27 (Total Line Payment) at 106% = $46.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,51.41,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87530 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,51.41,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87530 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,42.84,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,51.41,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.41 from Fee Schedule UHC_98227C for Rev 306 Proc 87530 * Qty 1 = $51.41 at 100% = $51.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,UNITY HEALTH PLAN,UNITY HOSPICE,42.84,,,,,,,42.8400,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,195.12,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $195.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,168.02,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $168.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,195.12,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $195.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,195.12,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $195.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HSV QUANT  TYPE 1 & 2 DNA QN RT PCR,87530,CPT,306,RC,30600344,CDM,,,,both,,,271.0000,178.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,162.60,,,,,,,42.8400,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $271.00 in Billed Charges for Rev 306 Proc 87530 = $162.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,AETNA,AETNA HSHS,379.85,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $379.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,AETNA,AETNA MEDICARE,128.29,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,AETNA,ALL COMMERCIAL AETNA,588.00,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,ANTHEM,ANTEHM MEDICAID,132.56,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87505 at $132.56 (Fee Schedule) = $132.56 (Total Line Payment) at 100% = $132.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,128.29,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,ANTHEM,ANTHEM POS/HMO,449.02,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $449.02 from Fee Schedule WII28_25 for Rev 306 Proc 87505 Mod TC * Qty 1 = $449.02 at 100% = $449.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,ANTHEM,ANTHEM PPO,449.02,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $449.02 from Fee Schedule WII28_25 for Rev 306 Proc 87505 Mod TC * Qty 1 = $449.02 at 100% = $449.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,588.00,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,CENPATICO,ALL MEDICAID CENPATICO,588.00,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,499.80,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $499.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,CIGNA,ALL COMMERCIAL CIGNA,411.60,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $411.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,COFINITY,COFINITY,588.00,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,132.56,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87505 at $132.56 (Fee Schedule) = $132.56 (Total Line Payment) at 100% = $132.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,132.56,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87505 at $132.56 (Fee Schedule) = $132.56 (Total Line Payment) at 100% = $132.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,558.60,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $558.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,493.92,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $493.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,417.48,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $417.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,429.24,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $429.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,285.77,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $285.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,499.80,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $499.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HUMANA,HUMANA CHOICE CARE HMO,218.09,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.09 from Fee Schedule 005543_170 for Rev 306 Proc 87505 * Qty 1 = $218.09 at 100% = $218.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HUMANA,HUMANA CHOICE CARE PPO,499.80,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $499.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HUMANA,HUMANA MEDICARE ADVANTAGE,128.29,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,HUMANA,HUMANA NATIIONAL POS HMO,218.09,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.09 from Fee Schedule 005543_170 for Rev 306 Proc 87505 * Qty 1 = $218.09 at 100% = $218.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,429.24,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $429.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,588.00,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,132.56,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87505 at $132.56 (Fee Schedule) = $132.56 (Total Line Payment) at 100% = $132.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,128.29,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,132.56,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87505 at $132.56 (Fee Schedule) = $132.56 (Total Line Payment) at 100% = $132.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,140.51,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87505 at $132.56 (Fee Schedule) = $132.56 (Total Line Payment) at 100% = $132.56... $132.56 at 106% = $140.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,MOLINA HEALTHCARE,MOLINA MEDICARE,128.29,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,294.00,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $294.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,493.92,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $493.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,NAPHCARE,ALL COMMERICAL NAPHCARE,288.65,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,441.00,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $441.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,540.96,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $540.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,166.78,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,166.78,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,PREVEA HEALTH NETWORK,PREVEA360,166.78,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,166.78,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,375.32,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $375.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,129.57,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,423.36,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $423.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,TRIOLOGY,TRILOGY MEDICAID,140.51,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87505 at $132.56 (Fee Schedule) = $132.56 (Total Line Payment) at 106% = $140.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,153.95,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $153.95 from Fee Schedule UHC_98227C for Rev 306 Proc 87505 * Qty 1 = $153.95 at 100% = $153.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,153.95,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $153.95 from Fee Schedule UHC_98227C for Rev 306 Proc 87505 * Qty 1 = $153.95 at 100% = $153.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,128.29,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,153.95,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $153.95 from Fee Schedule UHC_98227C for Rev 306 Proc 87505 * Qty 1 = $153.95 at 100% = $153.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,UNITY HEALTH PLAN,UNITY HOSPICE,128.29,,,,,,,128.2900,588.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,423.36,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $423.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,364.56,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $364.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,423.36,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $423.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,423.36,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $423.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 3-5 TARGETS,87505,CPT,306,RC,30600347,CDM,,,,both,,,588.0000,388.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,352.80,,,,,,,128.2900,588.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $588.00 in Billed Charges for Rev 306 Proc 87505 = $352.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA HSHS,484.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $484.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,AETNA,ALL COMMERCIAL AETNA,750.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87798 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87798 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,750.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,CENPATICO,ALL MEDICAID CENPATICO,750.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,637.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,CIGNA,ALL COMMERCIAL CIGNA,525.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $525.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,COFINITY,COFINITY,750.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,712.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $712.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,630.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,532.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $532.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,547.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,364.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $364.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,637.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87798 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE PPO,637.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87798 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,547.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,750.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,375.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,630.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,562.50,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $562.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,690.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.73,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $478.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,540.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,540.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,465.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,540.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,540.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INFECT AMP (ZIKA VIRUS REAL TIME PCR RNA QL),87798,CPT,306,RC,30600350,CDM,,,,both,,,750.0000,495.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,450.00,,,,,,,35.0900,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $750.00 in Billed Charges for Rev 306 Proc 87798 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,AETNA,AETNA HSHS,35.53,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $35.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,AETNA,AETNA MEDICARE,12.01,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,AETNA,ALL COMMERCIAL AETNA,55.00,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,ANTHEM,ANTEHM MEDICAID,8.17,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86628 at $8.17 (Fee Schedule) = $8.17 (Total Line Payment) at 100% = $8.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,12.01,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,ANTHEM,ANTHEM POS/HMO,42.04,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.04 from Fee Schedule WII28_25 for Rev 306 Proc 86628 Mod TC * Qty 1 = $42.04 at 100% = $42.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,ANTHEM,ANTHEM PPO,42.04,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.04 from Fee Schedule WII28_25 for Rev 306 Proc 86628 Mod TC * Qty 1 = $42.04 at 100% = $42.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,55.00,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,CENPATICO,ALL MEDICAID CENPATICO,55.00,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,46.75,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $46.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,CIGNA,ALL COMMERCIAL CIGNA,38.50,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $38.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,COFINITY,COFINITY,55.00,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.17,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86628 at $8.17 (Fee Schedule) = $8.17 (Total Line Payment) at 100% = $8.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.17,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86628 at $8.17 (Fee Schedule) = $8.17 (Total Line Payment) at 100% = $8.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,52.25,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $52.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,46.20,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,39.05,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $39.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,40.15,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $40.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,26.73,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $26.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,46.75,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $46.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HUMANA,HUMANA CHOICE CARE HMO,20.42,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.42 from Fee Schedule 005543_170 for Rev 306 Proc 86628 * Qty 1 = $20.42 at 100% = $20.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HUMANA,HUMANA CHOICE CARE PPO,46.75,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $46.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,12.01,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,HUMANA,HUMANA NATIIONAL POS HMO,20.42,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.42 from Fee Schedule 005543_170 for Rev 306 Proc 86628 * Qty 1 = $20.42 at 100% = $20.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,40.15,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $40.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,55.00,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $55.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.17,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86628 at $8.17 (Fee Schedule) = $8.17 (Total Line Payment) at 100% = $8.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.01,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.17,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86628 at $8.17 (Fee Schedule) = $8.17 (Total Line Payment) at 100% = $8.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,8.66,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86628 at $8.17 (Fee Schedule) = $8.17 (Total Line Payment) at 100% = $8.17... $8.17 at 106% = $8.66 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,12.01,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27.50,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $27.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,46.20,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,27.02,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,41.25,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $41.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,50.60,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $50.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.61,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.61,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,PREVEA HEALTH NETWORK,PREVEA360,15.61,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.61,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,35.11,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $35.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,12.13,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,39.60,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,TRIOLOGY,TRILOGY MEDICAID,8.66,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86628 at $8.17 (Fee Schedule) = $8.17 (Total Line Payment) at 106% = $8.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.41,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.41 from Fee Schedule UHC_98227C for Rev 306 Proc 86628 * Qty 1 = $14.41 at 100% = $14.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,14.41,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.41 from Fee Schedule UHC_98227C for Rev 306 Proc 86628 * Qty 1 = $14.41 at 100% = $14.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,12.01,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,14.41,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $14.41 from Fee Schedule UHC_98227C for Rev 306 Proc 86628 * Qty 1 = $14.41 at 100% = $14.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,UNITY HEALTH PLAN,UNITY HOSPICE,12.01,,,,,,,8.1700,55.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,39.60,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,34.10,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $34.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,39.60,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,39.60,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $39.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANDIDA AB  IGA IGG IBM,86628,CPT,306,RC,30600351,CDM,,,,both,,,55.0000,36.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,33.00,,,,,,,8.1700,55.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $55.00 in Billed Charges for Rev 306 Proc 86628 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,28.07,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87563 at $28.07 (Fee Schedule) = $28.07 (Total Line Payment) at 100% = $28.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87563 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87563 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,28.07,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87563 at $28.07 (Fee Schedule) = $28.07 (Total Line Payment) at 100% = $28.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,28.07,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87563 at $28.07 (Fee Schedule) = $28.07 (Total Line Payment) at 100% = $28.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87563 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87563 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,28.07,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87563 at $28.07 (Fee Schedule) = $28.07 (Total Line Payment) at 100% = $28.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,28.07,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87563 at $28.07 (Fee Schedule) = $28.07 (Total Line Payment) at 100% = $28.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,29.75,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87563 at $28.07 (Fee Schedule) = $28.07 (Total Line Payment) at 100% = $28.07... $28.07 at 106% = $29.75 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,29.75,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87563 at $28.07 (Fee Schedule) = $28.07 (Total Line Payment) at 106% = $29.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87563 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87563 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87563 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,28.0700,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"HC INFECT AMP (MYCOPLASMA/UREAPLASMA PNL, PCR)",87563,CPT,306,RC,30600352,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,28.0700,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87563 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,AETNA,AETNA HSHS,127.91,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $127.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,AETNA,AETNA MEDICARE,5.88,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,AETNA,ALL COMMERCIAL AETNA,198.00,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,ANTHEM,ANTEHM MEDICAID,6.08,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87176 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5.88,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,ANTHEM,ANTHEM POS/HMO,20.58,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.58 from Fee Schedule WII28_25 for Rev 306 Proc 87176 Mod TC * Qty 1 = $20.58 at 100% = $20.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,ANTHEM,ANTHEM PPO,20.58,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.58 from Fee Schedule WII28_25 for Rev 306 Proc 87176 Mod TC * Qty 1 = $20.58 at 100% = $20.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,198.00,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,CENPATICO,ALL MEDICAID CENPATICO,198.00,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,168.30,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $168.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,CIGNA,ALL COMMERCIAL CIGNA,138.60,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $138.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,COFINITY,COFINITY,198.00,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.08,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87176 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.08,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87176 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,188.10,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $188.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,166.32,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $166.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,140.58,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $140.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,144.54,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $144.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,96.23,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $96.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,168.30,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $168.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HUMANA,HUMANA CHOICE CARE HMO,10.00,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.00 from Fee Schedule 005543_170 for Rev 306 Proc 87176 * Qty 1 = $10.00 at 100% = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HUMANA,HUMANA CHOICE CARE PPO,168.30,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $168.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,5.88,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,HUMANA,HUMANA NATIIONAL POS HMO,10.00,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.00 from Fee Schedule 005543_170 for Rev 306 Proc 87176 * Qty 1 = $10.00 at 100% = $10.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,144.54,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $144.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,198.00,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.08,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87176 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5.88,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.08,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87176 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,6.44,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87176 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 100% = $6.08... $6.08 at 106% = $6.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,5.88,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,99.00,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $99.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,166.32,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $166.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,13.23,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,148.50,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $148.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,182.16,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $182.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.64,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.64,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,PREVEA HEALTH NETWORK,PREVEA360,7.64,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.64,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,126.38,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $126.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5.94,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,142.56,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $142.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,TRIOLOGY,TRILOGY MEDICAID,6.44,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87176 at $6.08 (Fee Schedule) = $6.08 (Total Line Payment) at 106% = $6.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.06,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.06 from Fee Schedule UHC_98227C for Rev 306 Proc 87176 * Qty 1 = $7.06 at 100% = $7.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,7.06,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.06 from Fee Schedule UHC_98227C for Rev 306 Proc 87176 * Qty 1 = $7.06 at 100% = $7.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5.88,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,7.06,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.06 from Fee Schedule UHC_98227C for Rev 306 Proc 87176 * Qty 1 = $7.06 at 100% = $7.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,UNITY HEALTH PLAN,UNITY HOSPICE,5.88,,,,,,,5.8800,198.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,142.56,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $142.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,122.76,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $122.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,142.56,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $142.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,142.56,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $142.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HOMOGENIZATION TISSU,87176,CPT,306,RC,30600379,CDM,,,,both,,,198.0000,130.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,118.80,,,,,,,5.8800,198.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $198.00 in Billed Charges for Rev 306 Proc 87176 = $118.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,AETNA,AETNA HSHS,472.87,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $472.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,AETNA,AETNA MEDICARE,262.99,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,AETNA,ALL COMMERCIAL AETNA,732.00,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $732.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,ANTHEM,ANTEHM MEDICAID,232.94,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,262.99,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,ANTHEM,ANTHEM POS/HMO,732.00,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $920.47 from Fee Schedule WII28_25 for Rev 306 Proc 87506 Mod TC * Qty 1 = $920.47 at 100% = $920.47 (Limited to $732.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,ANTHEM,ANTHEM PPO,732.00,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $920.47 from Fee Schedule WII28_25 for Rev 306 Proc 87506 Mod TC * Qty 1 = $920.47 at 100% = $920.47 (Limited to $732.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,732.00,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $732.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,CENPATICO,ALL MEDICAID CENPATICO,732.00,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $732.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,622.20,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $622.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,CIGNA,ALL COMMERCIAL CIGNA,512.40,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $512.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,COFINITY,COFINITY,732.00,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $732.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,232.94,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,232.94,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,695.40,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $695.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,614.88,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $614.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,519.72,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $519.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,534.36,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $534.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,355.75,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $355.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,622.20,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $622.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HUMANA,HUMANA CHOICE CARE HMO,447.08,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $447.08 from Fee Schedule 005543_170 for Rev 306 Proc 87506 * Qty 1 = $447.08 at 100% = $447.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HUMANA,HUMANA CHOICE CARE PPO,622.20,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $622.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,262.99,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,HUMANA,HUMANA NATIIONAL POS HMO,447.08,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $447.08 from Fee Schedule 005543_170 for Rev 306 Proc 87506 * Qty 1 = $447.08 at 100% = $447.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,534.36,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $534.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,732.00,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $732.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,232.94,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,262.99,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,232.94,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,246.92,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94... $232.94 at 106% = $246.92 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,262.99,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,366.00,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $366.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,614.88,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $614.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,591.73,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,549.00,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $549.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,673.44,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $673.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,341.89,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,341.89,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,PREVEA HEALTH NETWORK,PREVEA360,341.89,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,341.89,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,467.24,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $467.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,265.62,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,527.04,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $527.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,TRIOLOGY,TRILOGY MEDICAID,246.92,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 106% = $246.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,315.59,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 87506 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,315.59,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 87506 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,262.99,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,315.59,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 87506 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,UNITY HEALTH PLAN,UNITY HOSPICE,262.99,,,,,,,232.9400,732.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,527.04,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $527.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,453.84,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $453.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,527.04,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $527.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,527.04,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $527.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 6-8 TARGETS,87506,CPT,306,RC,30600498,CDM,,,,both,,,732.0000,483.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,439.20,,,,,,,232.9400,732.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $732.00 in Billed Charges for Rev 306 Proc 87506 = $439.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,AETNA,AETNA HSHS,523.91,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $523.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,AETNA,AETNA MEDICARE,262.99,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,AETNA,ALL COMMERCIAL AETNA,811.00,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,ANTHEM,ANTEHM MEDICAID,232.94,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,262.99,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,ANTHEM,ANTHEM POS/HMO,811.00,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $920.47 from Fee Schedule WII28_25 for Rev 306 Proc 87506 Mod TC * Qty 1 = $920.47 at 100% = $920.47 (Limited to $811.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,ANTHEM,ANTHEM PPO,811.00,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $920.47 from Fee Schedule WII28_25 for Rev 306 Proc 87506 Mod TC * Qty 1 = $920.47 at 100% = $920.47 (Limited to $811.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,811.00,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,CENPATICO,ALL MEDICAID CENPATICO,811.00,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,689.35,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $689.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,CIGNA,ALL COMMERCIAL CIGNA,567.70,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $567.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,COFINITY,COFINITY,811.00,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,232.94,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,232.94,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,770.45,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $770.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,681.24,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $681.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,575.81,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $575.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,592.03,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $592.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,394.15,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $394.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,689.35,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $689.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HUMANA,HUMANA CHOICE CARE HMO,447.08,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $447.08 from Fee Schedule 005543_170 for Rev 306 Proc 87506 * Qty 1 = $447.08 at 100% = $447.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HUMANA,HUMANA CHOICE CARE PPO,689.35,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $689.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,262.99,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,HUMANA,HUMANA NATIIONAL POS HMO,447.08,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $447.08 from Fee Schedule 005543_170 for Rev 306 Proc 87506 * Qty 1 = $447.08 at 100% = $447.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,592.03,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $592.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,811.00,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,232.94,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,262.99,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,232.94,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,246.92,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 100% = $232.94... $232.94 at 106% = $246.92 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,262.99,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,405.50,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $405.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,681.24,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $681.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,591.73,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,608.25,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $608.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,746.12,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $746.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,341.89,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,341.89,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,PREVEA HEALTH NETWORK,PREVEA360,341.89,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,341.89,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,517.66,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $517.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,265.62,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,583.92,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $583.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,TRIOLOGY,TRILOGY MEDICAID,246.92,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87506 at $232.94 (Fee Schedule) = $232.94 (Total Line Payment) at 106% = $246.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,315.59,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 87506 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,315.59,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 87506 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,262.99,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,315.59,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $315.59 from Fee Schedule UHC_98227C for Rev 306 Proc 87506 * Qty 1 = $315.59 at 100% = $315.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,UNITY HEALTH PLAN,UNITY HOSPICE,262.99,,,,,,,232.9400,811.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,583.92,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $583.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,502.82,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $502.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,583.92,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $583.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,583.92,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $583.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GI ENTERIC PATHOGEN PANEL 9-11 TARGETS,87506,CPT,306,RC,30600499,CDM,,,,both,,,811.0000,535.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,486.60,,,,,,,232.9400,811.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $811.00 in Billed Charges for Rev 306 Proc 87506 = $486.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,AETNA,AETNA HSHS,310.08,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $310.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,AETNA,ALL COMMERCIAL AETNA,480.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87798 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87798 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,480.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,CENPATICO,ALL MEDICAID CENPATICO,480.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,408.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,CIGNA,ALL COMMERCIAL CIGNA,336.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,COFINITY,COFINITY,480.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,456.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $456.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,403.20,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,340.80,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $340.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,350.40,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $350.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,233.28,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $233.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,408.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87798 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA CHOICE CARE PPO,408.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87798 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,350.40,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $350.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,480.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $480.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,240.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,403.20,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,360.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,441.60,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $441.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,306.38,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $306.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,345.60,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87798 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87798 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,480.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,345.60,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,297.60,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,345.60,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,345.60,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $345.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IF AGENT PARAPERTUSSIS DNA DETECTION METHOD,87798,CPT,306,RC,30600540,CDM,,,,both,,,480.0000,316.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,288.00,,,,,,,35.0900,480.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $480.00 in Billed Charges for Rev 306 Proc 87798 = $288.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,AETNA,AETNA HSHS,472.23,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $472.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,AETNA,AETNA MEDICARE,48.24,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,AETNA,ALL COMMERCIAL AETNA,731.00,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTEHM MEDICAID,49.35,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87551 at $49.35 (Fee Schedule) = $49.35 (Total Line Payment) at 100% = $49.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,48.24,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM POS/HMO,168.84,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $168.84 from Fee Schedule WII28_25 for Rev 306 Proc 87551 Mod TC * Qty 1 = $168.84 at 100% = $168.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM PPO,168.84,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $168.84 from Fee Schedule WII28_25 for Rev 306 Proc 87551 Mod TC * Qty 1 = $168.84 at 100% = $168.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,731.00,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,CENPATICO,ALL MEDICAID CENPATICO,731.00,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,621.35,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,CIGNA,ALL COMMERCIAL CIGNA,511.70,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $511.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,COFINITY,COFINITY,731.00,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,49.35,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87551 at $49.35 (Fee Schedule) = $49.35 (Total Line Payment) at 100% = $49.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,49.35,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87551 at $49.35 (Fee Schedule) = $49.35 (Total Line Payment) at 100% = $49.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,694.45,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $694.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,614.04,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $614.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,519.01,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $519.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,533.63,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,355.27,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $355.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,621.35,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA CHOICE CARE HMO,82.01,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $82.01 from Fee Schedule 005543_170 for Rev 306 Proc 87551 * Qty 1 = $82.01 at 100% = $82.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA CHOICE CARE PPO,621.35,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,48.24,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA NATIIONAL POS HMO,82.01,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $82.01 from Fee Schedule 005543_170 for Rev 306 Proc 87551 * Qty 1 = $82.01 at 100% = $82.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,533.63,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,731.00,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,49.35,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87551 at $49.35 (Fee Schedule) = $49.35 (Total Line Payment) at 100% = $49.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,48.24,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,49.35,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87551 at $49.35 (Fee Schedule) = $49.35 (Total Line Payment) at 100% = $49.35. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,52.31,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87551 at $49.35 (Fee Schedule) = $49.35 (Total Line Payment) at 100% = $49.35... $49.35 at 106% = $52.31 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,48.24,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,365.50,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $365.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,614.04,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $614.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,108.54,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,548.25,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $548.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,672.52,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $672.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,62.71,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,62.71,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA360,62.71,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,62.71,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,466.60,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $466.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,48.72,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,526.32,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,TRIOLOGY,TRILOGY MEDICAID,52.31,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87551 at $49.35 (Fee Schedule) = $49.35 (Total Line Payment) at 106% = $52.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,57.89,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.89 from Fee Schedule UHC_98227C for Rev 306 Proc 87551 * Qty 1 = $57.89 at 100% = $57.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,57.89,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.89 from Fee Schedule UHC_98227C for Rev 306 Proc 87551 * Qty 1 = $57.89 at 100% = $57.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,48.24,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,57.89,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $57.89 from Fee Schedule UHC_98227C for Rev 306 Proc 87551 * Qty 1 = $57.89 at 100% = $57.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,UNITY HEALTH PLAN,UNITY HOSPICE,48.24,,,,,,,48.2400,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,526.32,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,453.22,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $453.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,526.32,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,526.32,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MYCOBACTERIA DAN AMP PROBE,87551,CPT,306,RC,30600621,CDM,,,,both,,,731.0000,482.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,438.60,,,,,,,48.2400,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $731.00 in Billed Charges for Rev 306 Proc 87551 = $438.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,AETNA,AETNA HSHS,48.45,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $48.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,AETNA,AETNA MEDICARE,6.63,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,AETNA,ALL COMMERCIAL AETNA,75.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTEHM MEDICAID,6.85,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87081 at $6.85 (Fee Schedule) = $6.85 (Total Line Payment) at 100% = $6.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,6.63,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM POS/HMO,23.21,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.21 from Fee Schedule WII28_25 for Rev 306 Proc 87081 Mod TC * Qty 1 = $23.21 at 100% = $23.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,ANTHEM,ANTHEM PPO,23.21,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.21 from Fee Schedule WII28_25 for Rev 306 Proc 87081 Mod TC * Qty 1 = $23.21 at 100% = $23.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,75.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,CENPATICO,ALL MEDICAID CENPATICO,75.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,63.75,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,CIGNA,ALL COMMERCIAL CIGNA,52.50,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $52.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,COFINITY,COFINITY,75.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.85,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87081 at $6.85 (Fee Schedule) = $6.85 (Total Line Payment) at 100% = $6.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.85,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87081 at $6.85 (Fee Schedule) = $6.85 (Total Line Payment) at 100% = $6.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,71.25,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,63.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,53.25,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $53.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.75,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,36.45,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $36.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,63.75,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA CHOICE CARE HMO,11.27,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.27 from Fee Schedule 005543_170 for Rev 306 Proc 87081 * Qty 1 = $11.27 at 100% = $11.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA CHOICE CARE PPO,63.75,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,6.63,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,HUMANA,HUMANA NATIIONAL POS HMO,11.27,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.27 from Fee Schedule 005543_170 for Rev 306 Proc 87081 * Qty 1 = $11.27 at 100% = $11.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.75,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,75.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.85,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87081 at $6.85 (Fee Schedule) = $6.85 (Total Line Payment) at 100% = $6.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,6.63,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.85,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87081 at $6.85 (Fee Schedule) = $6.85 (Total Line Payment) at 100% = $6.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,7.26,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87081 at $6.85 (Fee Schedule) = $6.85 (Total Line Payment) at 100% = $6.85... $6.85 at 106% = $7.26 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,6.63,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.50,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $37.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,63.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,14.92,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,56.25,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $56.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,69.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.62,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.62,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA360,8.62,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.62,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.87,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $47.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,6.70,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,54.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,TRIOLOGY,TRILOGY MEDICAID,7.26,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87081 at $6.85 (Fee Schedule) = $6.85 (Total Line Payment) at 106% = $7.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.96,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.96 from Fee Schedule UHC_98227C for Rev 306 Proc 87081 * Qty 1 = $7.96 at 100% = $7.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,7.96,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.96 from Fee Schedule UHC_98227C for Rev 306 Proc 87081 * Qty 1 = $7.96 at 100% = $7.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,6.63,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,7.96,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.96 from Fee Schedule UHC_98227C for Rev 306 Proc 87081 * Qty 1 = $7.96 at 100% = $7.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,UNITY HEALTH PLAN,UNITY HOSPICE,6.63,,,,,,,6.6300,75.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,54.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,46.50,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $46.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,54.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,54.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $54.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CULTURE SCREEN ONLY,87081,CPT,306,RC,30600622,CDM,,,,both,,,75.0000,49.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,45.00,,,,,,,6.6300,75.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $75.00 in Billed Charges for Rev 306 Proc 87081 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,AETNA,AETNA HSHS,123.39,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $123.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,AETNA,AETNA MEDICARE,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,AETNA,ALL COMMERCIAL AETNA,191.00,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,ANTHEM,ANTEHM MEDICAID,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,ANTHEM,ANTHEM POS/HMO,179.59,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $179.59 from Fee Schedule WII28_25 for Rev 306 Proc 87635 Mod TC * Qty 1 = $179.59 at 100% = $179.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,ANTHEM,ANTHEM PPO,179.59,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $179.59 from Fee Schedule WII28_25 for Rev 306 Proc 87635 Mod TC * Qty 1 = $179.59 at 100% = $179.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,191.00,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,CENPATICO,ALL MEDICAID CENPATICO,191.00,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,162.35,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $162.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,CIGNA,ALL COMMERCIAL CIGNA,133.70,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,COFINITY,COFINITY,191.00,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,181.45,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $181.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,160.44,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $160.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,135.61,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $135.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,139.43,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $139.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,92.83,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $92.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,162.35,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $162.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HUMANA,HUMANA CHOICE CARE HMO,87.23,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $87.23 from Fee Schedule 005543_170 for Rev 306 Proc 87635 * Qty 1 = $87.23 at 100% = $87.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HUMANA,HUMANA CHOICE CARE PPO,162.35,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $162.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HUMANA,HUMANA MEDICARE ADVANTAGE,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,HUMANA,HUMANA NATIIONAL POS HMO,87.23,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $87.23 from Fee Schedule 005543_170 for Rev 306 Proc 87635 * Qty 1 = $87.23 at 100% = $87.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,139.43,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $139.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,191.00,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $191.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,MOLINA HEALTHCARE,MOLINA MEDICAID,54.39,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 100% = $51.31... $51.31 at 106% = $54.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,MOLINA HEALTHCARE,MOLINA MEDICARE,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,95.50,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $95.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,160.44,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $160.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,NAPHCARE,ALL COMMERICAL NAPHCARE,115.45,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,143.25,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $143.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,175.72,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $175.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,66.70,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,66.70,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,PREVEA HEALTH NETWORK,PREVEA360,66.70,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,66.70,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,121.92,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $121.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.82,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,137.52,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $137.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,TRIOLOGY,TRILOGY MEDICAID,54.39,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87635 at $51.31 (Fee Schedule) = $51.31 (Total Line Payment) at 106% = $54.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,61.57,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87635 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,61.57,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87635 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,61.57,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87635 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,UNITY HEALTH PLAN,UNITY HOSPICE,51.31,,,,,,,51.3100,191.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,137.52,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $137.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,118.42,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $118.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,137.52,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $137.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,137.52,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $137.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARS-COV-2 COVID-19 AMP PRB,87635,CPT,306,RC,30600647,CDM,,,,both,,,191.0000,126.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,114.60,,,,,,,51.3100,191.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $191.00 in Billed Charges for Rev 306 Proc 87635 = $114.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,AETNA,AETNA HSHS,140.83,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $140.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,AETNA,AETNA MEDICARE,6.64,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,AETNA,ALL COMMERCIAL AETNA,218.00,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,ANTHEM,ANTEHM MEDICAID,6.86,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87188 at $6.86 (Fee Schedule) = $6.86 (Total Line Payment) at 100% = $6.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,6.64,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,ANTHEM,ANTHEM POS/HMO,23.24,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.24 from Fee Schedule WII28_25 for Rev 306 Proc 87188 Mod TC * Qty 1 = $23.24 at 100% = $23.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,ANTHEM,ANTHEM PPO,23.24,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.24 from Fee Schedule WII28_25 for Rev 306 Proc 87188 Mod TC * Qty 1 = $23.24 at 100% = $23.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,218.00,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,CENPATICO,ALL MEDICAID CENPATICO,218.00,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,185.30,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $185.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,CIGNA,ALL COMMERCIAL CIGNA,152.60,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $152.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,COFINITY,COFINITY,218.00,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.86,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87188 at $6.86 (Fee Schedule) = $6.86 (Total Line Payment) at 100% = $6.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.86,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87188 at $6.86 (Fee Schedule) = $6.86 (Total Line Payment) at 100% = $6.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,207.10,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $207.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,183.12,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $183.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,154.78,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $154.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,159.14,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $159.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,105.95,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $105.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,185.30,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $185.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HUMANA,HUMANA CHOICE CARE HMO,11.29,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.29 from Fee Schedule 005543_170 for Rev 306 Proc 87188 * Qty 1 = $11.29 at 100% = $11.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HUMANA,HUMANA CHOICE CARE PPO,185.30,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $185.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,6.64,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,HUMANA,HUMANA NATIIONAL POS HMO,11.29,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.29 from Fee Schedule 005543_170 for Rev 306 Proc 87188 * Qty 1 = $11.29 at 100% = $11.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,159.14,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $159.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,218.00,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.86,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87188 at $6.86 (Fee Schedule) = $6.86 (Total Line Payment) at 100% = $6.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,6.64,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.86,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87188 at $6.86 (Fee Schedule) = $6.86 (Total Line Payment) at 100% = $6.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,7.27,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87188 at $6.86 (Fee Schedule) = $6.86 (Total Line Payment) at 100% = $6.86... $6.86 at 106% = $7.27 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,6.64,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,109.00,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $109.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,183.12,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $183.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,14.94,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,163.50,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $163.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,200.56,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $200.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.63,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.63,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,PREVEA HEALTH NETWORK,PREVEA360,8.63,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.63,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,139.15,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $139.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,6.71,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,156.96,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,TRIOLOGY,TRILOGY MEDICAID,7.27,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00396 Proc 87188 at $6.86 (Fee Schedule) = $6.86 (Total Line Payment) at 106% = $7.27. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.97,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.97 from Fee Schedule UHC_98227C for Rev 306 Proc 87188 * Qty 1 = $7.97 at 100% = $7.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,7.97,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.97 from Fee Schedule UHC_98227C for Rev 306 Proc 87188 * Qty 1 = $7.97 at 100% = $7.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,6.64,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,7.97,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.97 from Fee Schedule UHC_98227C for Rev 306 Proc 87188 * Qty 1 = $7.97 at 100% = $7.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,UNITY HEALTH PLAN,UNITY HOSPICE,6.64,,,,,,,6.6400,218.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,156.96,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,135.16,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $135.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,156.96,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,156.96,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MACROTUBE DIL METH 5DRG PNL,87188,CPT,306,RC,30600665,CDM,,,,both,,,218.0000,143.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,130.80,,,,,,,6.6400,218.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $218.00 in Billed Charges for Rev 306 Proc 87188 = $130.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87468 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87468 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87468 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87468 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87468 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87468 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87468 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87468 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87468 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,37.20,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87468 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 100% = $35.09... $35.09 at 106% = $37.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,37.20,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87468 at $35.09 (Fee Schedule) = $35.09 (Total Line Payment) at 106% = $37.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87468 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87468 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87468 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,306,RC,30600667,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,35.0900,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 306 Proc 87468 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA HSHS,484.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $484.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA MEDICARE,51.31,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,AETNA,ALL COMMERCIAL AETNA,750.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTEHM MEDICAID,50.68,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87662 at $50.68 (Fee Schedule) = $50.68 (Total Line Payment) at 100% = $50.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,51.31,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM POS/HMO,179.59,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $179.59 from Fee Schedule WII28_25 for Rev 306 Proc 87662 Mod TC * Qty 1 = $179.59 at 100% = $179.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM PPO,179.59,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $179.59 from Fee Schedule WII28_25 for Rev 306 Proc 87662 Mod TC * Qty 1 = $179.59 at 100% = $179.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,750.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,CENPATICO,ALL MEDICAID CENPATICO,750.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,637.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,CIGNA,ALL COMMERCIAL CIGNA,525.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $525.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,COFINITY,COFINITY,750.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.68,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87662 at $50.68 (Fee Schedule) = $50.68 (Total Line Payment) at 100% = $50.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.68,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87662 at $50.68 (Fee Schedule) = $50.68 (Total Line Payment) at 100% = $50.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,712.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $712.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,630.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,532.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $532.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,547.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,364.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $364.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,637.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE HMO,87.23,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $87.23 from Fee Schedule 005543_170 for Rev 306 Proc 87662 * Qty 1 = $87.23 at 100% = $87.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE PPO,637.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,51.31,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA NATIIONAL POS HMO,87.23,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $87.23 from Fee Schedule 005543_170 for Rev 306 Proc 87662 * Qty 1 = $87.23 at 100% = $87.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,547.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,750.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.68,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87662 at $50.68 (Fee Schedule) = $50.68 (Total Line Payment) at 100% = $50.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,51.31,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.68,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87662 at $50.68 (Fee Schedule) = $50.68 (Total Line Payment) at 100% = $50.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,53.72,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87662 at $50.68 (Fee Schedule) = $50.68 (Total Line Payment) at 100% = $50.68... $50.68 at 106% = $53.72 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,51.31,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,375.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,630.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,115.45,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,562.50,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $562.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,690.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,66.70,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,66.70,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360,66.70,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,66.70,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.73,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $478.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.82,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,540.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,TRILOGY MEDICAID,53.72,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87662 at $50.68 (Fee Schedule) = $50.68 (Total Line Payment) at 106% = $53.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,61.57,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87662 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,61.57,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87662 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,51.31,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,61.57,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.57 from Fee Schedule UHC_98227C for Rev 306 Proc 87662 * Qty 1 = $61.57 at 100% = $61.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,UNITY HEALTH PLAN,UNITY HOSPICE,51.31,,,,,,,50.6800,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,540.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,465.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,540.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,540.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ZIKA VIRUS DNA/RNA AMP PROBE,87662,CPT,306,RC,30600671,CDM,,,,both,,,750.0000,495.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,450.00,,,,,,,50.6800,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $750.00 in Billed Charges for Rev 306 Proc 87662 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,AETNA,AETNA HSHS,427.65,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $427.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,AETNA,AETNA MEDICARE,41.76,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,AETNA,ALL COMMERCIAL AETNA,662.00,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,ANTHEM,ANTEHM MEDICAID,43.15,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87533 at $43.15 (Fee Schedule) = $43.15 (Total Line Payment) at 100% = $43.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,41.76,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,ANTHEM,ANTHEM POS/HMO,146.16,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.16 from Fee Schedule WII28_25 for Rev 306 Proc 87533 Mod TC * Qty 1 = $146.16 at 100% = $146.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,ANTHEM,ANTHEM PPO,146.16,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.16 from Fee Schedule WII28_25 for Rev 306 Proc 87533 Mod TC * Qty 1 = $146.16 at 100% = $146.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,662.00,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,CENPATICO,ALL MEDICAID CENPATICO,662.00,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,562.70,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $562.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,CIGNA,ALL COMMERCIAL CIGNA,463.40,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $463.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,COFINITY,COFINITY,662.00,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,43.15,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87533 at $43.15 (Fee Schedule) = $43.15 (Total Line Payment) at 100% = $43.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,43.15,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87533 at $43.15 (Fee Schedule) = $43.15 (Total Line Payment) at 100% = $43.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,628.90,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $628.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,556.08,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $556.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,470.02,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $470.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,483.26,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $483.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,321.73,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $321.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,562.70,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $562.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HUMANA,HUMANA CHOICE CARE HMO,70.99,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $70.99 from Fee Schedule 005543_170 for Rev 306 Proc 87533 * Qty 1 = $70.99 at 100% = $70.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HUMANA,HUMANA CHOICE CARE PPO,562.70,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $562.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,41.76,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,HUMANA,HUMANA NATIIONAL POS HMO,70.99,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $70.99 from Fee Schedule 005543_170 for Rev 306 Proc 87533 * Qty 1 = $70.99 at 100% = $70.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,483.26,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $483.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,662.00,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $662.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,43.15,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87533 at $43.15 (Fee Schedule) = $43.15 (Total Line Payment) at 100% = $43.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,41.76,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,43.15,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87533 at $43.15 (Fee Schedule) = $43.15 (Total Line Payment) at 100% = $43.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,45.74,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87533 at $43.15 (Fee Schedule) = $43.15 (Total Line Payment) at 100% = $43.15... $43.15 at 106% = $45.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,41.76,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,331.00,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $331.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,556.08,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $556.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,93.96,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,496.50,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $496.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,609.04,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $609.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,54.29,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,54.29,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,PREVEA HEALTH NETWORK,PREVEA360,54.29,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,54.29,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,422.55,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $422.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,42.18,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,476.64,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $476.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,TRIOLOGY,TRILOGY MEDICAID,45.74,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87533 at $43.15 (Fee Schedule) = $43.15 (Total Line Payment) at 106% = $45.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,50.11,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87533 * Qty 1 = $50.11 at 100% = $50.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,50.11,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87533 * Qty 1 = $50.11 at 100% = $50.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,41.76,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,50.11,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87533 * Qty 1 = $50.11 at 100% = $50.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,UNITY HEALTH PLAN,UNITY HOSPICE,41.76,,,,,,,41.7600,662.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,476.64,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $476.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,410.44,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $410.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,476.64,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $476.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,476.64,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $476.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HHV-6 DNA QUANT,87533,CPT,306,RC,30600682,CDM,,,,both,,,662.0000,436.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,397.20,,,,,,,41.7600,662.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $662.00 in Billed Charges for Rev 306 Proc 87533 = $397.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,12.05,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $763.21 from Fee Schedule WII28_25 for Rev 306 Proc 87154 Mod TC * Qty 1 = $763.21 at 100% = $763.21 (Limited to $150.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $763.21 from Fee Schedule WII28_25 for Rev 306 Proc 87154 Mod TC * Qty 1 = $763.21 at 100% = $763.21 (Limited to $150.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.05,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.05,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $370.70 from Fee Schedule 005543_170 for Rev 306 Proc 87154 * Qty 1 = $370.70 at 100% = $370.70 (Limited to $150.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $370.70 from Fee Schedule 005543_170 for Rev 306 Proc 87154 * Qty 1 = $370.70 at 100% = $370.70 (Limited to $150.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.05,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.05,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,12.77,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 100% = $12.05... $12.05 at 106% = $12.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,337.50,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,151.50,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,12.77,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00388 Proc 87154 at $12.05 (Fee Schedule) = $12.05 (Total Line Payment) at 106% = $12.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,150.00,,,,,,,12.0500,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $261.67 from Fee Schedule UHC_98227C for Rev 306 Proc 87154 * Qty 1 = $261.67 at 100% = $261.67 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,150.00,,,,,,,12.0500,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $261.67 from Fee Schedule UHC_98227C for Rev 306 Proc 87154 * Qty 1 = $261.67 at 100% = $261.67 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,150.00,,,,,,,12.0500,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $261.67 from Fee Schedule UHC_98227C for Rev 306 Proc 87154 * Qty 1 = $261.67 at 100% = $261.67 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,150.00,,,,,,,12.0500,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CUL TYP ID BLD PTHGN 6+ TRGT,87154,CPT,306,RC,30600686,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,12.0500,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 306 Proc 87154 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,AETNA,AETNA HSHS,310.73,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $310.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,AETNA,AETNA MEDICARE,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,AETNA,ALL COMMERCIAL AETNA,481.00,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,ANTHEM,ANTEHM MEDICAID,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87636 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,ANTHEM,ANTHEM POS/HMO,481.00,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $499.21 from Fee Schedule WII28_25 for Rev 306 Proc 87636 Mod TC * Qty 1 = $499.21 at 100% = $499.21 (Limited to $481.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,ANTHEM,ANTHEM PPO,481.00,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $499.21 from Fee Schedule WII28_25 for Rev 306 Proc 87636 Mod TC * Qty 1 = $499.21 at 100% = $499.21 (Limited to $481.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,481.00,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,CENPATICO,ALL MEDICAID CENPATICO,481.00,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,408.85,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $408.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,CIGNA,ALL COMMERCIAL CIGNA,336.70,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $336.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,COFINITY,COFINITY,481.00,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87636 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87636 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,456.95,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $456.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,404.04,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $404.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,341.51,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $341.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,351.13,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $351.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,233.77,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $233.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,408.85,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $408.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HUMANA,HUMANA CHOICE CARE HMO,242.47,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.47 from Fee Schedule 005543_170 for Rev 306 Proc 87636 * Qty 1 = $242.47 at 100% = $242.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HUMANA,HUMANA CHOICE CARE PPO,408.85,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $408.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,HUMANA,HUMANA NATIIONAL POS HMO,242.47,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.47 from Fee Schedule 005543_170 for Rev 306 Proc 87636 * Qty 1 = $242.47 at 100% = $242.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,351.13,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $351.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,481.00,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87636 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87636 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,151.19,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87636 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 100% = $142.63... $142.63 at 106% = $151.19 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,240.50,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $240.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,404.04,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $404.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,320.92,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,360.75,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $360.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,442.52,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $442.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,185.42,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,185.42,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,PREVEA HEALTH NETWORK,PREVEA360,185.42,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,185.42,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,307.02,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $307.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,144.06,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,346.32,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,TRIOLOGY,TRILOGY MEDICAID,151.19,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87636 at $142.63 (Fee Schedule) = $142.63 (Total Line Payment) at 106% = $151.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,171.16,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 306 Proc 87636 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,171.16,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 306 Proc 87636 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,171.16,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.16 from Fee Schedule UHC_98227C for Rev 306 Proc 87636 * Qty 1 = $171.16 at 100% = $171.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,UNITY HEALTH PLAN,UNITY HOSPICE,142.63,,,,,,,142.6300,481.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,346.32,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,298.22,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $298.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,346.32,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,346.32,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $346.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SARSCOV2 & INF A&B AMP PRB,87636,CPT,306,RC,30600701,CDM,,,,both,,,481.0000,317.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,288.60,,,,,,,142.6300,481.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $481.00 in Billed Charges for Rev 306 Proc 87636 = $288.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,AETNA,AETNA HSHS,195.09,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $195.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,AETNA,ALL COMMERCIAL AETNA,302.00,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87641 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87641 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,302.00,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,CENPATICO,ALL MEDICAID CENPATICO,302.00,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,256.70,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $256.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,CIGNA,ALL COMMERCIAL CIGNA,211.40,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $211.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,COFINITY,COFINITY,302.00,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,286.90,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $286.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,253.68,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $253.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,214.42,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $214.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,220.46,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $220.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,146.77,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $146.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,256.70,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $256.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87641 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HUMANA,HUMANA CHOICE CARE PPO,256.70,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $256.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87641 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,220.46,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $220.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,302.00,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,151.00,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,253.68,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $253.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,226.50,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $226.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,277.84,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $277.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,192.77,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $192.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,217.44,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $217.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87641 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87641 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87641 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87641 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,302.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,217.44,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $217.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,187.24,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $187.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,217.44,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $217.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,217.44,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $217.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MR STAPH PCR PROBE,87641,CPT,306,RC,30600717,CDM,,,,both,,,302.0000,199.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,181.20,,,,,,,35.0900,302.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $302.00 in Billed Charges for Rev 306 Proc 87641 = $181.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,AETNA,AETNA HSHS,161.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $161.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,AETNA,ALL COMMERCIAL AETNA,250.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,ANTHEM,ANTHEM POS/HMO,170.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 306 Proc 87594 $250.00 in Billed Charges at 68% = $170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,ANTHEM,ANTHEM PPO,170.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 306 Proc 87594 $250.00 in Billed Charges at 68% = $170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,250.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,CENPATICO,ALL MEDICAID CENPATICO,250.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,212.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $212.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,CIGNA,ALL COMMERCIAL CIGNA,175.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,COFINITY,COFINITY,250.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,237.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $237.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,210.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,177.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $177.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,182.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $182.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,121.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $121.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,212.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $212.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,HUMANA,HUMANA CHOICE CARE PPO,212.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $212.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,182.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $182.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,250.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,125.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,210.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,187.50,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $187.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,230.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $230.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,159.58,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $159.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,180.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87594 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87594 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87594 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,250.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,180.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,155.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,180.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,180.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ,87594,CPT,306,RC,30600722,CDM,,,,both,,,250.0000,165.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,150.00,,,,,,,35.0900,250.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $250.00 in Billed Charges for Rev 306 Proc 87594 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,AETNA,AETNA HSHS,169.90,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $169.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,AETNA,ALL COMMERCIAL AETNA,263.00,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87150 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87150 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,263.00,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,CENPATICO,ALL MEDICAID CENPATICO,263.00,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,223.55,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $223.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,CIGNA,ALL COMMERCIAL CIGNA,184.10,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $184.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,COFINITY,COFINITY,263.00,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,249.85,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $249.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,220.92,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $220.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,186.73,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $186.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,191.99,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $191.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,127.82,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $127.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,223.55,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $223.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87150 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HUMANA,HUMANA CHOICE CARE PPO,223.55,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $223.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87150 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,191.99,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $191.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,263.00,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $263.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,131.50,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $131.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,220.92,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $220.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,197.25,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $197.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,241.96,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $241.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,167.87,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $167.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,189.36,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $189.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87150 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87150 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87150 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87150 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,263.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,189.36,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $189.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,163.06,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $163.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,189.36,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $189.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,189.36,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $189.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM,87150,CPT,306,RC,30600727,CDM,,,,both,,,263.0000,173.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,157.80,,,,,,,35.0900,263.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.00 in Billed Charges for Rev 306 Proc 87150 = $157.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA HSHS,75.58,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $75.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA MEDICARE,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,AETNA,ALL COMMERCIAL AETNA,117.00,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTEHM MEDICAID,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86769 at $42.13 (Fee Schedule) = $42.13 (Total Line Payment) at 100% = $42.13. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM POS/HMO,117.00,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $147.46 from Fee Schedule WII28_25 for Rev 306 Proc 86769 Mod TC * Qty 1 = $147.46 at 100% = $147.46 (Limited to $117.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM PPO,117.00,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $147.46 from Fee Schedule WII28_25 for Rev 306 Proc 86769 Mod TC * Qty 1 = $147.46 at 100% = $147.46 (Limited to $117.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,117.00,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,CENPATICO,ALL MEDICAID CENPATICO,117.00,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,99.45,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,CIGNA,ALL COMMERCIAL CIGNA,81.90,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $81.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,COFINITY,COFINITY,117.00,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86769 at $42.13 (Fee Schedule) = $42.13 (Total Line Payment) at 100% = $42.13. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86769 at $42.13 (Fee Schedule) = $42.13 (Total Line Payment) at 100% = $42.13. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,111.15,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $111.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,98.28,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.07,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $83.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,85.41,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,56.86,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $56.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,99.45,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE HMO,71.62,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $71.62 from Fee Schedule 005543_170 for Rev 306 Proc 86769 * Qty 1 = $71.62 at 100% = $71.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE PPO,99.45,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA NATIIONAL POS HMO,71.62,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $71.62 from Fee Schedule 005543_170 for Rev 306 Proc 86769 * Qty 1 = $71.62 at 100% = $71.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,85.41,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,117.00,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86769 at $42.13 (Fee Schedule) = $42.13 (Total Line Payment) at 100% = $42.13. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86769 at $42.13 (Fee Schedule) = $42.13 (Total Line Payment) at 100% = $42.13. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,44.66,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86769 at $42.13 (Fee Schedule) = $42.13 (Total Line Payment) at 100% = $42.13... $42.13 at 106% = $44.66 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,58.50,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,98.28,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,94.79,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,87.75,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $87.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,107.64,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $107.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,54.77,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,54.77,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360,54.77,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,54.77,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,74.68,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $74.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,42.55,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.24,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,TRILOGY MEDICAID,44.66,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00394 Proc 86769 at $42.13 (Fee Schedule) = $42.13 (Total Line Payment) at 106% = $44.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,50.56,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.56 from Fee Schedule UHC_98227C for Rev 306 Proc 86769 * Qty 1 = $50.56 at 100% = $50.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,50.56,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.56 from Fee Schedule UHC_98227C for Rev 306 Proc 86769 * Qty 1 = $50.56 at 100% = $50.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,50.56,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $50.56 from Fee Schedule UHC_98227C for Rev 306 Proc 86769 * Qty 1 = $50.56 at 100% = $50.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,UNITY HEALTH PLAN,UNITY HOSPICE,42.13,,,,,,,42.1300,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.24,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,72.54,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $72.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.24,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.24,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,306,RC,30682014,CDM,,,,both,,,117.0000,77.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.20,,,,,,,42.1300,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $117.00 in Billed Charges for Rev 306 Proc 86769 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,AETNA,AETNA HSHS,147.29,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $147.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,AETNA,AETNA MEDICARE,35.09,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,AETNA,ALL COMMERCIAL AETNA,228.00,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,ANTHEM,ANTEHM MEDICAID,36.26,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87661 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,35.09,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,ANTHEM,ANTHEM POS/HMO,122.82,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87661 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,ANTHEM,ANTHEM PPO,122.82,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $122.82 from Fee Schedule WII28_25 for Rev 306 Proc 87661 Mod TC * Qty 1 = $122.82 at 100% = $122.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,228.00,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,CENPATICO,ALL MEDICAID CENPATICO,228.00,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,193.80,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,CIGNA,ALL COMMERCIAL CIGNA,159.60,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $159.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,COFINITY,COFINITY,228.00,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,36.26,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87661 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,36.26,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87661 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,216.60,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $216.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,191.52,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $191.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,161.88,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $161.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,166.44,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $166.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,110.81,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $110.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,193.80,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HUMANA,HUMANA CHOICE CARE HMO,59.65,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87661 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HUMANA,HUMANA CHOICE CARE PPO,193.80,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HUMANA,HUMANA MEDICARE ADVANTAGE,35.09,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,HUMANA,HUMANA NATIIONAL POS HMO,59.65,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.65 from Fee Schedule 005543_170 for Rev 306 Proc 87661 * Qty 1 = $59.65 at 100% = $59.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,166.44,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $166.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,228.00,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,36.26,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87661 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.09,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,36.26,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87661 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,MOLINA HEALTHCARE,MOLINA MEDICAID,38.44,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87661 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 100% = $36.26... $36.26 at 106% = $38.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,MOLINA HEALTHCARE,MOLINA MEDICARE,35.09,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,114.00,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,191.52,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $191.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,NAPHCARE,ALL COMMERICAL NAPHCARE,78.95,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,171.00,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $171.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,209.76,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $209.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,45.62,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,45.62,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,PREVEA HEALTH NETWORK,PREVEA360,45.62,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,45.62,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,145.53,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $145.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,35.44,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,164.16,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $164.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,TRIOLOGY,TRILOGY MEDICAID,38.44,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00397 Proc 87661 at $36.26 (Fee Schedule) = $36.26 (Total Line Payment) at 106% = $38.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.11,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87661 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,42.11,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87661 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,35.09,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,42.11,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.11 from Fee Schedule UHC_98227C for Rev 306 Proc 87661 * Qty 1 = $42.11 at 100% = $42.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,UNITY HEALTH PLAN,UNITY HOSPICE,35.09,,,,,,,35.0900,228.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,164.16,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $164.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,141.36,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $141.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,164.16,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $164.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,164.16,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $164.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,306,RC,30682027,CDM,,,,both,,,228.0000,150.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,136.80,,,,,,,35.0900,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $228.00 in Billed Charges for Rev 306 Proc 87661 = $136.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,AETNA,AETNA HSHS,16.80,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $16.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,AETNA,AETNA MEDICARE,2.25,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,AETNA,ALL COMMERCIAL AETNA,26.00,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,ANTHEM,ANTEHM MEDICAID,2.32,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.25,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,ANTHEM,ANTHEM POS/HMO,7.88,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,ANTHEM,ANTHEM PPO,7.88,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.88 from Fee Schedule WII28_25 for Rev 307 Proc 81003 Mod TC (QW) * Qty 1 = $7.88 at 100% = $7.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,26.00,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,CENPATICO,ALL MEDICAID CENPATICO,26.00,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,22.10,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $22.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,CIGNA,ALL COMMERCIAL CIGNA,18.20,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,COFINITY,COFINITY,26.00,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2.32,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2.32,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,24.70,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $24.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,21.84,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $21.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,18.46,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.98,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,12.64,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $12.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,22.10,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $22.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HUMANA,HUMANA CHOICE CARE HMO,3.83,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HUMANA,HUMANA CHOICE CARE PPO,22.10,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $22.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,2.25,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,HUMANA,HUMANA NATIIONAL POS HMO,3.83,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.83 from Fee Schedule 005543_170 for Rev 307 Proc 81003 Mod QW * Qty 1 = $3.83 at 100% = $3.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.98,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,26.00,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2.32,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.25,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2.32,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,MOLINA HEALTHCARE,MOLINA MEDICAID,2.46,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 100% = $2.32... $2.32 at 106% = $2.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,2.25,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.00,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $13.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,21.84,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $21.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,5.06,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,19.50,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $19.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,23.92,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $23.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.93,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.93,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,PREVEA HEALTH NETWORK,PREVEA360,2.93,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.93,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,16.60,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $16.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.27,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,18.72,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,TRIOLOGY,TRILOGY MEDICAID,2.46,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81003 at $2.32 (Fee Schedule) = $2.32 (Total Line Payment) at 106% = $2.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.70,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,2.70,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.25,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,2.70,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.70 from Fee Schedule UHC_98227C for Rev 307 Proc 81003 Mod QW * Qty 1 = $2.70 at 100% = $2.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,UNITY HEALTH PLAN,UNITY HOSPICE,2.25,,,,,,,2.2500,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,18.72,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.12,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $16.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,18.72,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,18.72,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,30700107,CDM,,,QW,both,,,26.0000,17.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.60,,,,,,,2.2500,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.00 in Billed Charges for Rev 307 Proc 81003 Mod QW = $15.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,AETNA,AETNA HSHS,63.31,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $63.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,AETNA,AETNA MEDICARE,2.17,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,AETNA,ALL COMMERCIAL AETNA,98.00,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,ANTHEM,ANTEHM MEDICAID,2.24,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.17,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,ANTHEM,ANTHEM POS/HMO,7.60,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.60 from Fee Schedule WII28_25 for Rev 307 Proc 81005 Mod TC * Qty 1 = $7.60 at 100% = $7.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,ANTHEM,ANTHEM PPO,7.60,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.60 from Fee Schedule WII28_25 for Rev 307 Proc 81005 Mod TC * Qty 1 = $7.60 at 100% = $7.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,98.00,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,CENPATICO,ALL MEDICAID CENPATICO,98.00,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,83.30,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $83.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,CIGNA,ALL COMMERCIAL CIGNA,68.60,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $68.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,COFINITY,COFINITY,98.00,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2.24,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2.24,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,93.10,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $93.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,82.32,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $82.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,69.58,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $69.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,71.54,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $71.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,47.63,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $47.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,83.30,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $83.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HUMANA,HUMANA CHOICE CARE HMO,3.69,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.69 from Fee Schedule 005543_170 for Rev 307 Proc 81005 * Qty 1 = $3.69 at 100% = $3.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HUMANA,HUMANA CHOICE CARE PPO,83.30,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $83.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,2.17,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,HUMANA,HUMANA NATIIONAL POS HMO,3.69,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.69 from Fee Schedule 005543_170 for Rev 307 Proc 81005 * Qty 1 = $3.69 at 100% = $3.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,71.54,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $71.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,98.00,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2.24,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.17,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2.24,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,2.37,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 100% = $2.24... $2.24 at 106% = $2.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,2.17,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,49.00,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,82.32,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $82.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,4.88,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,73.50,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $73.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,90.16,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $90.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.82,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.82,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,PREVEA HEALTH NETWORK,PREVEA360,2.82,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.82,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,62.55,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $62.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.19,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,70.56,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $70.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,TRIOLOGY,TRILOGY MEDICAID,2.37,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81005 at $2.24 (Fee Schedule) = $2.24 (Total Line Payment) at 106% = $2.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.60,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.60 from Fee Schedule UHC_98227C for Rev 307 Proc 81005 * Qty 1 = $2.60 at 100% = $2.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,2.60,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.60 from Fee Schedule UHC_98227C for Rev 307 Proc 81005 * Qty 1 = $2.60 at 100% = $2.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.17,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,2.60,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.60 from Fee Schedule UHC_98227C for Rev 307 Proc 81005 * Qty 1 = $2.60 at 100% = $2.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,UNITY HEALTH PLAN,UNITY HOSPICE,2.17,,,,,,,2.1700,98.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,70.56,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $70.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,60.76,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $60.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,70.56,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $70.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,70.56,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $70.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC QUALITATIVE SUGARS SCREEN,81005,CPT,307,RC,30700114,CDM,,,,both,,,98.0000,64.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,58.80,,,,,,,2.1700,98.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $98.00 in Billed Charges for Rev 307 Proc 81005 = $58.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,AETNA,AETNA HSHS,21.32,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $21.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,AETNA,AETNA MEDICARE,3.05,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,AETNA,ALL COMMERCIAL AETNA,33.00,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,ANTHEM,ANTEHM MEDICAID,3.15,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81015 at $3.15 (Fee Schedule) = $3.15 (Total Line Payment) at 100% = $3.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.05,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,ANTHEM,ANTHEM POS/HMO,10.68,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.68 from Fee Schedule WII28_25 for Rev 307 Proc 81015 Mod TC * Qty 1 = $10.68 at 100% = $10.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,ANTHEM,ANTHEM PPO,10.68,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $10.68 from Fee Schedule WII28_25 for Rev 307 Proc 81015 Mod TC * Qty 1 = $10.68 at 100% = $10.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,33.00,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,CENPATICO,ALL MEDICAID CENPATICO,33.00,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,28.05,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,CIGNA,ALL COMMERCIAL CIGNA,23.10,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $23.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,COFINITY,COFINITY,33.00,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,3.15,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81015 at $3.15 (Fee Schedule) = $3.15 (Total Line Payment) at 100% = $3.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,3.15,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81015 at $3.15 (Fee Schedule) = $3.15 (Total Line Payment) at 100% = $3.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,31.35,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $31.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,27.72,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $27.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,23.43,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $23.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,24.09,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $24.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,16.04,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $16.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,28.05,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HUMANA,HUMANA CHOICE CARE HMO,5.19,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.19 from Fee Schedule 005543_170 for Rev 307 Proc 81015 * Qty 1 = $5.19 at 100% = $5.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HUMANA,HUMANA CHOICE CARE PPO,28.05,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,3.05,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,HUMANA,HUMANA NATIIONAL POS HMO,5.19,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.19 from Fee Schedule 005543_170 for Rev 307 Proc 81015 * Qty 1 = $5.19 at 100% = $5.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,24.09,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $24.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,33.00,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,3.15,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81015 at $3.15 (Fee Schedule) = $3.15 (Total Line Payment) at 100% = $3.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.05,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,3.15,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81015 at $3.15 (Fee Schedule) = $3.15 (Total Line Payment) at 100% = $3.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,3.34,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81015 at $3.15 (Fee Schedule) = $3.15 (Total Line Payment) at 100% = $3.15... $3.15 at 106% = $3.34 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,3.05,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.50,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $16.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,27.72,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $27.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,6.86,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,24.75,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,30.36,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $30.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.97,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.97,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,PREVEA HEALTH NETWORK,PREVEA360,3.97,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.97,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,21.06,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $21.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.08,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,23.76,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,TRIOLOGY,TRILOGY MEDICAID,3.34,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00410 Proc 81015 at $3.15 (Fee Schedule) = $3.15 (Total Line Payment) at 106% = $3.34. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.66,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.66 from Fee Schedule UHC_98227C for Rev 307 Proc 81015 * Qty 1 = $3.66 at 100% = $3.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,3.66,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.66 from Fee Schedule UHC_98227C for Rev 307 Proc 81015 * Qty 1 = $3.66 at 100% = $3.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.05,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,3.66,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.66 from Fee Schedule UHC_98227C for Rev 307 Proc 81015 * Qty 1 = $3.66 at 100% = $3.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,UNITY HEALTH PLAN,UNITY HOSPICE,3.05,,,,,,,3.0500,33.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,23.76,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,20.46,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $20.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,23.76,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,23.76,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MICROSCOPIC EXAM OF URINE,81015,CPT,307,RC,30700115,CDM,,,,both,,,33.0000,21.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,19.80,,,,,,,3.0500,33.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.00 in Billed Charges for Rev 307 Proc 81015 = $19.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,AETNA,AETNA HSHS,468.35,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $468.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,AETNA,AETNA MEDICARE,207.31,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,AETNA,ALL COMMERCIAL AETNA,725.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $725.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,ANTHEM,ANTEHM MEDICAID,165.85,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81168 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,207.31,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,ANTHEM,ANTHEM POS/HMO,725.00,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $725.59 from Fee Schedule WII28_25 for Rev 309 Proc 81168 Mod TC * Qty 1 = $725.59 at 100% = $725.59 (Limited to $725.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,ANTHEM,ANTHEM PPO,725.00,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $725.59 from Fee Schedule WII28_25 for Rev 309 Proc 81168 Mod TC * Qty 1 = $725.59 at 100% = $725.59 (Limited to $725.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,725.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $725.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,CENPATICO,ALL MEDICAID CENPATICO,725.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $725.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,616.25,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $616.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,CIGNA,ALL COMMERCIAL CIGNA,507.50,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $507.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,COFINITY,COFINITY,725.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $725.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,165.85,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81168 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,165.85,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81168 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,688.75,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $688.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,609.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $609.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,514.75,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $514.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,529.25,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $529.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,352.35,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $352.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,616.25,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $616.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HUMANA,HUMANA CHOICE CARE HMO,352.43,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $352.43 from Fee Schedule 005543_170 for Rev 309 Proc 81168 * Qty 1 = $352.43 at 100% = $352.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HUMANA,HUMANA CHOICE CARE PPO,616.25,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $616.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,207.31,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,HUMANA,HUMANA NATIIONAL POS HMO,352.43,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $352.43 from Fee Schedule 005543_170 for Rev 309 Proc 81168 * Qty 1 = $352.43 at 100% = $352.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,529.25,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $529.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,725.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $725.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,165.85,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81168 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,207.31,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,165.85,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81168 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,175.80,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81168 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85... $165.85 at 106% = $175.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,207.31,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,362.50,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $362.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,609.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $609.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,466.45,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,543.75,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $543.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,667.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $667.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,269.50,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,269.50,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,PREVEA HEALTH NETWORK,PREVEA360,269.50,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,269.50,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,462.77,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $462.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,209.38,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,522.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $522.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,TRIOLOGY,TRILOGY MEDICAID,175.80,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81168 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 106% = $175.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,248.77,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 309 Proc 81168 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,248.77,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 309 Proc 81168 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,207.31,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,248.77,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 309 Proc 81168 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,UNITY HEALTH PLAN,UNITY HOSPICE,207.31,,,,,,,165.8500,725.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,522.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $522.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,449.50,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $449.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,522.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $522.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,522.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $522.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CCND1/IGH TRANSLOCATION ANALYSIS,81168,CPT,309,RC,30900200,CDM,,,,both,,,725.0000,478.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,435.00,,,,,,,165.8500,725.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $725.00 in Billed Charges for Rev 309 Proc 81168 = $435.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,AETNA,AETNA HSHS,278.43,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $278.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,AETNA,AETNA MEDICARE,207.31,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,AETNA,ALL COMMERCIAL AETNA,431.00,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,ANTHEM,ANTEHM MEDICAID,165.85,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81278 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,207.31,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,ANTHEM,ANTHEM POS/HMO,431.00,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $725.59 from Fee Schedule WII28_25 for Rev 309 Proc 81278 Mod TC * Qty 1 = $725.59 at 100% = $725.59 (Limited to $431.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,ANTHEM,ANTHEM PPO,431.00,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $725.59 from Fee Schedule WII28_25 for Rev 309 Proc 81278 Mod TC * Qty 1 = $725.59 at 100% = $725.59 (Limited to $431.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,431.00,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,CENPATICO,ALL MEDICAID CENPATICO,431.00,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,366.35,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $366.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,CIGNA,ALL COMMERCIAL CIGNA,301.70,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $301.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,COFINITY,COFINITY,431.00,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,165.85,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81278 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,165.85,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81278 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,409.45,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $409.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,362.04,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $362.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,306.01,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $306.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,314.63,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $314.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,209.47,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $209.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,366.35,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $366.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HUMANA,HUMANA CHOICE CARE HMO,352.43,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $352.43 from Fee Schedule 005543_170 for Rev 309 Proc 81278 * Qty 1 = $352.43 at 100% = $352.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HUMANA,HUMANA CHOICE CARE PPO,366.35,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $366.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,207.31,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,HUMANA,HUMANA NATIIONAL POS HMO,352.43,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $352.43 from Fee Schedule 005543_170 for Rev 309 Proc 81278 * Qty 1 = $352.43 at 100% = $352.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,314.63,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $314.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,431.00,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,165.85,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81278 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,207.31,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,165.85,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81278 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,175.80,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81278 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 100% = $165.85... $165.85 at 106% = $175.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,207.31,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,215.50,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $215.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,362.04,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $362.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,466.45,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,323.25,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $323.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,396.52,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $396.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,269.50,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,269.50,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,PREVEA HEALTH NETWORK,PREVEA360,269.50,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,269.50,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,275.11,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $275.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,209.38,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,310.32,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $310.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,TRIOLOGY,TRILOGY MEDICAID,175.80,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81278 at $165.85 (Fee Schedule) = $165.85 (Total Line Payment) at 106% = $175.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,248.77,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 309 Proc 81278 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,248.77,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 309 Proc 81278 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,207.31,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,248.77,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $248.77 from Fee Schedule UHC_98227C for Rev 309 Proc 81278 * Qty 1 = $248.77 at 100% = $248.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,UNITY HEALTH PLAN,UNITY HOSPICE,207.31,,,,,,,165.8500,466.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,310.32,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $310.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,267.22,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $267.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,310.32,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $310.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,310.32,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $310.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH@/BCL2 TRANSLOCATION ALYS,81278,CPT,309,RC,30900201,CDM,,,,both,,,431.0000,284.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,258.60,,,,,,,165.8500,466.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $431.00 in Billed Charges for Rev 309 Proc 81278 = $258.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,AETNA,AETNA HSHS,4795.26,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $4,795.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,AETNA,AETNA MEDICARE,2919.60,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,AETNA,ALL COMMERCIAL AETNA,7423.00,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $7,423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,ANTHEM,ANTEHM MEDICAID,866.06,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81456 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2919.60,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,ANTHEM,ANTHEM POS/HMO,7423.00,,,,,,,866.0600,7423.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,218.60 from Fee Schedule WII28_25 for Rev 309 Proc 81456 Mod TC * Qty 1 = $10,218.60 at 100% = $10,218.60 (Limited to $7,423.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,ANTHEM,ANTHEM PPO,7423.00,,,,,,,866.0600,7423.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,218.60 from Fee Schedule WII28_25 for Rev 309 Proc 81456 Mod TC * Qty 1 = $10,218.60 at 100% = $10,218.60 (Limited to $7,423.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7423.00,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $7,423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,CENPATICO,ALL MEDICAID CENPATICO,7423.00,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $7,423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6309.55,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $6,309.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,CIGNA,ALL COMMERCIAL CIGNA,5196.10,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,196.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,COFINITY,COFINITY,7423.00,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $7,423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,866.06,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81456 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,866.06,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81456 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7051.85,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $7,051.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,6235.32,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $6,235.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5270.33,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,270.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5418.79,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,418.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,3607.58,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $3,607.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6309.55,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $6,309.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HUMANA,HUMANA CHOICE CARE HMO,4963.32,,,,,,,866.0600,7423.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,963.32 from Fee Schedule 005543_170 for Rev 309 Proc 81456 * Qty 1 = $4,963.32 at 100% = $4,963.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HUMANA,HUMANA CHOICE CARE PPO,6309.55,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $6,309.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,2919.60,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,HUMANA,HUMANA NATIIONAL POS HMO,4963.32,,,,,,,866.0600,7423.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,963.32 from Fee Schedule 005543_170 for Rev 309 Proc 81456 * Qty 1 = $4,963.32 at 100% = $4,963.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5418.79,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,418.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,7423.00,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $7,423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,866.06,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81456 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2919.60,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,866.06,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81456 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,918.02,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81456 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06... $866.06 at 106% = $918.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,2919.60,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3711.50,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $3,711.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6235.32,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $6,235.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,6569.10,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5567.25,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,567.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6829.16,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $6,829.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3795.48,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3795.48,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,PREVEA HEALTH NETWORK,PREVEA360,3795.48,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3795.48,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4738.10,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $4,738.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2948.80,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5344.56,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,344.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,TRIOLOGY,TRILOGY MEDICAID,918.03,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81456 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 106% = $918.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3503.52,,,,,,,866.0600,7423.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,503.52 from Fee Schedule UHC_98227C for Rev 309 Proc 81456 * Qty 1 = $3,503.52 at 100% = $3,503.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,3503.52,,,,,,,866.0600,7423.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,503.52 from Fee Schedule UHC_98227C for Rev 309 Proc 81456 * Qty 1 = $3,503.52 at 100% = $3,503.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2919.60,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,3503.52,,,,,,,866.0600,7423.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,503.52 from Fee Schedule UHC_98227C for Rev 309 Proc 81456 * Qty 1 = $3,503.52 at 100% = $3,503.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,UNITY HEALTH PLAN,UNITY HOSPICE,2919.60,,,,,,,866.0600,7423.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5344.56,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,344.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4602.26,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $4,602.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5344.56,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,344.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5344.56,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $5,344.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS,81456,CPT,309,RC,30900202,CDM,,,,both,,,7423.0000,4899.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4453.80,,,,,,,866.0600,7423.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,423.00 in Billed Charges for Rev 309 Proc 81456 = $4,453.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,AETNA,AETNA HSHS,33.59,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $52.00 in Billed Charges for Rev 310 = $33.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,AETNA,ALL COMMERCIAL AETNA,52.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 310 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,ANTHEM,ANTHEM POS/HMO,35.36,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $52.00 in Billed Charges at 68% = $35.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,ANTHEM,ANTHEM PPO,35.36,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $52.00 in Billed Charges at 68% = $35.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,52.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 310 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,CENPATICO,ALL MEDICAID CENPATICO,52.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 310 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,44.20,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.00 in Billed Charges for Rev 310 = $44.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,CIGNA,ALL COMMERCIAL CIGNA,36.40,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $52.00 in Billed Charges for Rev 310 = $36.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,COFINITY,COFINITY,52.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 310 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,49.40,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $52.00 in Billed Charges for Rev 310 = $49.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,43.68,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.00 in Billed Charges for Rev 310 = $43.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,36.92,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $52.00 in Billed Charges for Rev 310 = $36.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,37.96,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.00 in Billed Charges for Rev 310 = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,25.27,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $52.00 in Billed Charges for Rev 310 = $25.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,44.20,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.00 in Billed Charges for Rev 310 = $44.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,HUMANA,HUMANA CHOICE CARE PPO,44.20,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.00 in Billed Charges for Rev 310 = $44.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,37.96,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.00 in Billed Charges for Rev 310 = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,52.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.00 in Billed Charges for Rev 310 = $52.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $52.00 in Billed Charges for Rev 310 = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,43.68,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.00 in Billed Charges for Rev 310 = $43.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,39.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $52.00 in Billed Charges for Rev 310 = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,47.84,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $52.00 in Billed Charges for Rev 310 = $47.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,31.20,,,,,,,25.2700,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,31.20,,,,,,,25.2700,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,PREVEA HEALTH NETWORK,PREVEA360,31.20,,,,,,,25.2700,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,31.20,,,,,,,25.2700,52.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,33.19,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $52.00 in Billed Charges for Rev 310 = $33.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,37.44,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.00 in Billed Charges for Rev 310 = $37.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,26.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $52.00 in Billed Charges at 50% = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,26.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $52.00 in Billed Charges at 50% = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,26.00,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 310 $52.00 in Billed Charges at 50% = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,37.44,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.00 in Billed Charges for Rev 310 = $37.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.24,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $52.00 in Billed Charges for Rev 310 = $32.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,37.44,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.00 in Billed Charges for Rev 310 = $37.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,37.44,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.00 in Billed Charges for Rev 310 = $37.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AUTOPSY PER BLOCK-IN HOUSE,310,RC,31000002,CDM,,,,,,both,,,52.0000,34.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.20,,,,,,,25.2700,52.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.00 in Billed Charges for Rev 310 = $31.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,AETNA,AETNA HSHS,737.09,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $737.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,AETNA,AETNA MEDICARE,163.96,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,AETNA,ALL COMMERCIAL AETNA,1141.00,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $1,141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,ANTHEM,ANTEHM MEDICAID,169.42,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,163.96,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,ANTHEM,ANTHEM POS/HMO,573.86,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $573.86 from Fee Schedule WII28_25 for Rev 310 Proc 81206 Mod TC * Qty 1 = $573.86 at 100% = $573.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,ANTHEM,ANTHEM PPO,573.86,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $573.86 from Fee Schedule WII28_25 for Rev 310 Proc 81206 Mod TC * Qty 1 = $573.86 at 100% = $573.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1141.00,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $1,141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,CENPATICO,ALL MEDICAID CENPATICO,1141.00,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $1,141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,969.85,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $969.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,CIGNA,ALL COMMERCIAL CIGNA,798.70,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $798.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,COFINITY,COFINITY,1141.00,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $1,141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,169.42,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,169.42,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1083.95,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $1,083.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,958.44,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $958.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,810.11,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $810.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,832.93,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $832.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,554.53,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $554.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,969.85,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $969.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HUMANA,HUMANA CHOICE CARE HMO,278.73,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $278.73 from Fee Schedule 005543_170 for Rev 310 Proc 81206 * Qty 1 = $278.73 at 100% = $278.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HUMANA,HUMANA CHOICE CARE PPO,969.85,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $969.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HUMANA,HUMANA MEDICARE ADVANTAGE,163.96,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,HUMANA,HUMANA NATIIONAL POS HMO,278.73,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $278.73 from Fee Schedule 005543_170 for Rev 310 Proc 81206 * Qty 1 = $278.73 at 100% = $278.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,832.93,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $832.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1141.00,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $1,141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,169.42,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,163.96,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,169.42,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,MOLINA HEALTHCARE,MOLINA MEDICAID,179.59,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 100% = $169.42... $169.42 at 106% = $179.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,MOLINA HEALTHCARE,MOLINA MEDICARE,163.96,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,570.50,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $570.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,958.44,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $958.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,NAPHCARE,ALL COMMERICAL NAPHCARE,368.91,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,855.75,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $855.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1049.72,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $1,049.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,213.15,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,213.15,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,PREVEA HEALTH NETWORK,PREVEA360,213.15,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,213.15,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,728.30,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $728.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,165.60,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,821.52,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,TRIOLOGY,TRILOGY MEDICAID,179.59,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81206 at $169.42 (Fee Schedule) = $169.42 (Total Line Payment) at 106% = $179.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,196.75,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81206 * Qty 1 = $196.75 at 100% = $196.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,196.75,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81206 * Qty 1 = $196.75 at 100% = $196.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,163.96,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,196.75,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $196.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81206 * Qty 1 = $196.75 at 100% = $196.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,UNITY HEALTH PLAN,UNITY HOSPICE,163.96,,,,,,,163.9600,1141.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,821.52,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,707.42,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $707.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,821.52,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,821.52,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $821.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MAJOR BP,81206,CPT,310,RC,31000010,CDM,,,,both,,,1141.0000,753.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,684.60,,,,,,,163.9600,1141.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,141.00 in Billed Charges for Rev 310 Proc 81206 = $684.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,AETNA,AETNA HSHS,891.48,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $891.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,AETNA,AETNA MEDICARE,144.84,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,AETNA,ALL COMMERCIAL AETNA,1380.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,ANTHEM,ANTEHM MEDICAID,149.66,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,144.84,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,ANTHEM,ANTHEM POS/HMO,506.94,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $506.94 from Fee Schedule WII28_25 for Rev 310 Proc 81207 Mod TC * Qty 1 = $506.94 at 100% = $506.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,ANTHEM,ANTHEM PPO,506.94,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $506.94 from Fee Schedule WII28_25 for Rev 310 Proc 81207 Mod TC * Qty 1 = $506.94 at 100% = $506.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1380.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,CENPATICO,ALL MEDICAID CENPATICO,1380.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1173.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,CIGNA,ALL COMMERCIAL CIGNA,966.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $966.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,COFINITY,COFINITY,1380.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,149.66,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,149.66,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1311.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,311.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,1159.20,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,159.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,979.80,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $979.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1007.40,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,007.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,670.68,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $670.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1173.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HUMANA,HUMANA CHOICE CARE HMO,246.23,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $246.23 from Fee Schedule 005543_170 for Rev 310 Proc 81207 * Qty 1 = $246.23 at 100% = $246.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HUMANA,HUMANA CHOICE CARE PPO,1173.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,144.84,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,HUMANA,HUMANA NATIIONAL POS HMO,246.23,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $246.23 from Fee Schedule 005543_170 for Rev 310 Proc 81207 * Qty 1 = $246.23 at 100% = $246.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1007.40,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,007.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1380.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,380.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,149.66,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,144.84,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,149.66,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,158.64,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 100% = $149.66... $149.66 at 106% = $158.64 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,144.84,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,690.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1159.20,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,159.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,325.89,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1035.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1269.60,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $1,269.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,188.29,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,188.29,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,PREVEA HEALTH NETWORK,PREVEA360,188.29,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,188.29,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,880.85,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $880.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,146.29,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,993.60,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $993.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,TRIOLOGY,TRILOGY MEDICAID,158.64,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81207 at $149.66 (Fee Schedule) = $149.66 (Total Line Payment) at 106% = $158.64. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,173.81,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.81 from Fee Schedule UHC_98227C for Rev 310 Proc 81207 * Qty 1 = $173.81 at 100% = $173.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,173.81,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.81 from Fee Schedule UHC_98227C for Rev 310 Proc 81207 * Qty 1 = $173.81 at 100% = $173.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,144.84,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,173.81,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.81 from Fee Schedule UHC_98227C for Rev 310 Proc 81207 * Qty 1 = $173.81 at 100% = $173.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,UNITY HEALTH PLAN,UNITY HOSPICE,144.84,,,,,,,144.8400,1380.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,993.60,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $993.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,855.60,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $855.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,993.60,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $993.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,993.60,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $993.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BCR/ABL1 GENE MINOR BP,81207,CPT,310,RC,31000012,CDM,,,,both,,,1380.0000,910.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,828.00,,,,,,,144.8400,1380.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,380.00 in Billed Charges for Rev 310 Proc 81207 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,AETNA,AETNA HSHS,1551.69,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,551.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,AETNA,AETNA MEDICARE,450.91,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,AETNA,ALL COMMERCIAL AETNA,2402.00,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,ANTHEM,ANTEHM MEDICAID,133.58,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,450.91,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,ANTHEM,ANTHEM POS/HMO,1578.19,,,,,,,133.5800,2402.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,578.19 from Fee Schedule WII28_25 for Rev 310 Proc 81226 Mod TC * Qty 1 = $1,578.19 at 100% = $1,578.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,ANTHEM,ANTHEM PPO,1578.19,,,,,,,133.5800,2402.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,578.19 from Fee Schedule WII28_25 for Rev 310 Proc 81226 Mod TC * Qty 1 = $1,578.19 at 100% = $1,578.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2402.00,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,CENPATICO,ALL MEDICAID CENPATICO,2402.00,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2041.70,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,041.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,CIGNA,ALL COMMERCIAL CIGNA,1681.40,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,681.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,COFINITY,COFINITY,2402.00,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,133.58,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,133.58,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2281.90,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,281.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,2017.68,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,017.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1705.42,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,705.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1753.46,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,753.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,1167.37,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,167.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2041.70,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,041.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HUMANA,HUMANA CHOICE CARE HMO,766.55,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $766.55 from Fee Schedule 005543_170 for Rev 310 Proc 81226 * Qty 1 = $766.55 at 100% = $766.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HUMANA,HUMANA CHOICE CARE PPO,2041.70,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,041.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,450.91,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,HUMANA,HUMANA NATIIONAL POS HMO,766.55,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $766.55 from Fee Schedule 005543_170 for Rev 310 Proc 81226 * Qty 1 = $766.55 at 100% = $766.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1753.46,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,753.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2402.00,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,402.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,133.58,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,450.91,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,133.58,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,141.59,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58... $133.58 at 106% = $141.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,450.91,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1201.00,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,201.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2017.68,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,017.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,1014.55,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1801.50,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,801.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2209.84,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $2,209.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,586.18,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,586.18,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,PREVEA HEALTH NETWORK,PREVEA360,586.18,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,586.18,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1533.20,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,533.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,455.42,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1729.44,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,729.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,TRIOLOGY,TRILOGY MEDICAID,141.59,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 106% = $141.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,541.09,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $541.09 from Fee Schedule UHC_98227C for Rev 310 Proc 81226 * Qty 1 = $541.09 at 100% = $541.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,541.09,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $541.09 from Fee Schedule UHC_98227C for Rev 310 Proc 81226 * Qty 1 = $541.09 at 100% = $541.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,450.91,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,541.09,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $541.09 from Fee Schedule UHC_98227C for Rev 310 Proc 81226 * Qty 1 = $541.09 at 100% = $541.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,UNITY HEALTH PLAN,UNITY HOSPICE,450.91,,,,,,,133.5800,2402.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1729.44,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,729.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1489.24,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,489.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1729.44,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,729.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1729.44,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,729.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE COM VARIANTS,81226,CPT,310,RC,31000013,CDM,,,,both,,,2402.0000,1585.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1441.20,,,,,,,133.5800,2402.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,402.00 in Billed Charges for Rev 310 Proc 81226 = $1,441.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,AETNA,AETNA HSHS,1959.32,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $1,959.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,AETNA,AETNA MEDICARE,900.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,AETNA,ALL COMMERCIAL AETNA,3033.00,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $3,033.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,ANTHEM,ANTEHM MEDICAID,516.91,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81228 at $516.91 (Fee Schedule) = $516.91 (Total Line Payment) at 100% = $516.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,900.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,ANTHEM,ANTHEM POS/HMO,3033.00,,,,,,,516.9100,3033.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,150.00 from Fee Schedule WII28_25 for Rev 310 Proc 81228 Mod TC * Qty 1 = $3,150.00 at 100% = $3,150.00 (Limited to $3,033.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,ANTHEM,ANTHEM PPO,3033.00,,,,,,,516.9100,3033.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,150.00 from Fee Schedule WII28_25 for Rev 310 Proc 81228 Mod TC * Qty 1 = $3,150.00 at 100% = $3,150.00 (Limited to $3,033.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3033.00,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $3,033.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,CENPATICO,ALL MEDICAID CENPATICO,3033.00,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $3,033.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2578.05,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,578.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,CIGNA,ALL COMMERCIAL CIGNA,2123.10,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,123.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,COFINITY,COFINITY,3033.00,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $3,033.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,516.91,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81228 at $516.91 (Fee Schedule) = $516.91 (Total Line Payment) at 100% = $516.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,516.91,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81228 at $516.91 (Fee Schedule) = $516.91 (Total Line Payment) at 100% = $516.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2881.35,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,881.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,2547.72,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,547.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2153.43,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,153.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2214.09,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,214.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,1474.04,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $1,474.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2578.05,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,578.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HUMANA,HUMANA CHOICE CARE HMO,1530.00,,,,,,,516.9100,3033.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,530.00 from Fee Schedule 005543_170 for Rev 310 Proc 81228 * Qty 1 = $1,530.00 at 100% = $1,530.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HUMANA,HUMANA CHOICE CARE PPO,2578.05,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,578.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,900.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,HUMANA,HUMANA NATIIONAL POS HMO,1530.00,,,,,,,516.9100,3033.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,530.00 from Fee Schedule 005543_170 for Rev 310 Proc 81228 * Qty 1 = $1,530.00 at 100% = $1,530.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2214.09,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,214.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3033.00,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $3,033.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,516.91,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81228 at $516.91 (Fee Schedule) = $516.91 (Total Line Payment) at 100% = $516.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,900.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,516.91,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81228 at $516.91 (Fee Schedule) = $516.91 (Total Line Payment) at 100% = $516.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,547.92,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81228 at $516.91 (Fee Schedule) = $516.91 (Total Line Payment) at 100% = $516.91... $516.91 at 106% = $547.92 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,900.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1516.50,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $1,516.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2547.72,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,547.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,2025.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2274.75,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,274.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2790.36,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,790.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1170.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1170.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,PREVEA HEALTH NETWORK,PREVEA360,1170.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1170.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1935.96,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $1,935.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,909.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2183.76,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,183.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,TRIOLOGY,TRILOGY MEDICAID,547.92,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81228 at $516.91 (Fee Schedule) = $516.91 (Total Line Payment) at 106% = $547.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1080.00,,,,,,,516.9100,3033.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,080.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81228 * Qty 1 = $1,080.00 at 100% = $1,080.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,1080.00,,,,,,,516.9100,3033.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,080.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81228 * Qty 1 = $1,080.00 at 100% = $1,080.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,900.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,1080.00,,,,,,,516.9100,3033.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,080.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81228 * Qty 1 = $1,080.00 at 100% = $1,080.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,UNITY HEALTH PLAN,UNITY HOSPICE,900.00,,,,,,,516.9100,3033.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2183.76,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,183.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1880.46,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $1,880.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2183.76,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,183.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2183.76,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $2,183.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGEN MICRARRAY COPY NO,81228,CPT,310,RC,31000014,CDM,,,,both,,,3033.0000,2001.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1819.80,,,,,,,516.9100,3033.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,033.00 in Billed Charges for Rev 310 Proc 81228 = $1,819.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA HSHS,232.56,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,AETNA,AETNA MEDICARE,73.37,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,AETNA,ALL COMMERCIAL AETNA,360.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTEHM MEDICAID,66.70,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,73.37,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM POS/HMO,256.80,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $256.80 from Fee Schedule WII28_25 for Rev 310 Proc 81241 Mod TC * Qty 1 = $256.80 at 100% = $256.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,ANTHEM,ANTHEM PPO,256.80,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $256.80 from Fee Schedule WII28_25 for Rev 310 Proc 81241 Mod TC * Qty 1 = $256.80 at 100% = $256.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,CENPATICO,ALL MEDICAID CENPATICO,360.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,CIGNA,ALL COMMERCIAL CIGNA,252.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,COFINITY,COFINITY,360.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,66.70,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,66.70,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $342.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,302.40,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,255.60,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $255.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,262.80,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,174.96,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE HMO,124.73,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $124.73 from Fee Schedule 005543_170 for Rev 310 Proc 81241 * Qty 1 = $124.73 at 100% = $124.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA CHOICE CARE PPO,306.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $306.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,73.37,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,HUMANA,HUMANA NATIIONAL POS HMO,124.73,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $124.73 from Fee Schedule 005543_170 for Rev 310 Proc 81241 * Qty 1 = $124.73 at 100% = $124.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,262.80,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,66.70,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,73.37,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,66.70,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,70.70,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 100% = $66.70... $66.70 at 106% = $70.70 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,73.37,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $180.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,302.40,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,165.08,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,331.20,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $331.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,95.38,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,95.38,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360,95.38,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,95.38,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,229.79,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $229.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,74.10,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.20,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,TRIOLOGY,TRILOGY MEDICAID,70.70,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81241 at $66.70 (Fee Schedule) = $66.70 (Total Line Payment) at 106% = $70.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,88.04,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,88.04,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,73.37,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,88.04,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $88.04 from Fee Schedule UHC_98227C for Rev 310 Proc 81241 * Qty 1 = $88.04 at 100% = $88.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,UNITY HEALTH PLAN,UNITY HOSPICE,73.37,,,,,,,66.7000,360.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.20,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.20,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.20,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.20,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $259.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC F5 GENE ANAL LEIDEN VAR,81241,CPT,310,RC,31000016,CDM,,,,both,,,360.0000,237.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.00,,,,,,,66.7000,360.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.00 in Billed Charges for Rev 310 Proc 81241 = $216.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,AETNA,AETNA HSHS,417.32,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $417.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,AETNA,AETNA MEDICARE,65.36,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,AETNA,ALL COMMERCIAL AETNA,646.00,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $646.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,ANTHEM,ANTEHM MEDICAID,67.54,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,65.36,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,ANTHEM,ANTHEM POS/HMO,228.76,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $228.76 from Fee Schedule WII28_25 for Rev 310 Proc 81256 Mod TC * Qty 1 = $228.76 at 100% = $228.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,ANTHEM,ANTHEM PPO,228.76,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $228.76 from Fee Schedule WII28_25 for Rev 310 Proc 81256 Mod TC * Qty 1 = $228.76 at 100% = $228.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,646.00,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $646.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,CENPATICO,ALL MEDICAID CENPATICO,646.00,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $646.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,549.10,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $549.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,CIGNA,ALL COMMERCIAL CIGNA,452.20,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,COFINITY,COFINITY,646.00,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $646.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,67.54,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,67.54,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,613.70,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $613.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,542.64,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $542.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,458.66,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $458.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,471.58,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $471.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,313.96,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $313.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,549.10,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $549.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HUMANA,HUMANA CHOICE CARE HMO,111.11,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.11 from Fee Schedule 005543_170 for Rev 310 Proc 81256 * Qty 1 = $111.11 at 100% = $111.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HUMANA,HUMANA CHOICE CARE PPO,549.10,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $549.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,65.36,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,HUMANA,HUMANA NATIIONAL POS HMO,111.11,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.11 from Fee Schedule 005543_170 for Rev 310 Proc 81256 * Qty 1 = $111.11 at 100% = $111.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,471.58,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $471.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,646.00,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $646.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,67.54,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,65.36,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,67.54,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,71.59,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54... $67.54 at 106% = $71.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,65.36,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,323.00,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $323.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,542.64,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $542.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,147.06,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,484.50,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $484.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,594.32,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $594.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,84.97,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,84.97,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,PREVEA HEALTH NETWORK,PREVEA360,84.97,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,84.97,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,412.34,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $412.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,66.01,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,465.12,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $465.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,TRIOLOGY,TRILOGY MEDICAID,71.59,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 106% = $71.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,78.43,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.43 from Fee Schedule UHC_98227C for Rev 310 Proc 81256 * Qty 1 = $78.43 at 100% = $78.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,78.43,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.43 from Fee Schedule UHC_98227C for Rev 310 Proc 81256 * Qty 1 = $78.43 at 100% = $78.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,65.36,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,78.43,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.43 from Fee Schedule UHC_98227C for Rev 310 Proc 81256 * Qty 1 = $78.43 at 100% = $78.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,UNITY HEALTH PLAN,UNITY HOSPICE,65.36,,,,,,,65.3600,646.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,465.12,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $465.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,400.52,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $400.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,465.12,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $465.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,465.12,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $465.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE,81256,CPT,310,RC,31000018,CDM,,,,both,,,646.0000,426.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,387.60,,,,,,,65.3600,646.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $646.00 in Billed Charges for Rev 310 Proc 81256 = $387.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,AETNA,AETNA HSHS,1570.43,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,570.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,AETNA,AETNA MEDICARE,197.99,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,AETNA,ALL COMMERCIAL AETNA,2431.00,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,ANTHEM,ANTEHM MEDICAID,204.58,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,197.99,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,ANTHEM,ANTHEM POS/HMO,692.97,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $692.97 from Fee Schedule WII28_25 for Rev 310 Proc 81261 Mod TC * Qty 1 = $692.97 at 100% = $692.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,ANTHEM,ANTHEM PPO,692.97,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $692.97 from Fee Schedule WII28_25 for Rev 310 Proc 81261 Mod TC * Qty 1 = $692.97 at 100% = $692.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2431.00,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,CENPATICO,ALL MEDICAID CENPATICO,2431.00,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2066.35,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,066.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,CIGNA,ALL COMMERCIAL CIGNA,1701.70,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,701.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,COFINITY,COFINITY,2431.00,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,204.58,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,204.58,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2309.45,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,309.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,2042.04,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,042.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1726.01,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,726.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1774.63,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,774.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,1181.47,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,181.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2066.35,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,066.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,HUMANA CHOICE CARE HMO,336.58,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $336.58 from Fee Schedule 005543_170 for Rev 310 Proc 81261 * Qty 1 = $336.58 at 100% = $336.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,HUMANA CHOICE CARE PPO,2066.35,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,066.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,197.99,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,HUMANA NATIIONAL POS HMO,336.58,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $336.58 from Fee Schedule 005543_170 for Rev 310 Proc 81261 * Qty 1 = $336.58 at 100% = $336.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1774.63,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,774.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2431.00,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,204.58,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,197.99,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,204.58,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,216.85,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58... $204.58 at 106% = $216.85 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,197.99,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1215.50,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,215.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2042.04,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,042.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,445.48,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1823.25,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,823.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2236.52,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $2,236.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,257.39,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,257.39,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,PREVEA HEALTH NETWORK,PREVEA360,257.39,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,257.39,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1551.71,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,551.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,199.97,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1750.32,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,750.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,TRIOLOGY,TRILOGY MEDICAID,216.85,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 106% = $216.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,237.59,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,237.59,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,197.99,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,237.59,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,UNITY HEALTH PLAN,UNITY HOSPICE,197.99,,,,,,,197.9900,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1750.32,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,750.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1507.22,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,507.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1750.32,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,750.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1750.32,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,750.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH GENE REARRNG AMP METH,81261,CPT,310,RC,31000019,CDM,,,,both,,,2431.0000,1604.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1458.60,,,,,,,197.9900,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,431.00 in Billed Charges for Rev 310 Proc 81261 = $1,458.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,AETNA,AETNA HSHS,1570.43,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,570.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,AETNA,AETNA MEDICARE,172.73,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,AETNA,ALL COMMERCIAL AETNA,2431.00,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,ANTHEM,ANTEHM MEDICAID,162.98,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,172.73,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,ANTHEM,ANTHEM POS/HMO,604.56,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $604.56 from Fee Schedule WII28_25 for Rev 310 Proc 81264 Mod TC * Qty 1 = $604.56 at 100% = $604.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,ANTHEM,ANTHEM PPO,604.56,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $604.56 from Fee Schedule WII28_25 for Rev 310 Proc 81264 Mod TC * Qty 1 = $604.56 at 100% = $604.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2431.00,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,CENPATICO,ALL MEDICAID CENPATICO,2431.00,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2066.35,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,066.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,CIGNA,ALL COMMERCIAL CIGNA,1701.70,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,701.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,COFINITY,COFINITY,2431.00,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,162.98,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,162.98,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2309.45,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,309.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,2042.04,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,042.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1726.01,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,726.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1774.63,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,774.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,1181.47,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,181.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2066.35,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,066.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,HUMANA CHOICE CARE HMO,293.64,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $293.64 from Fee Schedule 005543_170 for Rev 310 Proc 81264 * Qty 1 = $293.64 at 100% = $293.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,HUMANA CHOICE CARE PPO,2066.35,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,066.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,172.73,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,HUMANA,HUMANA NATIIONAL POS HMO,293.64,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $293.64 from Fee Schedule 005543_170 for Rev 310 Proc 81264 * Qty 1 = $293.64 at 100% = $293.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1774.63,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,774.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2431.00,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,162.98,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,172.73,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,162.98,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,172.76,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 100% = $162.98... $162.98 at 106% = $172.76 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,172.73,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1215.50,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,215.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2042.04,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,042.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,388.64,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1823.25,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,823.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2236.52,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $2,236.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,224.55,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,224.55,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,PREVEA HEALTH NETWORK,PREVEA360,224.55,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,224.55,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1551.71,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,551.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,174.46,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1750.32,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,750.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,TRIOLOGY,TRILOGY MEDICAID,172.76,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81264 at $162.98 (Fee Schedule) = $162.98 (Total Line Payment) at 106% = $172.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,207.28,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81264 * Qty 1 = $207.28 at 100% = $207.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,207.28,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81264 * Qty 1 = $207.28 at 100% = $207.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,172.73,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,207.28,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81264 * Qty 1 = $207.28 at 100% = $207.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,UNITY HEALTH PLAN,UNITY HOSPICE,172.73,,,,,,,162.9800,2431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1750.32,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,750.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1507.22,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,507.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1750.32,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,750.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1750.32,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,750.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGK REARRANGE CLONAL POP,81264,CPT,310,RC,31000020,CDM,,,,both,,,2431.0000,1604.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1458.60,,,,,,,162.9800,2431.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,431.00 in Billed Charges for Rev 310 Proc 81264 = $1,458.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,AETNA,AETNA HSHS,911.51,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $911.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,AETNA,AETNA MEDICARE,193.25,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,AETNA,ALL COMMERCIAL AETNA,1411.00,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,ANTHEM,ANTEHM MEDICAID,157.98,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81275 at $157.98 (Fee Schedule) = $157.98 (Total Line Payment) at 100% = $157.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,193.25,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,ANTHEM,ANTHEM POS/HMO,676.38,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $676.38 from Fee Schedule WII28_25 for Rev 310 Proc 81275 Mod TC * Qty 1 = $676.38 at 100% = $676.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,ANTHEM,ANTHEM PPO,676.38,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $676.38 from Fee Schedule WII28_25 for Rev 310 Proc 81275 Mod TC * Qty 1 = $676.38 at 100% = $676.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1411.00,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,CENPATICO,ALL MEDICAID CENPATICO,1411.00,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1199.35,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,199.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,CIGNA,ALL COMMERCIAL CIGNA,987.70,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $987.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,COFINITY,COFINITY,1411.00,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,157.98,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81275 at $157.98 (Fee Schedule) = $157.98 (Total Line Payment) at 100% = $157.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,157.98,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81275 at $157.98 (Fee Schedule) = $157.98 (Total Line Payment) at 100% = $157.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1340.45,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,340.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,1185.24,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,185.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1001.81,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,001.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1030.03,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,030.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,685.75,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $685.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1199.35,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,199.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HUMANA,HUMANA CHOICE CARE HMO,328.53,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $328.53 from Fee Schedule 005543_170 for Rev 310 Proc 81275 * Qty 1 = $328.53 at 100% = $328.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HUMANA,HUMANA CHOICE CARE PPO,1199.35,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,199.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,193.25,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,HUMANA,HUMANA NATIIONAL POS HMO,328.53,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $328.53 from Fee Schedule 005543_170 for Rev 310 Proc 81275 * Qty 1 = $328.53 at 100% = $328.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1030.03,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,030.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1411.00,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,157.98,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81275 at $157.98 (Fee Schedule) = $157.98 (Total Line Payment) at 100% = $157.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,193.25,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,157.98,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81275 at $157.98 (Fee Schedule) = $157.98 (Total Line Payment) at 100% = $157.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,167.46,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81275 at $157.98 (Fee Schedule) = $157.98 (Total Line Payment) at 100% = $157.98... $157.98 at 106% = $167.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,193.25,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,705.50,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $705.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1185.24,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,185.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,434.81,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1058.25,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,058.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1298.12,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,298.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,251.23,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,251.23,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,PREVEA HEALTH NETWORK,PREVEA360,251.23,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,251.23,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,900.64,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $900.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,195.18,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1015.92,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,015.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,TRIOLOGY,TRILOGY MEDICAID,167.46,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81275 at $157.98 (Fee Schedule) = $157.98 (Total Line Payment) at 106% = $167.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,231.90,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $231.90 from Fee Schedule UHC_98227C for Rev 310 Proc 81275 * Qty 1 = $231.90 at 100% = $231.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,231.90,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $231.90 from Fee Schedule UHC_98227C for Rev 310 Proc 81275 * Qty 1 = $231.90 at 100% = $231.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,193.25,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,231.90,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $231.90 from Fee Schedule UHC_98227C for Rev 310 Proc 81275 * Qty 1 = $231.90 at 100% = $231.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,UNITY HEALTH PLAN,UNITY HOSPICE,193.25,,,,,,,157.9800,1411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1015.92,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,015.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,874.82,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $874.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1015.92,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,015.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1015.92,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $1,015.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC KRAS GENE,81275,CPT,310,RC,31000021,CDM,,,,both,,,1411.0000,931.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,846.60,,,,,,,157.9800,1411.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,411.00 in Billed Charges for Rev 310 Proc 81275 = $846.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,AETNA,AETNA HSHS,271.32,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $271.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,AETNA,AETNA MEDICARE,65.34,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,AETNA,ALL COMMERCIAL AETNA,420.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,ANTHEM,ANTEHM MEDICAID,17.32,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81291 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,65.34,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,ANTHEM,ANTHEM POS/HMO,228.69,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $228.69 from Fee Schedule WII28_25 for Rev 310 Proc 81291 Mod TC * Qty 1 = $228.69 at 100% = $228.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,ANTHEM,ANTHEM PPO,228.69,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $228.69 from Fee Schedule WII28_25 for Rev 310 Proc 81291 Mod TC * Qty 1 = $228.69 at 100% = $228.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,420.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,CENPATICO,ALL MEDICAID CENPATICO,420.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,357.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $357.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,CIGNA,ALL COMMERCIAL CIGNA,294.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $294.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,COFINITY,COFINITY,420.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.32,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81291 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.32,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81291 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,399.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $399.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,352.80,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $352.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,298.20,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $298.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,306.60,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $306.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,204.12,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $204.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,357.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $357.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HUMANA,HUMANA CHOICE CARE HMO,111.08,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.08 from Fee Schedule 005543_170 for Rev 310 Proc 81291 * Qty 1 = $111.08 at 100% = $111.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HUMANA,HUMANA CHOICE CARE PPO,357.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $357.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,65.34,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,HUMANA,HUMANA NATIIONAL POS HMO,111.08,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.08 from Fee Schedule 005543_170 for Rev 310 Proc 81291 * Qty 1 = $111.08 at 100% = $111.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,306.60,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $306.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,420.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.32,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81291 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,65.34,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.32,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81291 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,18.36,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81291 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32... $17.32 at 106% = $18.36 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,65.34,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,210.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,352.80,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $352.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,147.02,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,315.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,386.40,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $386.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,84.94,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,84.94,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,PREVEA HEALTH NETWORK,PREVEA360,84.94,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,84.94,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,268.09,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $268.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,65.99,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,302.40,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,TRIOLOGY,TRILOGY MEDICAID,18.36,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81291 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 106% = $18.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,78.41,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.41 from Fee Schedule UHC_98227C for Rev 310 Proc 81291 * Qty 1 = $78.41 at 100% = $78.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,78.41,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.41 from Fee Schedule UHC_98227C for Rev 310 Proc 81291 * Qty 1 = $78.41 at 100% = $78.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,65.34,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,78.41,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $78.41 from Fee Schedule UHC_98227C for Rev 310 Proc 81291 * Qty 1 = $78.41 at 100% = $78.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,UNITY HEALTH PLAN,UNITY HOSPICE,65.34,,,,,,,17.3200,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,302.40,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,260.40,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,302.40,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,302.40,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MTHFR GENE,81291,CPT,310,RC,31000022,CDM,,,,both,,,420.0000,277.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,252.00,,,,,,,17.3200,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $420.00 in Billed Charges for Rev 310 Proc 81291 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,AETNA,AETNA HSHS,320.42,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $320.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,AETNA,AETNA MEDICARE,51.07,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,AETNA,ALL COMMERCIAL AETNA,496.00,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,ANTHEM,ANTEHM MEDICAID,52.77,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81331 at $52.77 (Fee Schedule) = $52.77 (Total Line Payment) at 100% = $52.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,51.07,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,ANTHEM,ANTHEM POS/HMO,178.75,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $178.75 from Fee Schedule WII28_25 for Rev 310 Proc 81331 Mod TC * Qty 1 = $178.75 at 100% = $178.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,ANTHEM,ANTHEM PPO,178.75,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $178.75 from Fee Schedule WII28_25 for Rev 310 Proc 81331 Mod TC * Qty 1 = $178.75 at 100% = $178.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,496.00,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,CENPATICO,ALL MEDICAID CENPATICO,496.00,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,421.60,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $421.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,CIGNA,ALL COMMERCIAL CIGNA,347.20,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $347.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,COFINITY,COFINITY,496.00,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,52.77,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81331 at $52.77 (Fee Schedule) = $52.77 (Total Line Payment) at 100% = $52.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,52.77,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81331 at $52.77 (Fee Schedule) = $52.77 (Total Line Payment) at 100% = $52.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,471.20,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $471.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,416.64,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $416.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,352.16,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $352.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,362.08,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $362.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,241.06,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $241.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,421.60,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $421.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HUMANA,HUMANA CHOICE CARE HMO,86.82,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $86.82 from Fee Schedule 005543_170 for Rev 310 Proc 81331 * Qty 1 = $86.82 at 100% = $86.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HUMANA,HUMANA CHOICE CARE PPO,421.60,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $421.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,51.07,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,HUMANA,HUMANA NATIIONAL POS HMO,86.82,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $86.82 from Fee Schedule 005543_170 for Rev 310 Proc 81331 * Qty 1 = $86.82 at 100% = $86.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,362.08,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $362.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,496.00,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $496.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,52.77,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81331 at $52.77 (Fee Schedule) = $52.77 (Total Line Payment) at 100% = $52.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,51.07,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,52.77,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81331 at $52.77 (Fee Schedule) = $52.77 (Total Line Payment) at 100% = $52.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,55.94,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81331 at $52.77 (Fee Schedule) = $52.77 (Total Line Payment) at 100% = $52.77... $52.77 at 106% = $55.94 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,51.07,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,248.00,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $248.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,416.64,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $416.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,114.91,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,372.00,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,456.32,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $456.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,66.39,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,66.39,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,PREVEA HEALTH NETWORK,PREVEA360,66.39,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,66.39,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,316.60,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $316.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.58,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,357.12,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $357.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,TRIOLOGY,TRILOGY MEDICAID,55.94,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81331 at $52.77 (Fee Schedule) = $52.77 (Total Line Payment) at 106% = $55.94. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,61.28,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81331 * Qty 1 = $61.28 at 100% = $61.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,61.28,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81331 * Qty 1 = $61.28 at 100% = $61.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,51.07,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,61.28,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $61.28 from Fee Schedule UHC_98227C for Rev 310 Proc 81331 * Qty 1 = $61.28 at 100% = $61.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,UNITY HEALTH PLAN,UNITY HOSPICE,51.07,,,,,,,51.0700,496.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,357.12,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $357.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,307.52,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $307.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,357.12,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $357.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,357.12,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $357.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SNRPN/UBE3A GENE,81331,CPT,310,RC,31000027,CDM,,,,both,,,496.0000,327.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,297.60,,,,,,,51.0700,496.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $496.00 in Billed Charges for Rev 310 Proc 81331 = $297.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,AETNA,AETNA HSHS,649.23,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $649.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,AETNA,AETNA MEDICARE,43.65,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,AETNA,ALL COMMERCIAL AETNA,1005.00,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $1,005.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,ANTHEM,ANTEHM MEDICAID,17.32,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81332 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,43.65,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,ANTHEM,ANTHEM POS/HMO,152.78,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $152.78 from Fee Schedule WII28_25 for Rev 310 Proc 81332 Mod TC * Qty 1 = $152.78 at 100% = $152.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,ANTHEM,ANTHEM PPO,152.78,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $152.78 from Fee Schedule WII28_25 for Rev 310 Proc 81332 Mod TC * Qty 1 = $152.78 at 100% = $152.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1005.00,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $1,005.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,CENPATICO,ALL MEDICAID CENPATICO,1005.00,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $1,005.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,854.25,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $854.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,CIGNA,ALL COMMERCIAL CIGNA,703.50,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $703.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,COFINITY,COFINITY,1005.00,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $1,005.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.32,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81332 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.32,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81332 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,954.75,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $954.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,844.20,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $844.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,713.55,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $713.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,733.65,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $733.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,488.43,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $488.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,854.25,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $854.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HUMANA,HUMANA CHOICE CARE HMO,74.21,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $74.21 from Fee Schedule 005543_170 for Rev 310 Proc 81332 * Qty 1 = $74.21 at 100% = $74.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HUMANA,HUMANA CHOICE CARE PPO,854.25,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $854.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,43.65,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,HUMANA,HUMANA NATIIONAL POS HMO,74.21,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $74.21 from Fee Schedule 005543_170 for Rev 310 Proc 81332 * Qty 1 = $74.21 at 100% = $74.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,733.65,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $733.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1005.00,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $1,005.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.32,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81332 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,43.65,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.32,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81332 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,18.36,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81332 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32... $17.32 at 106% = $18.36 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,43.65,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,502.50,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $502.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,844.20,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $844.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,98.21,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,753.75,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $753.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,924.60,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $924.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,56.75,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,56.75,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,PREVEA HEALTH NETWORK,PREVEA360,56.75,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,56.75,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,641.49,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $641.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,44.09,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,723.60,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $723.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,TRIOLOGY,TRILOGY MEDICAID,18.36,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81332 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 106% = $18.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,52.38,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $52.38 from Fee Schedule UHC_98227C for Rev 310 Proc 81332 * Qty 1 = $52.38 at 100% = $52.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,52.38,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $52.38 from Fee Schedule UHC_98227C for Rev 310 Proc 81332 * Qty 1 = $52.38 at 100% = $52.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,43.65,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,52.38,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $52.38 from Fee Schedule UHC_98227C for Rev 310 Proc 81332 * Qty 1 = $52.38 at 100% = $52.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,UNITY HEALTH PLAN,UNITY HOSPICE,43.65,,,,,,,17.3200,1005.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,723.60,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $723.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,623.10,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $623.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,723.60,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $723.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,723.60,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $723.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
SERPINA1 GENE,81332,CPT,310,RC,31000028,CDM,,,,both,,,1005.0000,663.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,603.00,,,,,,,17.3200,1005.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,005.00 in Billed Charges for Rev 310 Proc 81332 = $603.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,AETNA,AETNA HSHS,363.05,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $363.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,AETNA,AETNA MEDICARE,63.96,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,AETNA,ALL COMMERCIAL AETNA,562.00,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $562.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,ANTHEM,ANTEHM MEDICAID,51.17,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81400 at $51.17 (Fee Schedule) = $51.17 (Total Line Payment) at 100% = $51.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,63.96,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,ANTHEM,ANTHEM POS/HMO,223.86,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $223.86 from Fee Schedule WII28_25 for Rev 310 Proc 81400 Mod TC * Qty 1 = $223.86 at 100% = $223.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,ANTHEM,ANTHEM PPO,223.86,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $223.86 from Fee Schedule WII28_25 for Rev 310 Proc 81400 Mod TC * Qty 1 = $223.86 at 100% = $223.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,562.00,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $562.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,CENPATICO,ALL MEDICAID CENPATICO,562.00,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $562.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,477.70,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $477.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,CIGNA,ALL COMMERCIAL CIGNA,393.40,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $393.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,COFINITY,COFINITY,562.00,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $562.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.17,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81400 at $51.17 (Fee Schedule) = $51.17 (Total Line Payment) at 100% = $51.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.17,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81400 at $51.17 (Fee Schedule) = $51.17 (Total Line Payment) at 100% = $51.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,533.90,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $533.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,472.08,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $472.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,399.02,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $399.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,410.26,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $410.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,273.13,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $273.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,477.70,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $477.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HUMANA,HUMANA CHOICE CARE HMO,108.73,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $108.73 from Fee Schedule 005543_170 for Rev 310 Proc 81400 * Qty 1 = $108.73 at 100% = $108.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HUMANA,HUMANA CHOICE CARE PPO,477.70,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $477.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,63.96,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,HUMANA,HUMANA NATIIONAL POS HMO,108.73,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $108.73 from Fee Schedule 005543_170 for Rev 310 Proc 81400 * Qty 1 = $108.73 at 100% = $108.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,410.26,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $410.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,562.00,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $562.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.17,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81400 at $51.17 (Fee Schedule) = $51.17 (Total Line Payment) at 100% = $51.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,63.96,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.17,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81400 at $51.17 (Fee Schedule) = $51.17 (Total Line Payment) at 100% = $51.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,54.24,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81400 at $51.17 (Fee Schedule) = $51.17 (Total Line Payment) at 100% = $51.17... $51.17 at 106% = $54.24 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,63.96,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,281.00,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $281.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,472.08,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $472.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,143.91,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,421.50,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $421.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,517.04,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $517.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,83.15,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,83.15,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,PREVEA HEALTH NETWORK,PREVEA360,83.15,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,83.15,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,358.72,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $358.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,64.60,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,404.64,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $404.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,TRIOLOGY,TRILOGY MEDICAID,54.24,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81400 at $51.17 (Fee Schedule) = $51.17 (Total Line Payment) at 106% = $54.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,76.75,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $76.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81400 * Qty 1 = $76.75 at 100% = $76.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,76.75,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $76.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81400 * Qty 1 = $76.75 at 100% = $76.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,63.96,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,76.75,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $76.75 from Fee Schedule UHC_98227C for Rev 310 Proc 81400 * Qty 1 = $76.75 at 100% = $76.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,UNITY HEALTH PLAN,UNITY HOSPICE,63.96,,,,,,,51.1700,562.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,404.64,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $404.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,348.44,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $348.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,404.64,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $404.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,404.64,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $404.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DPD MOPATH PROCEDURE L1,81400,CPT,310,RC,31000030,CDM,,,,both,,,562.0000,370.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,337.20,,,,,,,51.1700,562.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $562.00 in Billed Charges for Rev 310 Proc 81400 = $337.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA HSHS,484.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $484.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA MEDICARE,150.33,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,AETNA,ALL COMMERCIAL AETNA,750.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTEHM MEDICAID,120.26,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81402 at $120.26 (Fee Schedule) = $120.26 (Total Line Payment) at 100% = $120.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,150.33,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM POS/HMO,526.16,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $526.16 from Fee Schedule WII28_25 for Rev 310 Proc 81402 Mod TC * Qty 1 = $526.16 at 100% = $526.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM PPO,526.16,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $526.16 from Fee Schedule WII28_25 for Rev 310 Proc 81402 Mod TC * Qty 1 = $526.16 at 100% = $526.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,750.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,CENPATICO,ALL MEDICAID CENPATICO,750.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,637.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,CIGNA,ALL COMMERCIAL CIGNA,525.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $525.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,COFINITY,COFINITY,750.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.26,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81402 at $120.26 (Fee Schedule) = $120.26 (Total Line Payment) at 100% = $120.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.26,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81402 at $120.26 (Fee Schedule) = $120.26 (Total Line Payment) at 100% = $120.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,712.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $712.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,630.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,532.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $532.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,547.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,364.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $364.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,637.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE HMO,255.56,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $255.56 from Fee Schedule 005543_170 for Rev 310 Proc 81402 * Qty 1 = $255.56 at 100% = $255.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE PPO,637.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,150.33,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA NATIIONAL POS HMO,255.56,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $255.56 from Fee Schedule 005543_170 for Rev 310 Proc 81402 * Qty 1 = $255.56 at 100% = $255.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,547.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,750.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.26,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81402 at $120.26 (Fee Schedule) = $120.26 (Total Line Payment) at 100% = $120.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,150.33,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.26,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81402 at $120.26 (Fee Schedule) = $120.26 (Total Line Payment) at 100% = $120.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,127.48,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81402 at $120.26 (Fee Schedule) = $120.26 (Total Line Payment) at 100% = $120.26... $120.26 at 106% = $127.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,150.33,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,375.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,630.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,338.24,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,562.50,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $562.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,690.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,195.43,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,195.43,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360,195.43,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,195.43,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.73,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $478.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,151.83,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,540.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,TRILOGY MEDICAID,127.48,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81402 at $120.26 (Fee Schedule) = $120.26 (Total Line Payment) at 106% = $127.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,180.40,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $180.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81402 * Qty 1 = $180.40 at 100% = $180.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,180.40,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $180.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81402 * Qty 1 = $180.40 at 100% = $180.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,150.33,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,180.40,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $180.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81402 * Qty 1 = $180.40 at 100% = $180.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,UNITY HEALTH PLAN,UNITY HOSPICE,150.33,,,,,,,120.2600,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,540.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,465.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,540.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,540.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOPATH PROCEDURE LEVEL 3,81402,CPT,310,RC,31000032,CDM,,,,both,,,750.0000,495.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,450.00,,,,,,,120.2600,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $750.00 in Billed Charges for Rev 310 Proc 81402 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,AETNA,AETNA HSHS,455.43,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $455.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,AETNA,AETNA MEDICARE,201.50,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,AETNA,ALL COMMERCIAL AETNA,705.00,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,ANTHEM,ANTEHM MEDICAID,208.21,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81342 at $208.21 (Fee Schedule) = $208.21 (Total Line Payment) at 100% = $208.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,201.50,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,ANTHEM,ANTHEM POS/HMO,705.00,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $705.25 from Fee Schedule WII28_25 for Rev 310 Proc 81342 Mod TC * Qty 1 = $705.25 at 100% = $705.25 (Limited to $705.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,ANTHEM,ANTHEM PPO,705.00,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $705.25 from Fee Schedule WII28_25 for Rev 310 Proc 81342 Mod TC * Qty 1 = $705.25 at 100% = $705.25 (Limited to $705.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,705.00,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,CENPATICO,ALL MEDICAID CENPATICO,705.00,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,599.25,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $599.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,CIGNA,ALL COMMERCIAL CIGNA,493.50,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $493.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,COFINITY,COFINITY,705.00,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,208.21,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81342 at $208.21 (Fee Schedule) = $208.21 (Total Line Payment) at 100% = $208.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,208.21,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81342 at $208.21 (Fee Schedule) = $208.21 (Total Line Payment) at 100% = $208.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,669.75,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $669.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,592.20,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $592.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,500.55,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $500.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,514.65,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $514.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,342.63,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $342.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,599.25,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $599.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HUMANA,HUMANA CHOICE CARE HMO,342.55,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $342.55 from Fee Schedule 005543_170 for Rev 310 Proc 81342 * Qty 1 = $342.55 at 100% = $342.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HUMANA,HUMANA CHOICE CARE PPO,599.25,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $599.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,201.50,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,HUMANA,HUMANA NATIIONAL POS HMO,342.55,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $342.55 from Fee Schedule 005543_170 for Rev 310 Proc 81342 * Qty 1 = $342.55 at 100% = $342.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,514.65,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $514.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,705.00,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,208.21,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81342 at $208.21 (Fee Schedule) = $208.21 (Total Line Payment) at 100% = $208.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,201.50,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,208.21,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81342 at $208.21 (Fee Schedule) = $208.21 (Total Line Payment) at 100% = $208.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,220.70,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81342 at $208.21 (Fee Schedule) = $208.21 (Total Line Payment) at 100% = $208.21... $208.21 at 106% = $220.70 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,201.50,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,352.50,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $352.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,592.20,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $592.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,453.38,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,528.75,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $528.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,648.60,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $648.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,261.95,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,261.95,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,PREVEA HEALTH NETWORK,PREVEA360,261.95,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,261.95,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,450.00,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,203.52,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,507.60,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $507.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,TRIOLOGY,TRILOGY MEDICAID,220.70,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81342 at $208.21 (Fee Schedule) = $208.21 (Total Line Payment) at 106% = $220.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,241.80,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $241.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81342 * Qty 1 = $241.80 at 100% = $241.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,241.80,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $241.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81342 * Qty 1 = $241.80 at 100% = $241.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,201.50,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,241.80,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $241.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81342 * Qty 1 = $241.80 at 100% = $241.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,UNITY HEALTH PLAN,UNITY HOSPICE,201.50,,,,,,,201.5000,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,507.60,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $507.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,437.10,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $437.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,507.60,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $507.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,507.60,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $507.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRG GENE ARRANGEMENT ANALYSIS,81342,CPT,310,RC,31000053,CDM,,,,both,,,705.0000,465.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,423.00,,,,,,,201.5000,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $705.00 in Billed Charges for Rev 310 Proc 81342 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,AETNA,AETNA HSHS,79.46,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $79.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,AETNA,AETNA MEDICARE,65.36,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,AETNA,ALL COMMERCIAL AETNA,123.00,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTEHM MEDICAID,67.54,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,65.36,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM POS/HMO,123.00,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $228.76 from Fee Schedule WII28_25 for Rev 310 Proc 81256 Mod TC * Qty 1 = $228.76 at 100% = $228.76 (Limited to $123.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,ANTHEM,ANTHEM PPO,123.00,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $228.76 from Fee Schedule WII28_25 for Rev 310 Proc 81256 Mod TC * Qty 1 = $228.76 at 100% = $228.76 (Limited to $123.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,123.00,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,CENPATICO,ALL MEDICAID CENPATICO,123.00,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,104.55,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,CIGNA,ALL COMMERCIAL CIGNA,86.10,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $86.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,COFINITY,COFINITY,123.00,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,67.54,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,67.54,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,116.85,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $116.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,103.32,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $103.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,87.33,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $87.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.79,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $89.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,59.78,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $59.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,104.55,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA CHOICE CARE HMO,111.11,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $111.11 from Fee Schedule 005543_170 for Rev 310 Proc 81256 * Qty 1 = $111.11 at 100% = $111.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA CHOICE CARE PPO,104.55,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $104.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,65.36,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,HUMANA,HUMANA NATIIONAL POS HMO,111.11,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $111.11 from Fee Schedule 005543_170 for Rev 310 Proc 81256 * Qty 1 = $111.11 at 100% = $111.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.79,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $89.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,123.00,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,67.54,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,65.36,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,67.54,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,71.59,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 100% = $67.54... $67.54 at 106% = $71.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,65.36,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.50,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $61.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,103.32,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $103.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,147.06,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,92.25,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $92.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,113.16,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $113.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,84.97,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,84.97,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA360,84.97,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,84.97,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,78.51,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $78.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,66.01,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,88.56,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,TRIOLOGY,TRILOGY MEDICAID,71.59,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81256 at $67.54 (Fee Schedule) = $67.54 (Total Line Payment) at 106% = $71.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,78.43,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $78.43 from Fee Schedule UHC_98227C for Rev 310 Proc 81256 * Qty 1 = $78.43 at 100% = $78.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,78.43,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $78.43 from Fee Schedule UHC_98227C for Rev 310 Proc 81256 * Qty 1 = $78.43 at 100% = $78.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,65.36,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,78.43,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $78.43 from Fee Schedule UHC_98227C for Rev 310 Proc 81256 * Qty 1 = $78.43 at 100% = $78.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,UNITY HEALTH PLAN,UNITY HOSPICE,65.36,,,,,,,59.7800,147.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,88.56,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,76.26,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $76.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,88.56,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,88.56,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HFE GENE ANALYSIS,81256,CPT,310,RC,31000061,CDM,,,,both,,,123.0000,81.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.80,,,,,,,59.7800,147.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $123.00 in Billed Charges for Rev 310 Proc 81256 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,AETNA,AETNA HSHS,1047.17,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,047.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,AETNA,AETNA MEDICARE,91.66,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,AETNA,ALL COMMERCIAL AETNA,1621.00,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,ANTHEM,ANTEHM MEDICAID,94.71,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,91.66,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,ANTHEM,ANTHEM POS/HMO,320.81,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $320.81 from Fee Schedule WII28_25 for Rev 310 Proc 81270 Mod TC * Qty 1 = $320.81 at 100% = $320.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,ANTHEM,ANTHEM PPO,320.81,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $320.81 from Fee Schedule WII28_25 for Rev 310 Proc 81270 Mod TC * Qty 1 = $320.81 at 100% = $320.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1621.00,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,CENPATICO,ALL MEDICAID CENPATICO,1621.00,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1377.85,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,377.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,CIGNA,ALL COMMERCIAL CIGNA,1134.70,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,134.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,COFINITY,COFINITY,1621.00,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,94.71,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,94.71,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1539.95,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,539.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,1361.64,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,361.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1150.91,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,150.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1183.33,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,183.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,787.81,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $787.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1377.85,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,377.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HUMANA,HUMANA CHOICE CARE HMO,155.82,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $155.82 from Fee Schedule 005543_170 for Rev 310 Proc 81270 * Qty 1 = $155.82 at 100% = $155.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HUMANA,HUMANA CHOICE CARE PPO,1377.85,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,377.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,91.66,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,HUMANA,HUMANA NATIIONAL POS HMO,155.82,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $155.82 from Fee Schedule 005543_170 for Rev 310 Proc 81270 * Qty 1 = $155.82 at 100% = $155.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1183.33,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,183.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1621.00,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,94.71,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,91.66,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,94.71,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,100.39,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71... $94.71 at 106% = $100.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,91.66,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,810.50,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $810.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1361.64,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,361.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,206.24,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1215.75,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,215.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1491.32,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,491.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,119.16,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,119.16,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,PREVEA HEALTH NETWORK,PREVEA360,119.16,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,119.16,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1034.68,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,034.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,92.58,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1167.12,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,167.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,TRIOLOGY,TRILOGY MEDICAID,100.39,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 106% = $100.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,109.99,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,109.99,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,91.66,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,109.99,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,UNITY HEALTH PLAN,UNITY HOSPICE,91.66,,,,,,,91.6600,1621.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1167.12,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,167.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1005.02,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,005.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1167.12,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,167.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1167.12,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $1,167.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC JAK2 GENE ANALYSIS,81270,CPT,310,RC,31000062,CDM,,,,both,,,1621.0000,1069.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,972.60,,,,,,,91.6600,1621.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,621.00 in Billed Charges for Rev 310 Proc 81270 = $972.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,AETNA,AETNA HSHS,994.84,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $994.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,AETNA,AETNA MEDICARE,282.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,AETNA,ALL COMMERCIAL AETNA,1540.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,ANTHEM,ANTEHM MEDICAID,226.30,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81406 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,282.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,ANTHEM,ANTHEM POS/HMO,990.08,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $990.08 from Fee Schedule WII28_25 for Rev 310 Proc 81406 Mod TC * Qty 1 = $990.08 at 100% = $990.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,ANTHEM,ANTHEM PPO,990.08,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $990.08 from Fee Schedule WII28_25 for Rev 310 Proc 81406 Mod TC * Qty 1 = $990.08 at 100% = $990.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1540.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,CENPATICO,ALL MEDICAID CENPATICO,1540.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1309.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,309.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,CIGNA,ALL COMMERCIAL CIGNA,1078.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,078.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,COFINITY,COFINITY,1540.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,226.30,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81406 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,226.30,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81406 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1463.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,463.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,1293.60,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,293.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1093.40,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,093.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1124.20,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,124.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,748.44,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $748.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1309.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,309.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HUMANA,HUMANA CHOICE CARE HMO,480.90,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $480.90 from Fee Schedule 005543_170 for Rev 310 Proc 81406 * Qty 1 = $480.90 at 100% = $480.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HUMANA,HUMANA CHOICE CARE PPO,1309.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,309.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,282.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,HUMANA,HUMANA NATIIONAL POS HMO,480.90,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $480.90 from Fee Schedule 005543_170 for Rev 310 Proc 81406 * Qty 1 = $480.90 at 100% = $480.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1124.20,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,124.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1540.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,226.30,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81406 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,282.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,226.30,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81406 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,239.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81406 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30... $226.30 at 106% = $239.88 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,282.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,770.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $770.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1293.60,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,293.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,636.48,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1155.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1416.80,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,416.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,367.74,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,367.74,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,PREVEA HEALTH NETWORK,PREVEA360,367.74,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,367.74,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,982.98,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $982.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,285.71,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1108.80,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,TRIOLOGY,TRILOGY MEDICAID,239.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81406 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 106% = $239.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,339.46,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $339.46 from Fee Schedule UHC_98227C for Rev 310 Proc 81406 * Qty 1 = $339.46 at 100% = $339.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,339.46,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $339.46 from Fee Schedule UHC_98227C for Rev 310 Proc 81406 * Qty 1 = $339.46 at 100% = $339.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,282.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,339.46,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $339.46 from Fee Schedule UHC_98227C for Rev 310 Proc 81406 * Qty 1 = $339.46 at 100% = $339.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,UNITY HEALTH PLAN,UNITY HOSPICE,282.88,,,,,,,226.3000,1540.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1108.80,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,954.80,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $954.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1108.80,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1108.80,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $1,108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 7,81406,CPT,310,RC,31000066,CDM,,,,both,,,1540.0000,1016.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,924.00,,,,,,,226.3000,1540.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,540.00 in Billed Charges for Rev 310 Proc 81406 = $924.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,AETNA,AETNA HSHS,45.87,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $45.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,AETNA,AETNA MEDICARE,26.91,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,AETNA,ALL COMMERCIAL AETNA,71.00,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,ANTHEM,ANTEHM MEDICAID,26.72,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88285 at $26.72 (Fee Schedule) = $26.72 (Total Line Payment) at 100% = $26.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,26.91,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,ANTHEM,ANTHEM POS/HMO,71.00,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $94.19 from Fee Schedule WII28_25 for Rev 310 Proc 88285 Mod TC * Qty 1 = $94.19 at 100% = $94.19 (Limited to $71.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,ANTHEM,ANTHEM PPO,71.00,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $94.19 from Fee Schedule WII28_25 for Rev 310 Proc 88285 Mod TC * Qty 1 = $94.19 at 100% = $94.19 (Limited to $71.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,71.00,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,CENPATICO,ALL MEDICAID CENPATICO,71.00,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,60.35,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $60.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,CIGNA,ALL COMMERCIAL CIGNA,49.70,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $49.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,COFINITY,COFINITY,71.00,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.72,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88285 at $26.72 (Fee Schedule) = $26.72 (Total Line Payment) at 100% = $26.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.72,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88285 at $26.72 (Fee Schedule) = $26.72 (Total Line Payment) at 100% = $26.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,67.45,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $67.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,59.64,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $59.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,50.41,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $50.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,51.83,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $51.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,34.51,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $34.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,60.35,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $60.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HUMANA,HUMANA CHOICE CARE HMO,45.75,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $45.75 from Fee Schedule 005543_170 for Rev 310 Proc 88285 * Qty 1 = $45.75 at 100% = $45.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HUMANA,HUMANA CHOICE CARE PPO,60.35,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $60.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,26.91,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,HUMANA,HUMANA NATIIONAL POS HMO,45.75,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $45.75 from Fee Schedule 005543_170 for Rev 310 Proc 88285 * Qty 1 = $45.75 at 100% = $45.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,51.83,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $51.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,71.00,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.72,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88285 at $26.72 (Fee Schedule) = $26.72 (Total Line Payment) at 100% = $26.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,26.91,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.72,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88285 at $26.72 (Fee Schedule) = $26.72 (Total Line Payment) at 100% = $26.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,28.32,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88285 at $26.72 (Fee Schedule) = $26.72 (Total Line Payment) at 100% = $26.72... $26.72 at 106% = $28.32 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,26.91,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35.50,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $35.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,59.64,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $59.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,60.55,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,53.25,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $53.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,65.32,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $65.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,34.98,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,34.98,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,PREVEA HEALTH NETWORK,PREVEA360,34.98,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,34.98,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,45.32,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $45.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,27.18,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,51.12,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $51.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,TRIOLOGY,TRILOGY MEDICAID,28.32,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88285 at $26.72 (Fee Schedule) = $26.72 (Total Line Payment) at 106% = $28.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32.29,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.29 from Fee Schedule UHC_98227C for Rev 310 Proc 88285 * Qty 1 = $32.29 at 100% = $32.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,32.29,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.29 from Fee Schedule UHC_98227C for Rev 310 Proc 88285 * Qty 1 = $32.29 at 100% = $32.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,26.91,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,32.29,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.29 from Fee Schedule UHC_98227C for Rev 310 Proc 88285 * Qty 1 = $32.29 at 100% = $32.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,UNITY HEALTH PLAN,UNITY HOSPICE,26.91,,,,,,,26.7200,71.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,51.12,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $51.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,44.02,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $44.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,51.12,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $51.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,51.12,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $51.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHROMOSOME ADDL CELLS COUNTED EA STUDY,88285,CPT,310,RC,31000072,CDM,,,,both,,,71.0000,46.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42.60,,,,,,,26.7200,71.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $71.00 in Billed Charges for Rev 310 Proc 88285 = $42.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,AETNA,AETNA HSHS,38.76,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,AETNA,AETNA MEDICARE,6.47,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,AETNA,ALL COMMERCIAL AETNA,60.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTEHM MEDICAID,6.69,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 83540 at $6.69 (Fee Schedule) = $6.69 (Total Line Payment) at 100% = $6.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,6.47,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTHEM POS/HMO,22.65,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.65 from Fee Schedule WII28_25 for Rev 310 Proc 83540 Mod TC * Qty 1 = $22.65 at 100% = $22.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTHEM PPO,22.65,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.65 from Fee Schedule WII28_25 for Rev 310 Proc 83540 Mod TC * Qty 1 = $22.65 at 100% = $22.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,60.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,CENPATICO,ALL MEDICAID CENPATICO,60.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,51.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,CIGNA,ALL COMMERCIAL CIGNA,42.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,COFINITY,COFINITY,60.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.69,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 83540 at $6.69 (Fee Schedule) = $6.69 (Total Line Payment) at 100% = $6.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.69,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 83540 at $6.69 (Fee Schedule) = $6.69 (Total Line Payment) at 100% = $6.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,57.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,50.40,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42.60,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $42.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,43.80,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $43.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,29.16,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $29.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,51.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA CHOICE CARE HMO,11.00,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.00 from Fee Schedule 005543_170 for Rev 310 Proc 83540 * Qty 1 = $11.00 at 100% = $11.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA CHOICE CARE PPO,51.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,6.47,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA NATIIONAL POS HMO,11.00,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.00 from Fee Schedule 005543_170 for Rev 310 Proc 83540 * Qty 1 = $11.00 at 100% = $11.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,43.80,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $43.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,60.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.69,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 83540 at $6.69 (Fee Schedule) = $6.69 (Total Line Payment) at 100% = $6.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,6.47,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.69,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 83540 at $6.69 (Fee Schedule) = $6.69 (Total Line Payment) at 100% = $6.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,7.09,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 83540 at $6.69 (Fee Schedule) = $6.69 (Total Line Payment) at 100% = $6.69... $6.69 at 106% = $7.09 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,6.47,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,30.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $30.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,50.40,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,14.56,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,45.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,55.20,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $55.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.41,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.41,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA360,8.41,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.41,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38.30,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $38.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,6.53,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,43.20,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,TRIOLOGY,TRILOGY MEDICAID,7.09,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00402 Proc 83540 at $6.69 (Fee Schedule) = $6.69 (Total Line Payment) at 106% = $7.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.76,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.76 from Fee Schedule UHC_98227C for Rev 310 Proc 83540 * Qty 1 = $7.76 at 100% = $7.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,7.76,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.76 from Fee Schedule UHC_98227C for Rev 310 Proc 83540 * Qty 1 = $7.76 at 100% = $7.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,6.47,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,7.76,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.76 from Fee Schedule UHC_98227C for Rev 310 Proc 83540 * Qty 1 = $7.76 at 100% = $7.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,UNITY HEALTH PLAN,UNITY HOSPICE,6.47,,,,,,,6.4700,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,43.20,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37.20,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $37.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,43.20,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,43.20,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IRON LIVER TISSUE,83540,CPT,310,RC,31000101,CDM,,,,both,,,60.0000,39.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,36.00,,,,,,,6.4700,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $60.00 in Billed Charges for Rev 310 Proc 83540 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,AETNA,AETNA HSHS,74.29,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $115.00 in Billed Charges for Rev 360 = $74.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,AETNA,ALL COMMERCIAL AETNA,115.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.00 in Billed Charges for Rev 360 = $115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,115.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.00 in Billed Charges for Rev 360 = $115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,CENPATICO,ALL MEDICAID CENPATICO,115.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.00 in Billed Charges for Rev 360 = $115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,97.75,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.00 in Billed Charges for Rev 360 = $97.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,CIGNA,ALL COMMERCIAL CIGNA,80.50,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $115.00 in Billed Charges for Rev 360 = $80.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,COFINITY,COFINITY,115.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.00 in Billed Charges for Rev 360 = $115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,109.25,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $115.00 in Billed Charges for Rev 360 = $109.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,96.60,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $115.00 in Billed Charges for Rev 360 = $96.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,81.65,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $115.00 in Billed Charges for Rev 360 = $81.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,83.95,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $115.00 in Billed Charges for Rev 360 = $83.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,55.89,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $115.00 in Billed Charges for Rev 360 = $55.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,97.75,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.00 in Billed Charges for Rev 360 = $97.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,HUMANA,HUMANA CHOICE CARE PPO,97.75,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $115.00 in Billed Charges for Rev 360 = $97.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,83.95,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $115.00 in Billed Charges for Rev 360 = $83.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,115.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $115.00 in Billed Charges for Rev 360 = $115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,57.50,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $115.00 in Billed Charges for Rev 360 = $57.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,96.60,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $115.00 in Billed Charges for Rev 360 = $96.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,86.25,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $115.00 in Billed Charges for Rev 360 = $86.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,105.80,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $115.00 in Billed Charges for Rev 360 = $105.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,69.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $115.00 in Billed Charges for Rev 360 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,69.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $115.00 in Billed Charges for Rev 360 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,PREVEA HEALTH NETWORK,PREVEA360,69.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $115.00 in Billed Charges for Rev 360 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,69.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $115.00 in Billed Charges for Rev 360 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,73.40,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $115.00 in Billed Charges for Rev 360 = $73.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,82.80,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.00 in Billed Charges for Rev 360 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,82.80,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.00 in Billed Charges for Rev 360 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,71.30,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $115.00 in Billed Charges for Rev 360 = $71.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,82.80,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.00 in Billed Charges for Rev 360 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,82.80,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $115.00 in Billed Charges for Rev 360 = $82.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 4 PER MIN,360,RC,36060010,CDM,,,,,,both,,,115.0000,75.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,69.00,,,,,,,55.8900,115.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $115.00 in Billed Charges for Rev 360 = $69.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,AETNA,AETNA HSHS,4615.67,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $4,615.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,AETNA,AETNA MEDICARE,1896.75,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,AETNA,ALL COMMERCIAL AETNA,7145.00,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $7,145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,ANTHEM,ANTEHM MEDICAID,1529.67,,,,,,,1529.6700,7145.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00276 Proc 63661 at $125.60 (Base Rate) * 12.1789 (Relative Weight) = $1,529.67 (Total Line Payment) at 100% = $1,529.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1896.75,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,ANTHEM,ANTHEM POS/HMO,4804.00,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,ANTHEM,ANTHEM PPO,5200.00,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7145.00,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $7,145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,CENPATICO,ALL MEDICAID CENPATICO,7145.00,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $7,145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6073.25,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $6,073.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,CIGNA,ALL COMMERCIAL CIGNA,5001.50,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,001.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,COFINITY,COFINITY,7145.00,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $7,145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1529.67,,,,,,,1529.6700,7145.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00276 Proc 63661 at $125.60 (Base Rate) * 12.1789 (Relative Weight) = $1,529.67 (Total Line Payment) at 100% = $1,529.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1529.67,,,,,,,1529.6700,7145.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00276 Proc 63661 at $125.60 (Base Rate) * 12.1789 (Relative Weight) = $1,529.67 (Total Line Payment) at 100% = $1,529.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6787.75,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $6,787.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,6001.80,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $6,001.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5072.95,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,072.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5215.85,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,215.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,3472.47,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $3,472.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6073.25,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $6,073.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HUMANA,HUMANA CHOICE CARE HMO,7145.00,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $7,145.00 in Billed Charges - $0.00 in ASG Allowed Amount = $7,145.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HUMANA,HUMANA CHOICE CARE PPO,6073.25,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $6,073.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,1896.75,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,HUMANA,HUMANA NATIIONAL POS HMO,7145.00,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $7,145.00 in Billed Charges - $0.00 in ASG Allowed Amount = $7,145.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5215.85,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,215.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,7145.00,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $7,145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1529.67,,,,,,,1529.6700,7145.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00276 Proc 63661 at $125.60 (Base Rate) * 12.1789 (Relative Weight) = $1,529.67 (Total Line Payment) at 100% = $1,529.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1896.75,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1529.67,,,,,,,1529.6700,7145.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00276 Proc 63661 at $125.60 (Base Rate) * 12.1789 (Relative Weight) = $1,529.67 (Total Line Payment) at 100% = $1,529.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,1621.45,,,,,,,1529.6700,7145.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00276 Proc 63661 at $125.60 (Base Rate) * 12.1789 (Relative Weight) = $1,529.67 (Total Line Payment) at 100% = $1,529.67... $1,529.67 at 106% = $1,621.45 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,1896.75,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3572.50,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $3,572.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6001.80,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $6,001.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,4267.68,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5358.75,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,358.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6573.40,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $6,573.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5600.43,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5600.43,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,PREVEA HEALTH NETWORK,PREVEA360,5600.43,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5600.43,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4560.65,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $4,560.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1915.72,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5144.40,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,144.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,TRIOLOGY,TRILOGY MEDICAID,1621.45,,,,,,,1529.6700,7145.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00276 Proc 63661 at $125.60 (Base Rate) * 12.1789 (Relative Weight) = $1,529.67 (Total Line Payment) at 106% = $1,621.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6103.40,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,6103.40,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1896.75,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,6103.40,,,,,,,1529.6700,7145.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 63661 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,UNITY HEALTH PLAN,UNITY HOSPICE,1896.75,,,,,,,1529.6700,7145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5144.40,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,144.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4429.90,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $4,429.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5144.40,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,144.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5144.40,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $5,144.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RM SPINAL NEUROSTIM ELECTRD,63661,CPT,360,RC,36080001,CDM,,,,both,,,7145.0000,4715.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4287.00,,,,,,,1529.6700,7145.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,145.00 in Billed Charges for Rev 360 Proc 63661 = $4,287.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,AETNA,AETNA HSHS,1006.47,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,006.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,AETNA,AETNA MEDICARE,859.12,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,AETNA,ALL COMMERCIAL AETNA,1558.00,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,ANTHEM,ANTEHM MEDICAID,182.86,,,,,,,182.8600,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64417 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,859.12,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,ANTHEM,ANTHEM POS/HMO,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,ANTHEM,ANTHEM PPO,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1558.00,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,CENPATICO,ALL MEDICAID CENPATICO,1558.00,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1324.30,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,324.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,CIGNA,ALL COMMERCIAL CIGNA,1090.60,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,090.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,COFINITY,COFINITY,1558.00,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,182.86,,,,,,,182.8600,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64417 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,182.86,,,,,,,182.8600,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64417 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1480.10,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,480.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,1308.72,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,308.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1106.18,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,106.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1137.34,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,137.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,757.19,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $757.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1324.30,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,324.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,HUMANA CHOICE CARE HMO,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,HUMANA CHOICE CARE PPO,1324.30,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,324.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,859.12,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,HUMANA NATIIONAL POS HMO,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1137.34,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,137.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1558.00,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,182.86,,,,,,,182.8600,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64417 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,859.12,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,182.86,,,,,,,182.8600,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64417 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,193.83,,,,,,,182.8600,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64417 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86... $182.86 at 106% = $193.83 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,859.12,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,779.00,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $779.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1308.72,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,308.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,1933.01,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1168.50,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,168.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1433.36,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,433.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,PREVEA HEALTH NETWORK,PREVEA360,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,994.47,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $994.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,867.71,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1121.76,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,TRIOLOGY,TRILOGY MEDICAID,193.83,,,,,,,182.8600,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64417 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 106% = $193.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,859.12,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,1558.00,,,,,,,182.8600,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64417 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,558.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,558.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,UNITY HEALTH PLAN,UNITY HOSPICE,859.12,,,,,,,182.8600,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1121.76,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,965.96,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $965.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1121.76,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1121.76,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK AXILLARY NERVE W/IMG GUID IF PERFORMED,64417,CPT,360,RC,36080008,CDM,,,,both,,,1558.0000,1028.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,934.80,,,,,,,182.8600,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,558.00 in Billed Charges for Rev 360 Proc 64417 = $934.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,AETNA,AETNA HSHS,1357.89,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,357.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,AETNA,AETNA MEDICARE,880.98,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,AETNA,ALL COMMERCIAL AETNA,2102.00,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,ANTHEM,ANTEHM MEDICAID,178.30,,,,,,,178.3000,2102.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00130 Proc 47537 at $125.60 (Base Rate) * 1.4196 (Relative Weight) = $178.30 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $178.30 at 100% = $178.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,880.98,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,ANTHEM,ANTHEM POS/HMO,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,ANTHEM,ANTHEM PPO,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2102.00,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,CENPATICO,ALL MEDICAID CENPATICO,2102.00,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1786.70,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,786.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,CIGNA,ALL COMMERCIAL CIGNA,1471.40,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,471.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,COFINITY,COFINITY,2102.00,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,178.30,,,,,,,178.3000,2102.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00130 Proc 47537 at $125.60 (Base Rate) * 1.4196 (Relative Weight) = $178.30 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $178.30 at 100% = $178.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,178.30,,,,,,,178.3000,2102.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00130 Proc 47537 at $125.60 (Base Rate) * 1.4196 (Relative Weight) = $178.30 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $178.30 at 100% = $178.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1996.90,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,996.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,1765.68,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1492.42,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,492.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1534.46,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,534.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,1021.57,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,021.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1786.70,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,786.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,HUMANA CHOICE CARE HMO,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,HUMANA CHOICE CARE PPO,1786.70,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,786.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,880.98,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,HUMANA,HUMANA NATIIONAL POS HMO,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1534.46,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,534.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2102.00,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $2,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,178.30,,,,,,,178.3000,2102.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00130 Proc 47537 at $125.60 (Base Rate) * 1.4196 (Relative Weight) = $178.30 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $178.30 at 100% = $178.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,880.98,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,178.30,,,,,,,178.3000,2102.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00130 Proc 47537 at $125.60 (Base Rate) * 1.4196 (Relative Weight) = $178.30 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $178.30 at 100% = $178.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,189.00,,,,,,,178.3000,2102.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00130 Proc 47537 at $125.60 (Base Rate) * 1.4196 (Relative Weight) = $178.30 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $178.30 at 100% = $178.30... $178.30 at 106% = $189.00 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,880.98,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1051.00,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,051.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1765.68,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,765.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,1982.21,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1576.50,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,576.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1933.84,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,933.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,PREVEA HEALTH NETWORK,PREVEA360,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1341.71,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,341.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,889.79,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1513.44,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,513.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,TRIOLOGY,TRILOGY MEDICAID,189.00,,,,,,,178.3000,2102.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00130 Proc 47537 at $125.60 (Base Rate) * 1.4196 (Relative Weight) = $178.30 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $178.30 at 106% = $189.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,880.98,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,2102.00,,,,,,,178.3000,2102.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47537 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $2,102.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,102.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,UNITY HEALTH PLAN,UNITY HOSPICE,880.98,,,,,,,178.3000,2102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1513.44,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,513.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1303.24,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,303.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1513.44,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,513.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1513.44,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,513.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM BIL CATH W G SI CHOLANG,47537,CPT,361,RC,36100001,CDM,,,,both,,,2102.0000,1387.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1261.20,,,,,,,178.3000,2102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,102.00 in Billed Charges for Rev 361 Proc 47537 = $1,261.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,AETNA,AETNA HSHS,9055.63,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $9,055.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,AETNA,AETNA MEDICARE,5872.22,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,AETNA,ALL COMMERCIAL AETNA,14018.00,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $14,018.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,ANTHEM,ANTEHM MEDICAID,2485.28,,,,,,,2485.2800,14018.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47540 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5872.22,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,ANTHEM,ANTHEM POS/HMO,12888.00,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $12,888.00 at 100% of $12,888.00 = $12,888.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,ANTHEM,ANTHEM PPO,14018.00,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $15,700.00 at 100% of $15,700.00 = $15,700.00 Total (Limited to $14,018.00 in Billed Charges - $0.00 in ASG Allowed Amount = $14,018.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14018.00,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $14,018.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,CENPATICO,ALL MEDICAID CENPATICO,14018.00,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $14,018.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11915.30,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $11,915.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,CIGNA,ALL COMMERCIAL CIGNA,9812.60,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $9,812.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,COFINITY,COFINITY,14018.00,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $14,018.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2485.28,,,,,,,2485.2800,14018.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47540 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2485.28,,,,,,,2485.2800,14018.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47540 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13317.10,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $13,317.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,11775.12,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $11,775.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9952.78,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $9,952.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10233.14,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $10,233.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,6812.75,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $6,812.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11915.30,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $11,915.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HUMANA,HUMANA CHOICE CARE PPO,11915.30,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $11,915.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,5872.22,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10233.14,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $10,233.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,14018.00,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $14,018.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2485.28,,,,,,,2485.2800,14018.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47540 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5872.22,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2485.28,,,,,,,2485.2800,14018.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47540 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,2634.40,,,,,,,2485.2800,14018.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47540 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28... $2,485.28 at 106% = $2,634.40 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,5872.22,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7009.00,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $7,009.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11775.12,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $11,775.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,13212.49,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10513.50,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $10,513.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12896.56,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $12,896.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9798.59,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9798.59,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,PREVEA HEALTH NETWORK,PREVEA360,9798.59,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9798.59,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8947.69,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $8,947.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5930.94,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10092.96,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $10,092.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,TRIOLOGY,TRILOGY MEDICAID,2634.40,,,,,,,2485.2800,14018.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47540 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 106% = $2,634.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10678.60,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,10678.60,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5872.22,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,10678.60,,,,,,,2485.2800,14018.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47540 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,UNITY HEALTH PLAN,UNITY HOSPICE,5872.22,,,,,,,2485.2800,14018.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10092.96,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $10,092.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8691.16,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $8,691.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10092.96,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $10,092.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10092.96,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $10,092.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W GD SI  NEW ACCESS,47540,CPT,361,RC,36100003,CDM,,,,both,,,14018.0000,9251.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8410.80,,,,,,,2485.2800,14018.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $14,018.00 in Billed Charges for Rev 361 Proc 47540 = $8,410.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,AETNA,AETNA HSHS,1825.60,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $1,825.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,AETNA,AETNA MEDICARE,677.31,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,AETNA,ALL COMMERCIAL AETNA,2826.00,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,ANTHEM,ANTEHM MEDICAID,184.96,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00161 Proc 50430 at $125.60 (Base Rate) * 1.4726 (Relative Weight) = $184.96 (Total Line Payment) at 100% = $184.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,677.31,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,ANTHEM,ANTHEM POS/HMO,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,ANTHEM,ANTHEM PPO,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2826.00,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,CENPATICO,ALL MEDICAID CENPATICO,2826.00,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2402.10,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,402.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,CIGNA,ALL COMMERCIAL CIGNA,1978.20,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $1,978.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,COFINITY,COFINITY,2826.00,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,184.96,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00161 Proc 50430 at $125.60 (Base Rate) * 1.4726 (Relative Weight) = $184.96 (Total Line Payment) at 100% = $184.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,184.96,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00161 Proc 50430 at $125.60 (Base Rate) * 1.4726 (Relative Weight) = $184.96 (Total Line Payment) at 100% = $184.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2684.70,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,684.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,2373.84,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,373.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2006.46,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,006.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2062.98,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,062.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,1373.44,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $1,373.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2402.10,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,402.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HUMANA,HUMANA CHOICE CARE HMO,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HUMANA,HUMANA CHOICE CARE PPO,2402.10,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,402.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,677.31,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,HUMANA,HUMANA NATIIONAL POS HMO,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2062.98,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,062.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2826.00,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,826.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,184.96,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00161 Proc 50430 at $125.60 (Base Rate) * 1.4726 (Relative Weight) = $184.96 (Total Line Payment) at 100% = $184.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,677.31,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,184.96,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00161 Proc 50430 at $125.60 (Base Rate) * 1.4726 (Relative Weight) = $184.96 (Total Line Payment) at 100% = $184.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,MOLINA HEALTHCARE,MOLINA MEDICAID,196.06,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00161 Proc 50430 at $125.60 (Base Rate) * 1.4726 (Relative Weight) = $184.96 (Total Line Payment) at 100% = $184.96... $184.96 at 106% = $196.06 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,677.31,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1413.00,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $1,413.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2373.84,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,373.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,1523.94,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2119.50,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,119.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2599.92,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,599.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,PREVEA HEALTH NETWORK,PREVEA360,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1803.84,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $1,803.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,684.08,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2034.72,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,034.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,TRIOLOGY,TRILOGY MEDICAID,196.06,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00161 Proc 50430 at $125.60 (Base Rate) * 1.4726 (Relative Weight) = $184.96 (Total Line Payment) at 106% = $196.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,677.31,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,2826.00,,,,,,,184.9600,2826.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50430 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,826.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,826.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,UNITY HEALTH PLAN,UNITY HOSPICE,677.31,,,,,,,184.9600,2826.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2034.72,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,034.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1752.12,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $1,752.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2034.72,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,034.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2034.72,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $2,034.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ NEPH URET W G SI NEW ACCESS,50430,CPT,361,RC,36100004,CDM,,,,both,,,2826.0000,1865.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1695.60,,,,,,,184.9600,2826.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,826.00 in Billed Charges for Rev 361 Proc 50430 = $1,695.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,AETNA,AETNA HSHS,5795.27,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $5,795.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,AETNA,AETNA MEDICARE,3423.93,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,AETNA,ALL COMMERCIAL AETNA,8971.00,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $8,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,ANTHEM,ANTEHM MEDICAID,1327.06,,,,,,,1327.0600,8971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50433 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3423.93,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,ANTHEM,ANTHEM POS/HMO,4804.00,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,ANTHEM,ANTHEM PPO,5200.00,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8971.00,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $8,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,CENPATICO,ALL MEDICAID CENPATICO,8971.00,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $8,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7625.35,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $7,625.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,CIGNA,ALL COMMERCIAL CIGNA,6279.70,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,279.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,COFINITY,COFINITY,8971.00,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $8,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1327.06,,,,,,,1327.0600,8971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50433 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1327.06,,,,,,,1327.0600,8971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50433 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8522.45,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $8,522.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,7535.64,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $7,535.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6369.41,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,369.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6548.83,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,548.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,4359.91,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $4,359.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7625.35,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $7,625.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HUMANA,HUMANA CHOICE CARE PPO,7625.35,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $7,625.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,3423.93,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6548.83,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,548.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,8971.00,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $8,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1327.06,,,,,,,1327.0600,8971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50433 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3423.93,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1327.06,,,,,,,1327.0600,8971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50433 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,1406.68,,,,,,,1327.0600,8971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50433 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06... $1,327.06 at 106% = $1,406.68 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,3423.93,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4485.50,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $4,485.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7535.64,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $7,535.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,7703.84,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6728.25,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,728.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8253.32,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $8,253.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5600.43,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5600.43,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,PREVEA HEALTH NETWORK,PREVEA360,5600.43,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5600.43,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5726.19,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $5,726.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3458.17,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6459.12,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,459.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,TRIOLOGY,TRILOGY MEDICAID,1406.69,,,,,,,1327.0600,8971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50433 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 106% = $1,406.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6103.40,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,6103.40,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3423.93,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,6103.40,,,,,,,1327.0600,8971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50433 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,UNITY HEALTH PLAN,UNITY HOSPICE,3423.93,,,,,,,1327.0600,8971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6459.12,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,459.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5562.02,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $5,562.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6459.12,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,459.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6459.12,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $6,459.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL NEPH CAT W GD S&I NEW ACCESS,50433,CPT,361,RC,36100005,CDM,,,,both,,,8971.0000,5920.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5382.60,,,,,,,1327.0600,8971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,971.00 in Billed Charges for Rev 361 Proc 50433 = $5,382.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,AETNA,AETNA HSHS,425.07,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $425.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,AETNA,ALL COMMERCIAL AETNA,658.00,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $658.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,ANTHEM,ANTEHM MEDICAID,658.00,,,,,,,319.7900,697.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50606 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $658.00, claim capped at $658.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,ANTHEM,ANTHEM POS/HMO,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,ANTHEM,ANTHEM PPO,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,658.00,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $658.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,CENPATICO,ALL MEDICAID CENPATICO,658.00,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $658.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,559.30,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $559.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,CIGNA,ALL COMMERCIAL CIGNA,460.60,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $460.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,COFINITY,COFINITY,658.00,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $658.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,658.00,,,,,,,319.7900,697.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50606 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $658.00, claim capped at $658.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,658.00,,,,,,,319.7900,697.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50606 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $658.00, claim capped at $658.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,625.10,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $625.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,552.72,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $552.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,467.18,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $467.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,480.34,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $480.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,319.79,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $319.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,559.30,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $559.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,HUMANA,HUMANA CHOICE CARE HMO,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,HUMANA,HUMANA CHOICE CARE PPO,559.30,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $559.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,HUMANA,HUMANA NATIIONAL POS HMO,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,480.34,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $480.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,658.00,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $658.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,658.00,,,,,,,319.7900,697.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50606 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $658.00, claim capped at $658.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,658.00,,,,,,,319.7900,697.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50606 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $658.00, claim capped at $658.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,697.48,,,,,,,319.7900,697.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50606 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $658.00, claim capped at $658.00 in billed charges)... $658.00 at 106% = $697.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,329.00,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,552.72,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $552.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,493.50,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $493.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,605.36,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $605.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,PREVEA HEALTH NETWORK,PREVEA360,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,420.00,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,473.76,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $473.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,TRIOLOGY,TRILOGY MEDICAID,658.00,,,,,,,319.7900,697.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50606 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 106% = $3,310.81 (Service Line reduced to $658.00, claim capped at $658.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,658.00,,,,,,,319.7900,697.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50606 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $658.00 in Billed Charges - $0.00 in ASG Allowed Amount = $658.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,473.76,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $473.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,407.96,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $407.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,473.76,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $473.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,473.76,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $473.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ENDO BX URETER/RENAL PELVIS W/G SI,50606,CPT,361,RC,36100007,CDM,,,,both,,,658.0000,434.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,394.80,,,,,,,319.7900,697.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $658.00 in Billed Charges for Rev 361 Proc 50606 = $394.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,AETNA,AETNA HSHS,5419.29,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $5,419.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,AETNA,AETNA MEDICARE,3423.93,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,AETNA,ALL COMMERCIAL AETNA,8389.00,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $8,389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,ANTHEM,ANTEHM MEDICAID,1327.06,,,,,,,1327.0600,8389.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50694 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3423.93,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,ANTHEM,ANTHEM POS/HMO,8389.00,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total (Limited to $8,389.00 in Billed Charges - $0.00 in ASG Allowed Amount = $8,389.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,ANTHEM,ANTHEM PPO,8389.00,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total (Limited to $8,389.00 in Billed Charges - $0.00 in ASG Allowed Amount = $8,389.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8389.00,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $8,389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,CENPATICO,ALL MEDICAID CENPATICO,8389.00,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $8,389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7130.65,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $7,130.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,CIGNA,ALL COMMERCIAL CIGNA,5872.30,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $5,872.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,COFINITY,COFINITY,8389.00,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $8,389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1327.06,,,,,,,1327.0600,8389.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50694 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1327.06,,,,,,,1327.0600,8389.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50694 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7969.55,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $7,969.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,7046.76,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $7,046.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5956.19,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $5,956.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6123.97,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $6,123.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,4077.05,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $4,077.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7130.65,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $7,130.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HUMANA,HUMANA CHOICE CARE PPO,7130.65,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $7,130.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,3423.93,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6123.97,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $6,123.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,8389.00,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $8,389.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1327.06,,,,,,,1327.0600,8389.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50694 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3423.93,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1327.06,,,,,,,1327.0600,8389.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50694 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,1406.68,,,,,,,1327.0600,8389.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50694 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06... $1,327.06 at 106% = $1,406.68 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,3423.93,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4194.50,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $4,194.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7046.76,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $7,046.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,7703.84,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6291.75,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $6,291.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7717.88,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $7,717.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7350.03,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7350.03,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,PREVEA HEALTH NETWORK,PREVEA360,7350.03,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7350.03,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5354.70,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $5,354.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3458.17,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6040.08,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $6,040.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,TRIOLOGY,TRILOGY MEDICAID,1406.69,,,,,,,1327.0600,8389.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50694 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 106% = $1,406.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8009.70,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,8009.70,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3423.93,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,8009.70,,,,,,,1327.0600,8389.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50694 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,UNITY HEALTH PLAN,UNITY HOSPICE,3423.93,,,,,,,1327.0600,8389.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6040.08,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $6,040.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5201.18,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $5,201.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6040.08,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $6,040.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6040.08,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $6,040.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WO NEPH CATH,50694,CPT,361,RC,36100008,CDM,,,,both,,,8389.0000,5536.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5033.40,,,,,,,1327.0600,8389.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,389.00 in Billed Charges for Rev 361 Proc 50694 = $5,033.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,AETNA,AETNA HSHS,361.76,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,AETNA,ALL COMMERCIAL AETNA,560.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,ANTHEM,ANTEHM MEDICAID,560.00,,,,,,,272.1600,593.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50705 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $560.00, claim capped at $560.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,ANTHEM,ANTHEM POS/HMO,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,ANTHEM,ANTHEM PPO,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,560.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,CENPATICO,ALL MEDICAID CENPATICO,560.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,476.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,CIGNA,ALL COMMERCIAL CIGNA,392.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,COFINITY,COFINITY,560.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,560.00,,,,,,,272.1600,593.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50705 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $560.00, claim capped at $560.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,560.00,,,,,,,272.1600,593.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50705 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $560.00, claim capped at $560.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,532.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,470.40,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $470.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,397.60,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $397.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,408.80,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $408.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,272.16,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $272.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,476.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,HUMANA,HUMANA CHOICE CARE HMO,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,HUMANA,HUMANA CHOICE CARE PPO,476.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,HUMANA,HUMANA NATIIONAL POS HMO,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,408.80,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $408.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,560.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,560.00,,,,,,,272.1600,593.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50705 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $560.00, claim capped at $560.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,560.00,,,,,,,272.1600,593.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50705 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $560.00, claim capped at $560.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,593.60,,,,,,,272.1600,593.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50705 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $560.00, claim capped at $560.00 in billed charges)... $560.00 at 106% = $593.60 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,280.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $280.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,470.40,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $470.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,420.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,515.20,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $515.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA360,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,357.45,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $357.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,403.20,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,TRIOLOGY,TRILOGY MEDICAID,560.00,,,,,,,272.1600,593.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50705 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 106% = $3,310.81 (Service Line reduced to $560.00, claim capped at $560.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,560.00,,,,,,,272.1600,593.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50705 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $560.00 in Billed Charges - $0.00 in ASG Allowed Amount = $560.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,403.20,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,347.20,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $347.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,403.20,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,403.20,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC URETERAL EMBOL OR OCCLUSION W/G SI,50705,CPT,361,RC,36100010,CDM,,,,both,,,560.0000,369.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,336.00,,,,,,,272.1600,593.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 361 Proc 50705 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,AETNA,AETNA HSHS,2323.02,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,323.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,AETNA,AETNA MEDICARE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,AETNA,ALL COMMERCIAL AETNA,3596.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,ANTHEM,ANTEHM MEDICAID,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49185 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,ANTHEM,ANTHEM POS/HMO,2832.00,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,ANTHEM,ANTHEM PPO,3050.00,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3596.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,CENPATICO,ALL MEDICAID CENPATICO,3596.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3056.60,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,056.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,CIGNA,ALL COMMERCIAL CIGNA,2517.20,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,517.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,COFINITY,COFINITY,3596.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49185 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49185 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3416.20,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,416.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,3020.64,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,020.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2553.16,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,553.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2625.08,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,625.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,1747.66,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $1,747.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3056.60,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,056.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HUMANA,HUMANA CHOICE CARE HMO,3596.00,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $3,596.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,596.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HUMANA,HUMANA CHOICE CARE PPO,3056.60,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,056.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,HUMANA,HUMANA NATIIONAL POS HMO,3596.00,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $3,596.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,596.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2625.08,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,625.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,3596.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49185 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49185 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,350.57,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49185 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73... $330.73 at 106% = $350.57 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1798.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3020.64,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,020.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,3609.56,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2697.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,697.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3308.32,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $3,308.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3002.55,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3002.55,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,PREVEA HEALTH NETWORK,PREVEA360,3002.55,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3002.55,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2295.33,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,295.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1620.29,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2589.12,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,589.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,TRIOLOGY,TRILOGY MEDICAID,350.57,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49185 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 106% = $350.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3110.50,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,3110.50,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,3110.50,,,,,,,330.7300,3609.5600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 49185 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,UNITY HEALTH PLAN,UNITY HOSPICE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2589.12,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,589.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2229.52,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,229.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2589.12,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,589.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2589.12,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,589.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SCLEROTHERAPY FLUID COLLECTION PERC INJECT IG SI,49185,CPT,361,RC,36100011,CDM,,,,both,,,3596.0000,2373.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2157.60,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,596.00 in Billed Charges for Rev 361 Proc 49185 = $2,157.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,AETNA,AETNA HSHS,604.01,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $604.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,AETNA,ALL COMMERCIAL AETNA,935.00,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $935.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,ANTHEM,ANTEHM MEDICAID,935.00,,,,,,,454.4100,991.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50706 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $935.00, claim capped at $935.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,ANTHEM,ANTHEM POS/HMO,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,ANTHEM,ANTHEM PPO,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,935.00,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $935.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,CENPATICO,ALL MEDICAID CENPATICO,935.00,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $935.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,794.75,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $794.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,CIGNA,ALL COMMERCIAL CIGNA,654.50,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $654.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,COFINITY,COFINITY,935.00,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $935.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,935.00,,,,,,,454.4100,991.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50706 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $935.00, claim capped at $935.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,935.00,,,,,,,454.4100,991.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50706 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $935.00, claim capped at $935.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,888.25,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $888.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,785.40,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $785.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,663.85,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $663.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,682.55,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $682.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,454.41,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $454.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,794.75,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $794.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,HUMANA,HUMANA CHOICE CARE HMO,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,HUMANA,HUMANA CHOICE CARE PPO,794.75,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $794.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,HUMANA,HUMANA NATIIONAL POS HMO,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,682.55,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $682.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,935.00,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $935.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,935.00,,,,,,,454.4100,991.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50706 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $935.00, claim capped at $935.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,935.00,,,,,,,454.4100,991.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50706 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $935.00, claim capped at $935.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,991.10,,,,,,,454.4100,991.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50706 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 100% = $3,123.41 (Service Line reduced to $935.00, claim capped at $935.00 in billed charges)... $935.00 at 106% = $991.10 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,467.50,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $467.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,785.40,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $785.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,701.25,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $701.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,860.20,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $860.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,PREVEA HEALTH NETWORK,PREVEA360,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,596.81,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $596.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,673.20,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $673.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,TRIOLOGY,TRILOGY MEDICAID,935.00,,,,,,,454.4100,991.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00172 Proc 50706 at $125.60 (Base Rate) * 24.8679 (Relative Weight) = $3,123.41 (Total Line Payment) at 106% = $3,310.81 (Service Line reduced to $935.00, claim capped at $935.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,935.00,,,,,,,454.4100,991.1000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50706 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $935.00 in Billed Charges - $0.00 in ASG Allowed Amount = $935.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,673.20,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $673.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,579.70,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $579.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,673.20,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $673.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,673.20,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $673.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BALLOON DILATION URETERAL IG SI,50706,CPT,361,RC,36100012,CDM,,,,both,,,935.0000,617.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,561.00,,,,,,,454.4100,991.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $935.00 in Billed Charges for Rev 361 Proc 50706 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,AETNA,AETNA HSHS,11770.12,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $11,770.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,AETNA,AETNA MEDICARE,10325.10,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,AETNA,ALL COMMERCIAL AETNA,18220.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $18,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,ANTHEM,ANTEHM MEDICAID,2485.28,,,,,,,2485.2800,23231.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47383 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,10325.10,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,ANTHEM,ANTHEM POS/HMO,12888.00,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $12,888.00 at 100% of $12,888.00 = $12,888.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,ANTHEM,ANTHEM PPO,15700.00,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $15,700.00 at 100% of $15,700.00 = $15,700.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,18220.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $18,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,CENPATICO,ALL MEDICAID CENPATICO,18220.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $18,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15487.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $15,487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,CIGNA,ALL COMMERCIAL CIGNA,12754.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $12,754.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,COFINITY,COFINITY,18220.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $18,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2485.28,,,,,,,2485.2800,23231.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47383 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2485.28,,,,,,,2485.2800,23231.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47383 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17309.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $17,309.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,15304.80,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $15,304.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12936.20,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $12,936.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13300.60,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $13,300.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,8854.92,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $8,854.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15487.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $15,487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HUMANA,HUMANA CHOICE CARE PPO,15487.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $15,487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,10325.10,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13300.60,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $13,300.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,18220.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $18,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2485.28,,,,,,,2485.2800,23231.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47383 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10325.10,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2485.28,,,,,,,2485.2800,23231.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47383 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,2634.40,,,,,,,2485.2800,23231.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47383 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28... $2,485.28 at 106% = $2,634.40 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,10325.10,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9110.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $9,110.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15304.80,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $15,304.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,23231.48,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13665.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $13,665.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,16762.40,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $16,762.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9798.59,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9798.59,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,PREVEA HEALTH NETWORK,PREVEA360,9798.59,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9798.59,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11629.83,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $11,629.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,10428.35,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13118.40,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $13,118.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,TRIOLOGY,TRILOGY MEDICAID,2634.40,,,,,,,2485.2800,23231.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47383 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 106% = $2,634.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10678.60,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,10678.60,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,10325.10,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,10678.60,,,,,,,2485.2800,23231.4800,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47383 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,UNITY HEALTH PLAN,UNITY HOSPICE,10325.10,,,,,,,2485.2800,23231.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13118.40,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $13,118.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11296.40,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $11,296.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13118.40,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $13,118.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13118.40,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $13,118.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR LIVER CRYOABLATION,47383,CPT,361,RC,36100028,CDM,,,,both,,,18220.0000,12025.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10932.00,,,,,,,2485.2800,23231.4800,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $18,220.00 in Billed Charges for Rev 361 Proc 47383 = $10,932.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,AETNA,AETNA HSHS,693.16,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $693.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,AETNA,AETNA MEDICARE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,AETNA,ALL COMMERCIAL AETNA,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,ANTHEM,ANTEHM MEDICAID,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,ANTHEM,ANTHEM POS/HMO,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,ANTHEM,ANTHEM PPO,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,CENPATICO,ALL MEDICAID CENPATICO,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,912.05,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $912.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,CIGNA,ALL COMMERCIAL CIGNA,751.10,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $751.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,COFINITY,COFINITY,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1019.35,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $1,019.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,901.32,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $901.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,761.83,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $761.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,783.29,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $783.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,521.48,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $521.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,912.05,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $912.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HUMANA,HUMANA CHOICE CARE HMO,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HUMANA,HUMANA CHOICE CARE PPO,912.05,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $912.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,HUMANA,HUMANA NATIIONAL POS HMO,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,783.29,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $783.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,119.61,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84... $112.84 at 106% = $119.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,536.50,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $536.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,901.32,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $901.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,670.84,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,804.75,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $804.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,987.16,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $987.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,PREVEA HEALTH NETWORK,PREVEA360,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,684.90,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $684.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,301.13,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,772.56,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $772.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,TRIOLOGY,TRILOGY MEDICAID,119.61,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 106% = $119.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod LT ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,UNITY HEALTH PLAN,UNITY HOSPICE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,772.56,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $772.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,665.26,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $665.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,772.56,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $772.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,772.56,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $772.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-LT,20610,CPT,361,RC,36100067,CDM,,,LT,both,,,1073.0000,708.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,643.80,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod LT = $643.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,AETNA,AETNA HSHS,693.16,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $693.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,AETNA,AETNA MEDICARE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,AETNA,ALL COMMERCIAL AETNA,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,ANTHEM,ANTEHM MEDICAID,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,ANTHEM,ANTHEM POS/HMO,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,ANTHEM,ANTHEM PPO,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,CENPATICO,ALL MEDICAID CENPATICO,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,912.05,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $912.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,CIGNA,ALL COMMERCIAL CIGNA,751.10,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $751.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,COFINITY,COFINITY,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1019.35,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $1,019.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,901.32,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $901.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,761.83,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $761.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,783.29,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $783.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,521.48,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $521.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,912.05,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $912.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HUMANA,HUMANA CHOICE CARE HMO,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HUMANA,HUMANA CHOICE CARE PPO,912.05,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $912.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,HUMANA,HUMANA NATIIONAL POS HMO,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,783.29,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $783.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1073.00,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,112.84,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,119.61,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 100% = $112.84... $112.84 at 106% = $119.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,536.50,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $536.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,901.32,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $901.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,670.84,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,804.75,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $804.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,987.16,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $987.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,PREVEA HEALTH NETWORK,PREVEA360,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,684.90,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $684.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,301.13,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,772.56,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $772.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,TRIOLOGY,TRILOGY MEDICAID,119.61,,,,,,,112.8400,1073.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $112.84 at 106% = $119.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,1073.00,,,,,,,112.8400,1073.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod RT ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,073.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,073.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,UNITY HEALTH PLAN,UNITY HOSPICE,298.15,,,,,,,112.8400,1073.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,772.56,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $772.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,665.26,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $665.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,772.56,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $772.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,772.56,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $772.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-RT,20610,CPT,361,RC,36100068,CDM,,,RT,both,,,1073.0000,708.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,643.80,,,,,,,112.8400,1073.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,073.00 in Billed Charges for Rev 361 Proc 20610 Mod RT = $643.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,AETNA,AETNA HSHS,1744.20,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,700.00 in Billed Charges for Rev 361 = $1,744.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,AETNA,ALL COMMERCIAL AETNA,2700.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,700.00 in Billed Charges for Rev 361 = $2,700.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2700.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,700.00 in Billed Charges for Rev 361 = $2,700.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,CENPATICO,ALL MEDICAID CENPATICO,2700.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,700.00 in Billed Charges for Rev 361 = $2,700.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2295.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,700.00 in Billed Charges for Rev 361 = $2,295.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,CIGNA,ALL COMMERCIAL CIGNA,1890.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,700.00 in Billed Charges for Rev 361 = $1,890.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,COFINITY,COFINITY,2700.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,700.00 in Billed Charges for Rev 361 = $2,700.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2565.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,700.00 in Billed Charges for Rev 361 = $2,565.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,2268.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,700.00 in Billed Charges for Rev 361 = $2,268.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1917.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,700.00 in Billed Charges for Rev 361 = $1,917.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1971.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,700.00 in Billed Charges for Rev 361 = $1,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,1312.20,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,700.00 in Billed Charges for Rev 361 = $1,312.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2295.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,700.00 in Billed Charges for Rev 361 = $2,295.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,HUMANA,HUMANA CHOICE CARE PPO,2295.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,700.00 in Billed Charges for Rev 361 = $2,295.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1971.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,700.00 in Billed Charges for Rev 361 = $1,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2700.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,700.00 in Billed Charges for Rev 361 = $2,700.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1350.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,700.00 in Billed Charges for Rev 361 = $1,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2268.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,700.00 in Billed Charges for Rev 361 = $2,268.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2025.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,700.00 in Billed Charges for Rev 361 = $2,025.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2484.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,700.00 in Billed Charges for Rev 361 = $2,484.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1620.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,700.00 in Billed Charges for Rev 361 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1620.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,700.00 in Billed Charges for Rev 361 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,PREVEA HEALTH NETWORK,PREVEA360,1620.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,700.00 in Billed Charges for Rev 361 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1620.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,700.00 in Billed Charges for Rev 361 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1723.41,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,700.00 in Billed Charges for Rev 361 = $1,723.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1944.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,700.00 in Billed Charges for Rev 361 = $1,944.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1944.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,700.00 in Billed Charges for Rev 361 = $1,944.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1674.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,700.00 in Billed Charges for Rev 361 = $1,674.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1944.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,700.00 in Billed Charges for Rev 361 = $1,944.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1944.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,700.00 in Billed Charges for Rev 361 = $1,944.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CENTRAL LINE INSERTION,361,RC,36100093,CDM,,,,,,both,,,2700.0000,1782.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1620.00,,,,,,,1312.2000,2700.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,700.00 in Billed Charges for Rev 361 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,AETNA,AETNA HSHS,1161.51,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,161.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,AETNA,AETNA MEDICARE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,AETNA,ALL COMMERCIAL AETNA,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTEHM MEDICAID,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62320 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM POS/HMO,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM PPO,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,CENPATICO,ALL MEDICAID CENPATICO,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1528.30,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,CIGNA,ALL COMMERCIAL CIGNA,1258.60,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,258.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,COFINITY,COFINITY,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62320 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62320 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1708.10,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,708.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,1510.32,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1276.58,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,276.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1312.54,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,312.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,873.83,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $873.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1528.30,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA CHOICE CARE HMO,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA CHOICE CARE PPO,1528.30,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA NATIIONAL POS HMO,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1312.54,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,312.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62320 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62320 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,371.18,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62320 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17... $350.17 at 106% = $371.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,899.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $899.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1510.32,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,1542.70,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1348.50,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,348.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1654.16,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,654.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA360,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1147.66,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,147.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,692.51,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1294.56,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,TRIOLOGY,TRILOGY MEDICAID,371.18,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62320 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 106% = $371.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62320 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,UNITY HEALTH PLAN,UNITY HOSPICE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1294.56,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1114.76,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,114.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1294.56,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1294.56,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/O GUIDE,62320,CPT,361,RC,36100100,CDM,,,,both,,,1798.0000,1186.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1078.80,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,798.00 in Billed Charges for Rev 361 Proc 62320 = $1,078.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,AETNA,AETNA HSHS,1668.62,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,668.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,AETNA,AETNA MEDICARE,685.65,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,AETNA,ALL COMMERCIAL AETNA,2583.00,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,ANTHEM,ANTEHM MEDICAID,350.17,,,,,,,350.1700,2583.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62323 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,685.65,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,ANTHEM,ANTHEM POS/HMO,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,ANTHEM,ANTHEM PPO,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2583.00,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,CENPATICO,ALL MEDICAID CENPATICO,2583.00,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2195.55,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,195.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,CIGNA,ALL COMMERCIAL CIGNA,1808.10,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,808.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,COFINITY,COFINITY,2583.00,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,350.17,,,,,,,350.1700,2583.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62323 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,350.17,,,,,,,350.1700,2583.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62323 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2453.85,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,453.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,2169.72,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,169.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1833.93,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,833.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1885.59,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,885.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,1255.34,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,255.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2195.55,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,195.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HUMANA,HUMANA CHOICE CARE HMO,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HUMANA,HUMANA CHOICE CARE PPO,2195.55,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,195.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,685.65,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,HUMANA,HUMANA NATIIONAL POS HMO,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1885.59,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,885.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2583.00,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,350.17,,,,,,,350.1700,2583.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62323 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,685.65,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,350.17,,,,,,,350.1700,2583.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62323 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,371.18,,,,,,,350.1700,2583.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62323 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17... $350.17 at 106% = $371.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,685.65,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1291.50,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,291.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2169.72,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,169.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,1542.70,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1937.25,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,937.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2376.36,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $2,376.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,PREVEA HEALTH NETWORK,PREVEA360,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1648.73,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,648.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,692.51,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1859.76,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,859.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,TRIOLOGY,TRILOGY MEDICAID,371.18,,,,,,,350.1700,2583.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62323 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 106% = $371.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,685.65,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,2583.00,,,,,,,350.1700,2583.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62323 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,583.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,583.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,UNITY HEALTH PLAN,UNITY HOSPICE,685.65,,,,,,,350.1700,2583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1859.76,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,859.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1601.46,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,601.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1859.76,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,859.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1859.76,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,859.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/GUIDE,62323,CPT,361,RC,36100103,CDM,,,,both,,,2583.0000,1704.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1549.80,,,,,,,350.1700,2583.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,583.00 in Billed Charges for Rev 361 Proc 62323 = $1,549.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,AETNA,AETNA HSHS,1450.92,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,450.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,AETNA,AETNA MEDICARE,859.12,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,AETNA,ALL COMMERCIAL AETNA,2246.00,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $2,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,ANTHEM,ANTEHM MEDICAID,350.17,,,,,,,350.1700,2246.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62327 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,859.12,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,ANTHEM,ANTHEM POS/HMO,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,ANTHEM,ANTHEM PPO,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2246.00,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $2,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,CENPATICO,ALL MEDICAID CENPATICO,2246.00,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $2,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1909.10,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,909.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,CIGNA,ALL COMMERCIAL CIGNA,1572.20,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,572.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,COFINITY,COFINITY,2246.00,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $2,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,350.17,,,,,,,350.1700,2246.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62327 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,350.17,,,,,,,350.1700,2246.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62327 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2133.70,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $2,133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,1886.64,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,886.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1594.66,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,594.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1639.58,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,639.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,1091.56,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,091.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1909.10,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,909.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HUMANA,HUMANA CHOICE CARE HMO,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HUMANA,HUMANA CHOICE CARE PPO,1909.10,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,909.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,859.12,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,HUMANA,HUMANA NATIIONAL POS HMO,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1639.58,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,639.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2246.00,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $2,246.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,350.17,,,,,,,350.1700,2246.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62327 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,859.12,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,350.17,,,,,,,350.1700,2246.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62327 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,371.18,,,,,,,350.1700,2246.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62327 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17... $350.17 at 106% = $371.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,859.12,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1123.00,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1886.64,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,886.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,1933.01,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1684.50,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,684.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2066.32,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $2,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,PREVEA HEALTH NETWORK,PREVEA360,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1433.62,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,433.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,867.71,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1617.12,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,617.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,TRIOLOGY,TRILOGY MEDICAID,371.18,,,,,,,350.1700,2246.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62327 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 106% = $371.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,859.12,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,2246.00,,,,,,,350.1700,2246.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62327 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,246.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,246.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,UNITY HEALTH PLAN,UNITY HOSPICE,859.12,,,,,,,350.1700,2246.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1617.12,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,617.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1392.52,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,392.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1617.12,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,617.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1617.12,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,617.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/GUIDE,62327,CPT,361,RC,36100107,CDM,,,,both,,,2246.0000,1482.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1347.60,,,,,,,350.1700,2246.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,246.00 in Billed Charges for Rev 361 Proc 62327 = $1,347.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,AETNA,AETNA HSHS,899.88,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $899.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,AETNA,AETNA MEDICARE,407.51,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,AETNA,ALL COMMERCIAL AETNA,1393.00,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,393.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,ANTHEM,ANTEHM MEDICAID,123.63,,,,,,,123.6300,1393.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00039 Proc 29445 at $125.60 (Base Rate) * 0.6562 (Relative Weight) = $82.42 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $123.63 at 100% = $123.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,407.51,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,ANTHEM,ANTHEM POS/HMO,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,ANTHEM,ANTHEM PPO,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1393.00,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,393.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,CENPATICO,ALL MEDICAID CENPATICO,1393.00,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,393.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1184.05,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,184.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,CIGNA,ALL COMMERCIAL CIGNA,975.10,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $975.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,COFINITY,COFINITY,1393.00,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,393.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,123.63,,,,,,,123.6300,1393.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00039 Proc 29445 at $125.60 (Base Rate) * 0.6562 (Relative Weight) = $82.42 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $123.63 at 100% = $123.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,123.63,,,,,,,123.6300,1393.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00039 Proc 29445 at $125.60 (Base Rate) * 0.6562 (Relative Weight) = $82.42 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $123.63 at 100% = $123.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1323.35,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,323.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,1170.12,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,170.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,989.03,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $989.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1016.89,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,016.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,677.00,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $677.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1184.05,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,184.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HUMANA,HUMANA CHOICE CARE HMO,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $3,061.00 at 100% of $3,061.00 + 50% of $3,061.00 = $4,591.50 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HUMANA,HUMANA CHOICE CARE PPO,1184.05,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,184.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HUMANA,HUMANA MEDICARE ADVANTAGE,407.51,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,HUMANA,HUMANA NATIIONAL POS HMO,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $3,061.00 at 100% of $3,061.00 + 50% of $3,061.00 = $4,591.50 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1016.89,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,016.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1393.00,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,393.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,123.63,,,,,,,123.6300,1393.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00039 Proc 29445 at $125.60 (Base Rate) * 0.6562 (Relative Weight) = $82.42 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $123.63 at 100% = $123.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,407.51,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,123.63,,,,,,,123.6300,1393.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00039 Proc 29445 at $125.60 (Base Rate) * 0.6562 (Relative Weight) = $82.42 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $123.63 at 100% = $123.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,MOLINA HEALTHCARE,MOLINA MEDICAID,131.05,,,,,,,123.6300,1393.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00039 Proc 29445 at $125.60 (Base Rate) * 0.6562 (Relative Weight) = $82.42 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $123.63 at 100% = $123.63... $123.63 at 106% = $131.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,MOLINA HEALTHCARE,MOLINA MEDICARE,407.51,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,696.50,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $696.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1170.12,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,170.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,NAPHCARE,ALL COMMERICAL NAPHCARE,916.90,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1044.75,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,044.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1281.56,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,281.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $2,048.23 at 150% (50 @ 150%) Mod Percentage = $3,072.35 at 100% of $3,072.35 = $3,072.35 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $2,048.23 at 150% (50 @ 150%) Mod Percentage = $3,072.35 at 100% of $3,072.35 = $3,072.35 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,PREVEA HEALTH NETWORK,PREVEA360,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $2,048.23 at 100% of $2,048.23 + 50% of $2,048.23 = $3,072.35 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $2,048.23 at 150% (50 @ 150%) Mod Percentage = $3,072.35 at 100% of $3,072.35 = $3,072.35 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,889.15,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $889.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,411.59,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1002.96,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,002.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,TRIOLOGY,TRILOGY MEDICAID,131.05,,,,,,,123.6300,1393.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00039 Proc 29445 at $125.60 (Base Rate) * 0.6562 (Relative Weight) = $82.42 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $123.63 at 106% = $131.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $2,153.10 at 100% of $2,153.10 + 50% of $2,153.10 = $3,229.65 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,UNITED HEALTHCARE,UHC ONEIDA NATION,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $2,153.10 at 100% of $2,153.10 + 50% of $2,153.10 = $3,229.65 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,407.51,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,UNITED HEALTHCARE,UNITED HEALTHCARE,1393.00,,,,,,,123.6300,1393.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 29445 Mod 50 ASG Rate of $2,153.10 at 100% of $2,153.10 + 50% of $2,153.10 = $3,229.65 Total (Limited to $1,393.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,393.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,UNITY HEALTH PLAN,UNITY HOSPICE,407.51,,,,,,,123.6300,1393.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1002.96,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,002.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,863.66,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $863.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1002.96,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,002.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1002.96,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $1,002.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC APPL CAST LEG RIGID CONTACT -BIL,29445,CPT,361,RC,36100108,CDM,,,50,both,,,1393.0000,919.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,835.80,,,,,,,123.6300,1393.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,393.00 in Billed Charges for Rev 361 Proc 29445 Mod 50 = $835.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,AETNA,AETNA HSHS,1985.80,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $1,985.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,AETNA,AETNA MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,AETNA,ALL COMMERCIAL AETNA,3074.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,ANTHEM,ANTEHM MEDICAID,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31625 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,ANTHEM,ANTHEM POS/HMO,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,ANTHEM,ANTHEM PPO,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3074.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,CENPATICO,ALL MEDICAID CENPATICO,3074.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2612.90,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,612.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,CIGNA,ALL COMMERCIAL CIGNA,2151.80,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,151.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,COFINITY,COFINITY,3074.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31625 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31625 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2920.30,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,920.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,2582.16,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,582.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2182.54,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,182.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2244.02,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,244.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,1493.96,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $1,493.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2612.90,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,612.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,HUMANA CHOICE CARE HMO,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,HUMANA CHOICE CARE PPO,2612.90,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,612.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,HUMANA NATIIONAL POS HMO,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2244.02,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,244.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3074.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31625 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31625 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,870.80,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31625 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51... $821.51 at 106% = $870.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1537.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $1,537.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2582.16,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,582.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,3889.96,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2305.50,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,305.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2828.08,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,828.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,PREVEA HEALTH NETWORK,PREVEA360,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1962.13,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $1,962.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1746.16,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2213.28,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,213.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,TRIOLOGY,TRILOGY MEDICAID,870.80,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31625 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 106% = $870.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,3074.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31625 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,UNITY HEALTH PLAN,UNITY HOSPICE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2213.28,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,213.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1905.88,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $1,905.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2213.28,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,213.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2213.28,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $2,213.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY BX SGL/MULT SITES,31625,CPT,361,RC,36100135,CDM,,,,both,,,3074.0000,2028.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1844.40,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,074.00 in Billed Charges for Rev 361 Proc 31625 = $1,844.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,AETNA,AETNA HSHS,4167.99,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,167.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,AETNA,AETNA MEDICARE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,AETNA,ALL COMMERCIAL AETNA,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,ANTHEM,ANTEHM MEDICAID,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31629 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,ANTHEM,ANTHEM POS/HMO,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total (Limited to $6,452.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,452.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,ANTHEM,ANTHEM PPO,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total (Limited to $6,452.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,452.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,CENPATICO,ALL MEDICAID CENPATICO,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5484.20,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $5,484.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,CIGNA,ALL COMMERCIAL CIGNA,4516.40,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,516.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,COFINITY,COFINITY,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31629 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31629 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6129.40,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $6,129.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,5419.68,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $5,419.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4580.92,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,580.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4709.96,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,709.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,3135.67,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $3,135.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5484.20,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $5,484.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,HUMANA CHOICE CARE HMO,5023.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,HUMANA CHOICE CARE PPO,5484.20,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $5,484.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,HUMANA NATIIONAL POS HMO,5023.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4709.96,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,709.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31629 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31629 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,870.80,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31629 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51... $821.51 at 106% = $870.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3226.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $3,226.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5419.68,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $5,419.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,8148.29,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4839.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,839.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5935.84,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $5,935.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $6,452.00, claim capped at $6,452.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $6,452.00, claim capped at $6,452.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,PREVEA HEALTH NETWORK,PREVEA360,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $6,452.00, claim capped at $6,452.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $6,452.00, claim capped at $6,452.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4118.31,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,118.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3657.67,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4645.44,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,645.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,TRIOLOGY,TRILOGY MEDICAID,870.80,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31629 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 106% = $870.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $6,452.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,452.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $6,452.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,452.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31629 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $6,452.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,452.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,UNITY HEALTH PLAN,UNITY HOSPICE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4645.44,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,645.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4000.24,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,000.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4645.44,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,645.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4645.44,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $4,645.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/ASP BX TRANSHC BRONCH,31629,CPT,361,RC,36100137,CDM,,,,both,,,6452.0000,4258.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3871.20,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,452.00 in Billed Charges for Rev 361 Proc 31629 = $3,871.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,AETNA,AETNA HSHS,4167.99,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,167.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,AETNA,AETNA MEDICARE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,AETNA,ALL COMMERCIAL AETNA,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,ANTHEM,ANTEHM MEDICAID,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31628 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,ANTHEM,ANTHEM POS/HMO,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total (Limited to $6,452.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,452.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,ANTHEM,ANTHEM PPO,6452.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total (Limited to $6,452.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,452.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,CENPATICO,ALL MEDICAID CENPATICO,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5484.20,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $5,484.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,CIGNA,ALL COMMERCIAL CIGNA,4516.40,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,516.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,COFINITY,COFINITY,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31628 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31628 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6129.40,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $6,129.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,5419.68,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $5,419.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4580.92,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,580.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4709.96,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,709.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,3135.67,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $3,135.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5484.20,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $5,484.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,HUMANA CHOICE CARE HMO,5023.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,HUMANA CHOICE CARE PPO,5484.20,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $5,484.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,HUMANA,HUMANA NATIIONAL POS HMO,5023.00,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4709.96,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,709.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,6452.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $6,452.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31628 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,821.51,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31628 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,870.80,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31628 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51... $821.51 at 106% = $870.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3226.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $3,226.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5419.68,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $5,419.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,8148.29,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4839.00,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,839.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5935.84,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $5,935.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4366.95,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4366.95,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,PREVEA HEALTH NETWORK,PREVEA360,4366.95,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4366.95,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4118.31,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,118.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3657.67,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4645.44,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,645.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,TRIOLOGY,TRILOGY MEDICAID,870.80,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31628 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 106% = $870.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4523.30,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,4523.30,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,4523.30,,,,,,,821.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31628 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,UNITY HEALTH PLAN,UNITY HOSPICE,3621.46,,,,,,,821.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4645.44,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,645.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4000.24,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,000.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4645.44,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,645.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4645.44,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $4,645.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BX TRANSHC BRONCH SGL,31628,CPT,361,RC,36100141,CDM,,,,both,,,6452.0000,4258.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3871.20,,,,,,,821.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,452.00 in Billed Charges for Rev 361 Proc 31628 = $3,871.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,AETNA,AETNA HSHS,1899.24,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $1,899.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,AETNA,AETNA MEDICARE,903.30,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,AETNA,ALL COMMERCIAL AETNA,2940.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,940.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,ANTHEM,ANTEHM MEDICAID,659.22,,,,,,,659.2200,2940.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00141 Proc 46221 at $125.60 (Base Rate) * 5.2486 (Relative Weight) = $659.22 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $659.22 at 100% = $659.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,903.30,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,ANTHEM,ANTHEM POS/HMO,2832.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,ANTHEM,ANTHEM PPO,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2940.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,940.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,CENPATICO,ALL MEDICAID CENPATICO,2940.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,940.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2499.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,499.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,CIGNA,ALL COMMERCIAL CIGNA,2058.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,058.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,COFINITY,COFINITY,2940.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,940.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,659.22,,,,,,,659.2200,2940.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00141 Proc 46221 at $125.60 (Base Rate) * 5.2486 (Relative Weight) = $659.22 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $659.22 at 100% = $659.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,659.22,,,,,,,659.2200,2940.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00141 Proc 46221 at $125.60 (Base Rate) * 5.2486 (Relative Weight) = $659.22 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $659.22 at 100% = $659.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2793.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,793.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,2469.60,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,469.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2087.40,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,087.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2146.20,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,146.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,1428.84,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $1,428.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2499.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,499.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HUMANA,HUMANA CHOICE CARE HMO,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HUMANA,HUMANA CHOICE CARE PPO,2499.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,499.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,903.30,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,HUMANA,HUMANA NATIIONAL POS HMO,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2146.20,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,146.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2940.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,940.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,659.22,,,,,,,659.2200,2940.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00141 Proc 46221 at $125.60 (Base Rate) * 5.2486 (Relative Weight) = $659.22 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $659.22 at 100% = $659.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,903.30,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,659.22,,,,,,,659.2200,2940.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00141 Proc 46221 at $125.60 (Base Rate) * 5.2486 (Relative Weight) = $659.22 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $659.22 at 100% = $659.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,698.77,,,,,,,659.2200,2940.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00141 Proc 46221 at $125.60 (Base Rate) * 5.2486 (Relative Weight) = $659.22 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $659.22 at 100% = $659.22... $659.22 at 106% = $698.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,903.30,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1470.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $1,470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2469.60,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,469.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,2032.42,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2205.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,205.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2704.80,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,704.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,PREVEA HEALTH NETWORK,PREVEA360,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1876.60,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $1,876.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,912.33,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2116.80,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,116.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,TRIOLOGY,TRILOGY MEDICAID,698.78,,,,,,,659.2200,2940.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00141 Proc 46221 at $125.60 (Base Rate) * 5.2486 (Relative Weight) = $659.22 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $659.22 at 106% = $698.78. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,903.30,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,2940.00,,,,,,,659.2200,2940.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 46221 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,940.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,940.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,UNITY HEALTH PLAN,UNITY HOSPICE,903.30,,,,,,,659.2200,2940.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2116.80,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,116.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1822.80,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $1,822.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2116.80,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,116.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2116.80,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $2,116.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HEMORRHOIDECTOMY INTERNAL W/LIGATION,46221,CPT,361,RC,36100175,CDM,,,,both,,,2940.0000,1940.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1764.00,,,,,,,659.2200,2940.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,940.00 in Billed Charges for Rev 361 Proc 46221 = $1,764.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,AETNA,AETNA HSHS,724.17,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $724.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,AETNA,AETNA MEDICARE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,AETNA,ALL COMMERCIAL AETNA,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,ANTHEM,ANTEHM MEDICAID,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,ANTHEM,ANTHEM POS/HMO,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,ANTHEM,ANTHEM PPO,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,CENPATICO,ALL MEDICAID CENPATICO,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,952.85,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $952.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,CIGNA,ALL COMMERCIAL CIGNA,784.70,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $784.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,COFINITY,COFINITY,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1064.95,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $1,064.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,941.64,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $941.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,795.91,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $795.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,818.33,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $818.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,544.81,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $544.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,952.85,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $952.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HUMANA,HUMANA CHOICE CARE HMO,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HUMANA,HUMANA CHOICE CARE PPO,952.85,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $952.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,HUMANA,HUMANA NATIIONAL POS HMO,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,818.33,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $818.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,621.74,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55... $586.55 at 106% = $621.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,560.50,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,941.64,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $941.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,1542.70,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,840.75,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $840.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1031.32,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $1,031.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,PREVEA HEALTH NETWORK,PREVEA360,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,715.53,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $715.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,692.51,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,807.12,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $807.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,TRIOLOGY,TRILOGY MEDICAID,621.75,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 106% = $621.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,1121.00,,,,,,,544.8100,1542.7000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64447 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,121.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,121.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,UNITY HEALTH PLAN,UNITY HOSPICE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,807.12,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $807.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,695.02,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $695.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,807.12,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $807.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,807.12,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $807.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE W/IMG GUID IF PERFORMED,64447,CPT,361,RC,36100196,CDM,,,,both,,,1121.0000,739.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,672.60,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,121.00 in Billed Charges for Rev 361 Proc 64447 = $672.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,AETNA,AETNA HSHS,2191.23,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,191.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,AETNA,AETNA MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,AETNA,ALL COMMERCIAL AETNA,3392.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,ANTHEM,ANTEHM MEDICAID,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31635 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,ANTHEM,ANTHEM POS/HMO,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,ANTHEM,ANTHEM PPO,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3392.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,CENPATICO,ALL MEDICAID CENPATICO,3392.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2883.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,883.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,CIGNA,ALL COMMERCIAL CIGNA,2374.40,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,374.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,COFINITY,COFINITY,3392.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31635 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31635 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3222.40,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $3,222.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,2849.28,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,849.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2408.32,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,408.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2476.16,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,476.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,1648.51,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $1,648.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2883.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,883.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,HUMANA CHOICE CARE HMO,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,HUMANA CHOICE CARE PPO,2883.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,883.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,HUMANA NATIIONAL POS HMO,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2476.16,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,476.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,3392.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31635 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31635 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,870.80,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31635 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51... $821.51 at 106% = $870.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1696.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $1,696.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2849.28,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,849.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,3889.96,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2544.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,544.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3120.64,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $3,120.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,PREVEA HEALTH NETWORK,PREVEA360,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2165.11,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,165.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1746.16,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2442.24,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,442.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,TRIOLOGY,TRILOGY MEDICAID,870.80,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31635 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 106% = $870.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,3392.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31635 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,UNITY HEALTH PLAN,UNITY HOSPICE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2442.24,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,442.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2103.04,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,103.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2442.24,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,442.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2442.24,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,442.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/REM FOREIGN BODY,31635,CPT,361,RC,36100227,CDM,,,,both,,,3392.0000,2238.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2035.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,392.00 in Billed Charges for Rev 361 Proc 31635 = $2,035.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,AETNA,AETNA HSHS,2191.23,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,191.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,AETNA,AETNA MEDICARE,3621.46,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,AETNA,ALL COMMERCIAL AETNA,3392.00,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,ANTHEM,ANTEHM MEDICAID,1673.77,,,,,,,1648.5100,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31641 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3392.00,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,ANTHEM,ANTHEM POS/HMO,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,ANTHEM,ANTHEM PPO,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3392.00,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,CENPATICO,ALL MEDICAID CENPATICO,3392.00,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2883.20,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,883.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,CIGNA,ALL COMMERCIAL CIGNA,2374.40,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,374.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,COFINITY,COFINITY,3392.00,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1673.77,,,,,,,1648.5100,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31641 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1673.77,,,,,,,1648.5100,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31641 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3222.40,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $3,222.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,2849.28,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,849.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2408.32,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,408.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2476.16,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,476.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,1648.51,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $1,648.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2883.20,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,883.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,HUMANA CHOICE CARE HMO,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,HUMANA CHOICE CARE PPO,2883.20,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,883.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,3392.00,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,HUMANA,HUMANA NATIIONAL POS HMO,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2476.16,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,476.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,3392.00,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $3,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1673.77,,,,,,,1648.5100,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31641 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3621.46,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1673.77,,,,,,,1648.5100,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31641 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,1774.20,,,,,,,1648.5100,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31641 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77... $1,673.77 at 106% = $1,774.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,3621.46,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1696.00,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $1,696.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2849.28,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,849.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,8148.29,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2544.00,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,544.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3120.64,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $3,120.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $3,392.00, claim capped at $3,392.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $3,392.00, claim capped at $3,392.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,PREVEA HEALTH NETWORK,PREVEA360,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $3,392.00, claim capped at $3,392.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $3,392.00, claim capped at $3,392.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2165.11,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,165.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3657.67,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2442.24,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,442.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,TRIOLOGY,TRILOGY MEDICAID,1774.20,,,,,,,1648.5100,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31641 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 106% = $1,774.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3392.00,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,3392.00,,,,,,,1648.5100,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31641 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $3,392.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,392.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,UNITY HEALTH PLAN,UNITY HOSPICE,3621.46,,,,,,,1648.5100,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2442.24,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,442.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2103.04,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,103.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2442.24,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,442.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2442.24,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,442.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TUMOR DESTRUCTION,31641,CPT,361,RC,36100228,CDM,,,,both,,,3392.0000,2238.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2035.20,,,,,,,1648.5100,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,392.00 in Billed Charges for Rev 361 Proc 31641 = $2,035.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,AETNA,AETNA HSHS,8357.95,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $8,357.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,AETNA,AETNA MEDICARE,3423.93,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,AETNA,ALL COMMERCIAL AETNA,12938.00,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $12,938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,ANTHEM,ANTEHM MEDICAID,671.16,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50436 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3423.93,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,ANTHEM,ANTHEM POS/HMO,4804.00,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,ANTHEM,ANTHEM PPO,5200.00,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12938.00,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $12,938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,CENPATICO,ALL MEDICAID CENPATICO,12938.00,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $12,938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10997.30,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $10,997.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,CIGNA,ALL COMMERCIAL CIGNA,9056.60,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,056.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,COFINITY,COFINITY,12938.00,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $12,938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,671.16,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50436 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,671.16,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50436 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12291.10,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $12,291.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,10867.92,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $10,867.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9185.98,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,185.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9444.74,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,444.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,6287.87,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $6,287.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10997.30,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $10,997.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HUMANA,HUMANA CHOICE CARE PPO,10997.30,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $10,997.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HUMANA,HUMANA MEDICARE ADVANTAGE,3423.93,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9444.74,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,444.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,12938.00,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $12,938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,671.16,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50436 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3423.93,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,671.16,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50436 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,711.43,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50436 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16... $671.16 at 106% = $711.43 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,MOLINA HEALTHCARE,MOLINA MEDICARE,3423.93,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6469.00,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $6,469.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10867.92,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $10,867.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,NAPHCARE,ALL COMMERICAL NAPHCARE,7703.84,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9703.50,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,703.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11902.96,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $11,902.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5600.43,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5600.43,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,PREVEA HEALTH NETWORK,PREVEA360,5600.43,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5600.43,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8258.33,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $8,258.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3458.17,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9315.36,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,315.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,TRIOLOGY,TRILOGY MEDICAID,711.43,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50436 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 106% = $711.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6103.40,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,6103.40,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3423.93,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,6103.40,,,,,,,671.1600,12938.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50436 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,UNITY HEALTH PLAN,UNITY HOSPICE,3423.93,,,,,,,671.1600,12938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9315.36,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,315.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8021.56,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $8,021.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9315.36,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,315.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9315.36,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $9,315.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE,50436,CPT,361,RC,36100230,CDM,,,,both,,,12938.0000,8539.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7762.80,,,,,,,671.1600,12938.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $12,938.00 in Billed Charges for Rev 361 Proc 50436 = $7,762.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,AETNA,AETNA HSHS,8529.78,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $8,529.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,AETNA,AETNA MEDICARE,3423.93,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,AETNA,ALL COMMERCIAL AETNA,13204.00,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $13,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,ANTHEM,ANTEHM MEDICAID,671.16,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50437 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3423.93,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,ANTHEM,ANTHEM POS/HMO,8466.00,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,ANTHEM,ANTHEM PPO,8850.00,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13204.00,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $13,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,CENPATICO,ALL MEDICAID CENPATICO,13204.00,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $13,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11223.40,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $11,223.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,CIGNA,ALL COMMERCIAL CIGNA,9242.80,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,242.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,COFINITY,COFINITY,13204.00,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $13,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,671.16,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50437 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,671.16,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50437 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12543.80,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $12,543.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,11091.36,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $11,091.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9374.84,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,374.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9638.92,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,638.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,6417.14,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $6,417.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11223.40,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $11,223.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HUMANA,HUMANA CHOICE CARE PPO,11223.40,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $11,223.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,3423.93,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9638.92,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,638.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,13204.00,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $13,204.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,671.16,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50437 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3423.93,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,671.16,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50437 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,711.43,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50437 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16... $671.16 at 106% = $711.43 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,3423.93,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6602.00,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $6,602.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11091.36,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $11,091.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,7703.84,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9903.00,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,903.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12147.68,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $12,147.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7350.03,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7350.03,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,PREVEA HEALTH NETWORK,PREVEA360,7350.03,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7350.03,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8428.11,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $8,428.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3458.17,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9506.88,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,506.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,TRIOLOGY,TRILOGY MEDICAID,711.43,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50437 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 106% = $711.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8009.70,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,8009.70,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3423.93,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,8009.70,,,,,,,671.1600,13204.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50437 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,UNITY HEALTH PLAN,UNITY HOSPICE,3423.93,,,,,,,671.1600,13204.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9506.88,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,506.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8186.48,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $8,186.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9506.88,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,506.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9506.88,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $9,506.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DILATION EXIST TRACT ENDOURAL W/GUIDE & NEW RENAL ACCESS,50437,CPT,361,RC,36100231,CDM,,,,both,,,13204.0000,8714.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7922.40,,,,,,,671.1600,13204.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $13,204.00 in Billed Charges for Rev 361 Proc 50437 = $7,922.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,AETNA,AETNA HSHS,299.74,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $299.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,AETNA,AETNA MEDICARE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,AETNA,ALL COMMERCIAL AETNA,464.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $464.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,ANTHEM,ANTEHM MEDICAID,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11102 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,ANTHEM,ANTHEM POS/HMO,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,ANTHEM,ANTHEM PPO,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,464.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $464.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,CENPATICO,ALL MEDICAID CENPATICO,464.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $464.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,394.40,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $394.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,CIGNA,ALL COMMERCIAL CIGNA,324.80,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $324.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,COFINITY,COFINITY,464.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $464.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11102 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11102 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,440.80,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $440.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,389.76,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $389.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,329.44,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $329.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,338.72,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $338.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,225.50,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $225.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,394.40,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $394.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HUMANA,HUMANA CHOICE CARE HMO,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HUMANA,HUMANA CHOICE CARE PPO,394.40,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $394.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,HUMANA,HUMANA NATIIONAL POS HMO,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,338.72,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $338.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,464.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $464.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11102 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11102 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,204.29,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11102 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73... $192.73 at 106% = $204.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,232.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $232.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,389.76,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $389.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,888.44,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,348.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $348.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,426.88,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $426.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,PREVEA HEALTH NETWORK,PREVEA360,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,296.17,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $296.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,398.81,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,334.08,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $334.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,TRIOLOGY,TRILOGY MEDICAID,204.30,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11102 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 106% = $204.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,464.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11102 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $464.00 in Billed Charges - $0.00 in ASG Allowed Amount = $464.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,UNITY HEALTH PLAN,UNITY HOSPICE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,334.08,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $334.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,287.68,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $287.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,334.08,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $334.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,334.08,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $334.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL INIT LESN,11102,CPT,361,RC,36100235,CDM,,,,both,,,464.0000,306.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,278.40,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $464.00 in Billed Charges for Rev 361 Proc 11102 = $278.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,AETNA,AETNA HSHS,392.77,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $392.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,AETNA,AETNA MEDICARE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,AETNA,ALL COMMERCIAL AETNA,608.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $608.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,ANTHEM,ANTEHM MEDICAID,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11104 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,ANTHEM,ANTHEM POS/HMO,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,ANTHEM,ANTHEM PPO,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,608.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $608.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,CENPATICO,ALL MEDICAID CENPATICO,608.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $608.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,516.80,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $516.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,CIGNA,ALL COMMERCIAL CIGNA,425.60,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $425.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,COFINITY,COFINITY,608.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $608.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11104 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11104 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,577.60,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $577.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,510.72,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $510.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,431.68,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $431.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,443.84,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $443.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,295.49,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $295.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,516.80,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $516.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HUMANA,HUMANA CHOICE CARE HMO,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HUMANA,HUMANA CHOICE CARE PPO,516.80,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $516.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,HUMANA,HUMANA NATIIONAL POS HMO,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,443.84,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $443.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,608.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $608.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11104 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,192.73,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11104 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,204.29,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11104 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73... $192.73 at 106% = $204.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,304.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $304.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,510.72,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $510.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,888.44,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,456.00,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $456.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,559.36,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $559.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,PREVEA HEALTH NETWORK,PREVEA360,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,388.09,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $388.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,398.81,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,437.76,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $437.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,TRIOLOGY,TRILOGY MEDICAID,204.30,,,,,,,192.7300,888.4400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11104 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 106% = $204.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,608.00,,,,,,,192.7300,888.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11104 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $608.00 in Billed Charges - $0.00 in ASG Allowed Amount = $608.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,UNITY HEALTH PLAN,UNITY HOSPICE,394.86,,,,,,,192.7300,888.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,437.76,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $437.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,376.96,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $376.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,437.76,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $437.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,437.76,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $437.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH INIT LESN,11104,CPT,361,RC,36100236,CDM,,,,both,,,608.0000,401.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,364.80,,,,,,,192.7300,888.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $608.00 in Billed Charges for Rev 361 Proc 11104 = $364.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,AETNA,AETNA HSHS,1223.52,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,223.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,AETNA,AETNA MEDICARE,687.83,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,AETNA,ALL COMMERCIAL AETNA,1894.00,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,894.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,ANTHEM,ANTEHM MEDICAID,313.03,,,,,,,313.0300,1894.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10005 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,687.83,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,ANTHEM,ANTHEM POS/HMO,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,ANTHEM,ANTHEM PPO,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1894.00,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,894.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,CENPATICO,ALL MEDICAID CENPATICO,1894.00,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,894.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1609.90,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,609.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,CIGNA,ALL COMMERCIAL CIGNA,1325.80,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,325.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,COFINITY,COFINITY,1894.00,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,894.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,313.03,,,,,,,313.0300,1894.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10005 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,313.03,,,,,,,313.0300,1894.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10005 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1799.30,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,799.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,1590.96,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,590.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1344.74,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,344.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1382.62,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,382.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,920.48,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $920.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1609.90,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,609.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HUMANA,HUMANA CHOICE CARE HMO,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HUMANA,HUMANA CHOICE CARE PPO,1609.90,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,609.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HUMANA,HUMANA MEDICARE ADVANTAGE,687.83,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,HUMANA,HUMANA NATIIONAL POS HMO,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1382.62,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,382.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1894.00,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,894.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,313.03,,,,,,,313.0300,1894.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10005 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,687.83,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,313.03,,,,,,,313.0300,1894.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10005 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,MOLINA HEALTHCARE,MOLINA MEDICAID,331.81,,,,,,,313.0300,1894.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10005 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03... $313.03 at 106% = $331.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,MOLINA HEALTHCARE,MOLINA MEDICARE,687.83,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,947.00,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $947.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1590.96,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,590.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,NAPHCARE,ALL COMMERICAL NAPHCARE,1547.62,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1420.50,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,420.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1742.48,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,742.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,PREVEA HEALTH NETWORK,PREVEA360,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1208.94,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,208.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,694.71,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1363.68,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,363.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,TRIOLOGY,TRILOGY MEDICAID,331.81,,,,,,,313.0300,1894.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10005 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 106% = $331.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,687.83,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,1894.00,,,,,,,313.0300,1894.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10005 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,894.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,894.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,UNITY HEALTH PLAN,UNITY HOSPICE,687.83,,,,,,,313.0300,1894.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1363.68,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,363.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1174.28,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,174.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1363.68,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,363.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1363.68,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,363.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE INIT LESN,10005,CPT,361,RC,36100238,CDM,,,,both,,,1894.0000,1250.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1136.40,,,,,,,313.0300,1894.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,894.00 in Billed Charges for Rev 361 Proc 10005 = $1,136.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,AETNA,AETNA HSHS,1063.96,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,063.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,AETNA,AETNA MEDICARE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,AETNA,ALL COMMERCIAL AETNA,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,ANTHEM,ANTEHM MEDICAID,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10007 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM POS/HMO,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM PPO,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,CENPATICO,ALL MEDICAID CENPATICO,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1399.95,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,CIGNA,ALL COMMERCIAL CIGNA,1152.90,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,152.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,COFINITY,COFINITY,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10007 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10007 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1564.65,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,564.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,1383.48,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,383.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1169.37,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,169.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1202.31,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,202.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,800.44,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $800.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1399.95,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,HUMANA CHOICE CARE HMO,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,HUMANA CHOICE CARE PPO,1399.95,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,HUMANA NATIIONAL POS HMO,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1202.31,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,202.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10007 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10007 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,331.81,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10007 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03... $313.03 at 106% = $331.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,823.50,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $823.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1383.48,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,383.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,1547.62,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1235.25,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,235.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1515.24,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,515.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA360,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1051.28,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,051.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,694.71,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1185.84,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,TRIOLOGY,TRILOGY MEDICAID,331.81,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10007 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 106% = $331.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10007 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,UNITY HEALTH PLAN,UNITY HOSPICE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1185.84,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1021.14,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,021.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1185.84,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1185.84,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE INIT LESN,10007,CPT,361,RC,36100240,CDM,,,,both,,,1647.0000,1087.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,988.20,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,647.00 in Billed Charges for Rev 361 Proc 10007 = $988.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,AETNA,AETNA HSHS,532.30,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $532.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,AETNA,ALL COMMERCIAL AETNA,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTEHM MEDICAID,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10008 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,CENPATICO,ALL MEDICAID CENPATICO,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,CIGNA,ALL COMMERCIAL CIGNA,576.80,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $576.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,COFINITY,COFINITY,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10008 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10008 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,782.80,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $782.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,692.16,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $692.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,585.04,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $585.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,601.52,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $601.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,400.46,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $400.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA CHOICE CARE HMO,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA CHOICE CARE PPO,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA NATIIONAL POS HMO,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,601.52,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $601.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10008 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10008 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,331.81,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10008 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03... $313.03 at 106% = $331.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,412.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $412.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,692.16,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $692.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,618.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $618.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,758.08,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $758.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA360,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,525.96,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $525.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,TRIOLOGY,TRILOGY MEDICAID,331.81,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10008 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 106% = $331.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10008 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,510.88,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $510.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/FLUORO GUIDE EA ADDL LESN,10008,CPT,361,RC,36100241,CDM,,,,both,,,824.0000,543.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,494.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $824.00 in Billed Charges for Rev 361 Proc 10008 = $494.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,AETNA,AETNA HSHS,532.30,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $532.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,AETNA,ALL COMMERCIAL AETNA,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTEHM MEDICAID,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10010 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,CENPATICO,ALL MEDICAID CENPATICO,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,CIGNA,ALL COMMERCIAL CIGNA,576.80,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $576.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,COFINITY,COFINITY,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10010 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10010 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,782.80,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $782.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,692.16,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $692.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,585.04,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $585.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,601.52,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $601.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,400.46,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $400.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA CHOICE CARE HMO,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA CHOICE CARE PPO,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA NATIIONAL POS HMO,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,601.52,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $601.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10010 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10010 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,331.81,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10010 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03... $313.03 at 106% = $331.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,412.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $412.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,692.16,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $692.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,618.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $618.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,758.08,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $758.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA360,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,525.96,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $525.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,TRIOLOGY,TRILOGY MEDICAID,331.81,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10010 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 106% = $331.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10010 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,510.88,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $510.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE EA ADDL LESN,10010,CPT,361,RC,36100243,CDM,,,,both,,,824.0000,543.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,494.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $824.00 in Billed Charges for Rev 361 Proc 10010 = $494.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,AETNA,AETNA HSHS,2565.27,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,565.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,AETNA,AETNA MEDICARE,609.32,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,AETNA,ALL COMMERCIAL AETNA,3971.00,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,ANTHEM,ANTEHM MEDICAID,502.95,,,,,,,502.9500,3971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36572 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $502.95 at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,609.32,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,ANTHEM,ANTHEM POS/HMO,2832.00,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,ANTHEM,ANTHEM PPO,3050.00,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3971.00,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,CENPATICO,ALL MEDICAID CENPATICO,3971.00,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3375.35,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,375.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,CIGNA,ALL COMMERCIAL CIGNA,2779.70,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,779.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,COFINITY,COFINITY,3971.00,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,502.95,,,,,,,502.9500,3971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36572 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $502.95 at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,502.95,,,,,,,502.9500,3971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36572 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $502.95 at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3772.45,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,772.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,3335.64,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,335.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2819.41,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,819.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2898.83,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,898.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,1929.91,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $1,929.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3375.35,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,375.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HUMANA,HUMANA CHOICE CARE HMO,3971.00,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $3,971.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,971.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HUMANA,HUMANA CHOICE CARE PPO,3375.35,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,375.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,609.32,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,HUMANA,HUMANA NATIIONAL POS HMO,3971.00,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $3,971.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,971.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2898.83,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,898.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,3971.00,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,971.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,502.95,,,,,,,502.9500,3971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36572 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $502.95 at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,609.32,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,502.95,,,,,,,502.9500,3971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36572 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $502.95 at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,533.13,,,,,,,502.9500,3971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36572 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $502.95 at 100% = $502.95... $502.95 at 106% = $533.13 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,609.32,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1985.50,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $1,985.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3335.64,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,335.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,1370.97,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2978.25,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,978.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3653.32,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $3,653.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3002.55,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3002.55,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,PREVEA HEALTH NETWORK,PREVEA360,3002.55,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3002.55,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2534.69,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,534.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,615.41,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2859.12,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,859.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,TRIOLOGY,TRILOGY MEDICAID,533.13,,,,,,,502.9500,3971.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36572 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $502.95 at 106% = $533.13. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3110.50,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,3110.50,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,609.32,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,3110.50,,,,,,,502.9500,3971.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36572 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,UNITY HEALTH PLAN,UNITY HOSPICE,609.32,,,,,,,502.9500,3971.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2859.12,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,859.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2462.02,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,462.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2859.12,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,859.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2859.12,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,859.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS CATH PERIPH CV W/O PORT W/GUIDANCE <5,36572,CPT,361,RC,36100246,CDM,,,,both,,,3971.0000,2620.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2382.60,,,,,,,502.9500,3971.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,971.00 in Billed Charges for Rev 361 Proc 36572 = $2,382.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,AETNA,AETNA HSHS,3017.47,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,017.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,AETNA,AETNA MEDICARE,1529.03,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,AETNA,ALL COMMERCIAL AETNA,4671.00,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $4,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,ANTHEM,ANTEHM MEDICAID,502.95,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36573 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment) at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1529.03,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,ANTHEM,ANTHEM POS/HMO,4671.00,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $4,671.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,671.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,ANTHEM,ANTHEM PPO,4671.00,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $4,671.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,671.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4671.00,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $4,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,CENPATICO,ALL MEDICAID CENPATICO,4671.00,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $4,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3970.35,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,970.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,CIGNA,ALL COMMERCIAL CIGNA,3269.70,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,269.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,COFINITY,COFINITY,4671.00,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $4,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,502.95,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36573 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment) at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,502.95,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36573 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment) at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4437.45,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $4,437.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,3923.64,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,923.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3316.41,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,316.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3409.83,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,409.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,2270.11,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $2,270.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3970.35,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,970.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HUMANA,HUMANA CHOICE CARE HMO,4671.00,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $4,671.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,671.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HUMANA,HUMANA CHOICE CARE PPO,3970.35,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,970.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,1529.03,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,HUMANA,HUMANA NATIIONAL POS HMO,4671.00,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $4,671.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,671.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3409.83,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,409.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,4671.00,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $4,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,502.95,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36573 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment) at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1529.03,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,502.95,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36573 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment) at 100% = $502.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,533.13,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36573 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment) at 100% = $502.95... $502.95 at 106% = $533.13 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,1529.03,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2335.50,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $2,335.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3923.64,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,923.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,3440.31,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3503.25,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,503.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4297.32,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $4,297.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4366.95,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4366.95,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,PREVEA HEALTH NETWORK,PREVEA360,4366.95,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4366.95,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2981.50,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $2,981.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1544.32,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3363.12,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,363.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,TRIOLOGY,TRILOGY MEDICAID,533.13,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00075 Proc 36573 at $125.60 (Base Rate) * 4.0044 (Relative Weight) = $502.95 (Total Line Payment) at 106% = $533.13. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4523.30,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,4523.30,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1529.03,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,4523.30,,,,,,,502.9500,4671.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36573 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,UNITY HEALTH PLAN,UNITY HOSPICE,1529.03,,,,,,,502.9500,4671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3363.12,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,363.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2896.02,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $2,896.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3363.12,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,363.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3363.12,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $3,363.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INS PER CV CATH W/O PORT W/GUIDANCE 5>,36573,CPT,361,RC,36100247,CDM,,,,both,,,4671.0000,3082.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2802.60,,,,,,,502.9500,4671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,671.00 in Billed Charges for Rev 361 Proc 36573 = $2,802.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,AETNA,AETNA HSHS,3589.82,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $3,589.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,AETNA,AETNA MEDICARE,609.32,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,AETNA,ALL COMMERCIAL AETNA,5557.00,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $5,557.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,ANTHEM,ANTEHM MEDICAID,960.11,,,,,,,609.3200,5557.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00078 Proc 37799 at $125.60 (Base Rate) * 7.6442 (Relative Weight) = $960.11 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $960.11 at 100% = $960.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,609.32,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,ANTHEM,ANTHEM POS/HMO,5557.00,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $19,430.00 at 100% of $19,430.00 = $19,430.00 Total (Limited to $5,557.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,557.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,ANTHEM,ANTHEM PPO,5557.00,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $22,500.00 at 100% of $22,500.00 = $22,500.00 Total (Limited to $5,557.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,557.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5557.00,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $5,557.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,CENPATICO,ALL MEDICAID CENPATICO,5557.00,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $5,557.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4723.45,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,723.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,CIGNA,ALL COMMERCIAL CIGNA,3889.90,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $3,889.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,COFINITY,COFINITY,5557.00,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $5,557.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,960.11,,,,,,,609.3200,5557.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00078 Proc 37799 at $125.60 (Base Rate) * 7.6442 (Relative Weight) = $960.11 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $960.11 at 100% = $960.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,960.11,,,,,,,609.3200,5557.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00078 Proc 37799 at $125.60 (Base Rate) * 7.6442 (Relative Weight) = $960.11 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $960.11 at 100% = $960.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5279.15,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $5,279.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,4667.88,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,667.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3945.47,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $3,945.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4056.61,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,056.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,2700.70,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $2,700.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4723.45,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,723.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HUMANA,HUMANA CHOICE CARE HMO,3061.00,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HUMANA,HUMANA CHOICE CARE PPO,4723.45,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,723.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HUMANA,HUMANA MEDICARE ADVANTAGE,609.32,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,HUMANA,HUMANA NATIIONAL POS HMO,3061.00,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4056.61,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,056.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,5557.00,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $5,557.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,960.11,,,,,,,609.3200,5557.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00078 Proc 37799 at $125.60 (Base Rate) * 7.6442 (Relative Weight) = $960.11 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $960.11 at 100% = $960.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,609.32,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,960.11,,,,,,,609.3200,5557.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00078 Proc 37799 at $125.60 (Base Rate) * 7.6442 (Relative Weight) = $960.11 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $960.11 at 100% = $960.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,MOLINA HEALTHCARE,MOLINA MEDICAID,1017.72,,,,,,,609.3200,5557.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00078 Proc 37799 at $125.60 (Base Rate) * 7.6442 (Relative Weight) = $960.11 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $960.11 at 100% = $960.11... $960.11 at 106% = $1,017.72 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,MOLINA HEALTHCARE,MOLINA MEDICARE,609.32,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2778.50,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $2,778.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4667.88,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,667.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,NAPHCARE,ALL COMMERICAL NAPHCARE,1370.97,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4167.75,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,167.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5112.44,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $5,112.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3002.55,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3002.55,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,PREVEA HEALTH NETWORK,PREVEA360,3002.55,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3002.55,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3547.03,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $3,547.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,615.41,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4001.04,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,001.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,TRIOLOGY,TRILOGY MEDICAID,1017.72,,,,,,,609.3200,5557.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00078 Proc 37799 at $125.60 (Base Rate) * 7.6442 (Relative Weight) = $960.11 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $960.11 at 106% = $1,017.72. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3110.50,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,UNITED HEALTHCARE,UHC ONEIDA NATION,3110.50,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,609.32,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,UNITED HEALTHCARE,UNITED HEALTHCARE,3110.50,,,,,,,609.3200,5557.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 37799 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,UNITY HEALTH PLAN,UNITY HOSPICE,609.32,,,,,,,609.3200,5557.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4001.04,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,001.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3445.34,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $3,445.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4001.04,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,001.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4001.04,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $4,001.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION ARTERIES RADIOFREQ,37799,CPT,361,RC,36100257,CDM,,,,both,,,5557.0000,3667.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3334.20,,,,,,,609.3200,5557.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,557.00 in Billed Charges for Rev 361 Proc 37799 = $3,334.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,AETNA,AETNA HSHS,1756.47,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,756.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,AETNA,AETNA MEDICARE,1529.03,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,AETNA,ALL COMMERCIAL AETNA,2719.00,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,719.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,ANTHEM,ANTEHM MEDICAID,456.67,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33016 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1529.03,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,ANTHEM,ANTHEM POS/HMO,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,ANTHEM,ANTHEM PPO,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2719.00,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,719.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,CENPATICO,ALL MEDICAID CENPATICO,2719.00,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,719.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2311.15,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,311.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,CIGNA,ALL COMMERCIAL CIGNA,1903.30,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,903.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,COFINITY,COFINITY,2719.00,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,719.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,456.67,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33016 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,456.67,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33016 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2583.05,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,583.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,2283.96,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,283.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1930.49,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,930.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1984.87,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,984.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,1321.43,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,321.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2311.15,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,311.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HUMANA,HUMANA CHOICE CARE HMO,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HUMANA,HUMANA CHOICE CARE PPO,2311.15,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,311.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HUMANA,HUMANA MEDICARE ADVANTAGE,1529.03,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,HUMANA,HUMANA NATIIONAL POS HMO,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1984.87,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,984.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2719.00,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,719.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,456.67,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33016 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1529.03,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,456.67,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33016 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,MOLINA HEALTHCARE,MOLINA MEDICAID,484.07,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33016 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67... $456.67 at 106% = $484.07 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,MOLINA HEALTHCARE,MOLINA MEDICARE,1529.03,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1359.50,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,359.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2283.96,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,283.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,NAPHCARE,ALL COMMERICAL NAPHCARE,3440.31,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2039.25,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,039.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2501.48,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $2,501.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,PREVEA HEALTH NETWORK,PREVEA360,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1735.54,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,735.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1544.32,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1957.68,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,957.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,TRIOLOGY,TRILOGY MEDICAID,484.07,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33016 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 106% = $484.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1529.03,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,2719.00,,,,,,,456.6700,3440.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33016 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,719.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,719.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,UNITY HEALTH PLAN,UNITY HOSPICE,1529.03,,,,,,,456.6700,3440.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1957.68,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,957.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1685.78,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,685.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1957.68,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,957.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1957.68,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,957.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIOCENTESIS W/ OR W/O IMAGING,33016,CPT,361,RC,36100264,CDM,,,,both,,,2719.0000,1794.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1631.40,,,,,,,456.6700,3440.3100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,719.00 in Billed Charges for Rev 361 Proc 33016 = $1,631.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,AETNA,AETNA HSHS,1335.93,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,335.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,AETNA,AETNA MEDICARE,685.65,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,AETNA,ALL COMMERCIAL AETNA,2068.00,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $2,068.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,ANTHEM,ANTEHM MEDICAID,350.17,,,,,,,350.1700,2068.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62328 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,685.65,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,ANTHEM,ANTHEM POS/HMO,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,ANTHEM,ANTHEM PPO,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2068.00,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $2,068.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,CENPATICO,ALL MEDICAID CENPATICO,2068.00,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $2,068.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1757.80,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,757.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,CIGNA,ALL COMMERCIAL CIGNA,1447.60,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,447.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,COFINITY,COFINITY,2068.00,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $2,068.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,350.17,,,,,,,350.1700,2068.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62328 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,350.17,,,,,,,350.1700,2068.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62328 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1964.60,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,964.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,1737.12,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,737.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1468.28,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,468.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1509.64,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,509.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,1005.05,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,005.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1757.80,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,757.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HUMANA,HUMANA CHOICE CARE HMO,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HUMANA,HUMANA CHOICE CARE PPO,1757.80,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,757.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,685.65,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,HUMANA,HUMANA NATIIONAL POS HMO,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1509.64,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,509.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2068.00,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $2,068.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,350.17,,,,,,,350.1700,2068.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62328 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,685.65,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,350.17,,,,,,,350.1700,2068.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62328 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,371.18,,,,,,,350.1700,2068.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62328 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17... $350.17 at 106% = $371.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,685.65,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1034.00,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,034.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1737.12,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,737.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,1542.70,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1551.00,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1902.56,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,902.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,PREVEA HEALTH NETWORK,PREVEA360,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1320.00,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,320.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,692.51,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1488.96,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,488.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,TRIOLOGY,TRILOGY MEDICAID,371.18,,,,,,,350.1700,2068.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62328 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 106% = $371.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,685.65,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,2068.00,,,,,,,350.1700,2068.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62328 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,068.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,068.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,UNITY HEALTH PLAN,UNITY HOSPICE,685.65,,,,,,,350.1700,2068.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1488.96,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,488.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1282.16,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,282.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1488.96,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,488.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1488.96,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,488.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE DIAGNOSTIC W/FLUORO OR CT GUID,62328,CPT,361,RC,36100270,CDM,,,,both,,,2068.0000,1364.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1240.80,,,,,,,350.1700,2068.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,068.00 in Billed Charges for Rev 361 Proc 62328 = $1,240.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,AETNA,AETNA HSHS,1161.51,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,161.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,AETNA,AETNA MEDICARE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,AETNA,ALL COMMERCIAL AETNA,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTEHM MEDICAID,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62329 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM POS/HMO,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM PPO,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,CENPATICO,ALL MEDICAID CENPATICO,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1528.30,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,CIGNA,ALL COMMERCIAL CIGNA,1258.60,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,258.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,COFINITY,COFINITY,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62329 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62329 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1708.10,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,708.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,1510.32,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1276.58,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,276.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1312.54,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,312.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,873.83,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $873.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1528.30,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA CHOICE CARE HMO,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA CHOICE CARE PPO,1528.30,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA NATIIONAL POS HMO,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1312.54,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,312.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1798.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62329 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,350.17,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62329 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,371.18,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62329 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17... $350.17 at 106% = $371.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,899.00,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $899.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1510.32,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,1542.70,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1348.50,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,348.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1654.16,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,654.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA360,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1147.66,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,147.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,692.51,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1294.56,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,TRIOLOGY,TRILOGY MEDICAID,371.18,,,,,,,350.1700,1798.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62329 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 106% = $371.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,1798.00,,,,,,,350.1700,1798.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62329 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,UNITY HEALTH PLAN,UNITY HOSPICE,685.65,,,,,,,350.1700,1798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1294.56,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1114.76,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,114.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1294.56,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1294.56,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LUMBAR PUNCTURE THERAPEUTIC/DRAINAGE W//FLUORO OR CT GUID,62329,CPT,361,RC,36100271,CDM,,,,both,,,1798.0000,1186.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1078.80,,,,,,,350.1700,1798.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,798.00 in Billed Charges for Rev 361 Proc 62329 = $1,078.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,AETNA,AETNA HSHS,3955.46,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $3,955.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,AETNA,AETNA MEDICARE,1604.25,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,AETNA,ALL COMMERCIAL AETNA,6123.00,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $6,123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,ANTHEM,ANTEHM MEDICAID,456.67,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 32408 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1604.25,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,ANTHEM,ANTHEM POS/HMO,6123.00,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $6,123.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,123.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,ANTHEM,ANTHEM PPO,6123.00,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $6,123.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,123.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6123.00,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $6,123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,CENPATICO,ALL MEDICAID CENPATICO,6123.00,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $6,123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5204.55,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $5,204.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,CIGNA,ALL COMMERCIAL CIGNA,4286.10,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,286.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,COFINITY,COFINITY,6123.00,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $6,123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,456.67,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 32408 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,456.67,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 32408 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5816.85,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $5,816.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,5143.32,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $5,143.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4347.33,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,347.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4469.79,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,469.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,2975.78,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $2,975.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5204.55,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $5,204.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HUMANA,HUMANA CHOICE CARE HMO,6123.00,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $6,123.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,123.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HUMANA,HUMANA CHOICE CARE PPO,5204.55,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $5,204.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,1604.25,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,HUMANA,HUMANA NATIIONAL POS HMO,6123.00,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $6,123.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,123.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4469.79,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,469.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,6123.00,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $6,123.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,456.67,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 32408 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1604.25,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,456.67,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 32408 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,484.07,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 32408 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67... $456.67 at 106% = $484.07 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,1604.25,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3061.50,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $3,061.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5143.32,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $5,143.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,3609.56,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4592.25,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,592.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5633.16,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $5,633.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4366.95,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4366.95,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,PREVEA HEALTH NETWORK,PREVEA360,4366.95,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4366.95,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3908.31,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $3,908.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1620.29,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4408.56,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,408.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,TRIOLOGY,TRILOGY MEDICAID,484.07,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 32408 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 106% = $484.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4523.30,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,4523.30,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1604.25,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,4523.30,,,,,,,456.6700,6123.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 32408 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,UNITY HEALTH PLAN,UNITY HOSPICE,1604.25,,,,,,,456.6700,6123.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4408.56,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,408.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3796.26,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $3,796.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4408.56,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,408.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4408.56,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $4,408.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CORE NDL BX LUNG/MEDIASTINUM PERQ W IMG,32408,CPT,361,RC,36100281,CDM,,,,both,,,6123.0000,4041.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3673.80,,,,,,,456.6700,6123.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,123.00 in Billed Charges for Rev 361 Proc 32408 = $3,673.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,AETNA,AETNA HSHS,2315.91,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,315.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,AETNA,AETNA MEDICARE,2030.46,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,AETNA,ALL COMMERCIAL AETNA,3585.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,ANTHEM,ANTEHM MEDICAID,1313.29,,,,,,,757.3000,4568.5300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00166 Proc 53060 at $125.60 (Base Rate) * 10.4561 (Relative Weight) = $1,313.29 (Total Line Payment) at 100% = $1,313.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2030.46,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,ANTHEM,ANTHEM POS/HMO,2437.80,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,437.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,ANTHEM,ANTHEM PPO,2437.80,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,437.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3585.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,CENPATICO,ALL MEDICAID CENPATICO,3585.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3047.25,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,047.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,CIGNA,ALL COMMERCIAL CIGNA,2509.50,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,509.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,COFINITY,COFINITY,3585.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1313.29,,,,,,,757.3000,4568.5300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00166 Proc 53060 at $125.60 (Base Rate) * 10.4561 (Relative Weight) = $1,313.29 (Total Line Payment) at 100% = $1,313.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1313.29,,,,,,,757.3000,4568.5300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00166 Proc 53060 at $125.60 (Base Rate) * 10.4561 (Relative Weight) = $1,313.29 (Total Line Payment) at 100% = $1,313.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3405.75,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,405.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,3011.40,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,011.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2545.35,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,545.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2617.05,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,617.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,1742.31,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $1,742.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3047.25,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,047.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HUMANA,HUMANA CHOICE CARE HMO,2276.48,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,276.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HUMANA,HUMANA CHOICE CARE PPO,3047.25,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,047.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,2030.46,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,HUMANA,HUMANA NATIIONAL POS HMO,2276.48,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,276.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2617.05,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,617.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3585.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,585.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1313.29,,,,,,,757.3000,4568.5300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00166 Proc 53060 at $125.60 (Base Rate) * 10.4561 (Relative Weight) = $1,313.29 (Total Line Payment) at 100% = $1,313.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2030.46,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1313.29,,,,,,,757.3000,4568.5300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00166 Proc 53060 at $125.60 (Base Rate) * 10.4561 (Relative Weight) = $1,313.29 (Total Line Payment) at 100% = $1,313.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,1392.09,,,,,,,757.3000,4568.5300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00166 Proc 53060 at $125.60 (Base Rate) * 10.4561 (Relative Weight) = $1,313.29 (Total Line Payment) at 100% = $1,313.29... $1,313.29 at 106% = $1,392.09 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,2030.46,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1792.50,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $1,792.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3011.40,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,011.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,4568.53,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2688.75,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,688.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3298.20,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $3,298.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2151.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2151.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,PREVEA HEALTH NETWORK,PREVEA360,2151.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2151.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2288.31,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,288.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2050.76,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2581.20,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,581.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,TRIOLOGY,TRILOGY MEDICAID,1392.08,,,,,,,757.3000,4568.5300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00166 Proc 53060 at $125.60 (Base Rate) * 10.4561 (Relative Weight) = $1,313.29 (Total Line Payment) at 106% = $1,392.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,757.30,,,,,,,757.3000,4568.5300,case rate,ST VINCENT HOSPITAL (ACU). Rev 450 Proc 53060 at Case Rate $757.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,757.30,,,,,,,757.3000,4568.5300,case rate,ST VINCENT HOSPITAL (ACU). Rev 450 Proc 53060 at Case Rate $757.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2030.46,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,757.30,,,,,,,757.3000,4568.5300,case rate,ST VINCENT HOSPITAL (ACU). Rev 450 Proc 53060 at Case Rate $757.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,UNITY HEALTH PLAN,UNITY HOSPICE,2030.46,,,,,,,757.3000,4568.5300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2581.20,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,581.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2222.70,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,222.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2581.20,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,581.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2581.20,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,581.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN OF SKENE GLAND ABS OR CYST,53060,CPT,450,RC,36100284,CDM,,,,both,,,3585.0000,2366.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2151.00,,,,,,,757.3000,4568.5300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,585.00 in Billed Charges for Rev 450 Proc 53060 = $2,151.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,AETNA,AETNA HSHS,2198.98,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,198.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,AETNA,AETNA MEDICARE,880.98,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,AETNA,ALL COMMERCIAL AETNA,3404.00,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $3,404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,ANTHEM,ANTEHM MEDICAID,1015.38,,,,,,,880.9800,3404.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47999 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,015.38 at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,880.98,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,ANTHEM,ANTHEM POS/HMO,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $19,430.00 at 100% of $19,430.00 = $19,430.00 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,ANTHEM,ANTHEM PPO,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $22,500.00 at 100% of $22,500.00 = $22,500.00 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3404.00,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $3,404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,CENPATICO,ALL MEDICAID CENPATICO,3404.00,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $3,404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2893.40,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,893.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,CIGNA,ALL COMMERCIAL CIGNA,2382.80,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,382.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,COFINITY,COFINITY,3404.00,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $3,404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1015.38,,,,,,,880.9800,3404.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47999 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,015.38 at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1015.38,,,,,,,880.9800,3404.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47999 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,015.38 at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3233.80,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $3,233.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,2859.36,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,859.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2416.84,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,416.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2484.92,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,484.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,1654.34,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $1,654.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2893.40,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,893.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HUMANA,HUMANA CHOICE CARE HMO,3061.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HUMANA,HUMANA CHOICE CARE PPO,2893.40,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,893.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,880.98,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,HUMANA,HUMANA NATIIONAL POS HMO,3061.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2484.92,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,484.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3404.00,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $3,404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1015.38,,,,,,,880.9800,3404.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47999 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,015.38 at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,880.98,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1015.38,,,,,,,880.9800,3404.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47999 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,015.38 at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,1076.30,,,,,,,880.9800,3404.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47999 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,015.38 at 100% = $1,015.38... $1,015.38 at 106% = $1,076.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,880.98,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1702.00,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $1,702.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2859.36,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,859.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,1982.21,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2553.00,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,553.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3131.68,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $3,131.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,PREVEA HEALTH NETWORK,PREVEA360,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2172.77,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,172.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,889.79,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2450.88,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,450.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,TRIOLOGY,TRILOGY MEDICAID,1076.30,,,,,,,880.9800,3404.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47999 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,015.38 at 106% = $1,076.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,880.98,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,3404.00,,,,,,,880.9800,3404.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47999 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,404.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,404.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,UNITY HEALTH PLAN,UNITY HOSPICE,880.98,,,,,,,880.9800,3404.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2450.88,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,450.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2110.48,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,110.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2450.88,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,450.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2450.88,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,450.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BILIARY TRACT UNLISTED PROCEDURE,47999,CPT,361,RC,36100287,CDM,,,,both,,,3404.0000,2246.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2042.40,,,,,,,880.9800,3404.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,404.00 in Billed Charges for Rev 361 Proc 47999 = $2,042.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,AETNA,AETNA HSHS,9184.18,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $9,184.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,AETNA,AETNA MEDICARE,4859.04,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,AETNA,ALL COMMERCIAL AETNA,14217.00,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $14,217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,ANTHEM,ANTEHM MEDICAID,1065.36,,,,,,,1065.3600,14217.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 57155 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,4859.04,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,ANTHEM,ANTHEM POS/HMO,4804.00,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,ANTHEM,ANTHEM PPO,5200.00,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14217.00,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $14,217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,CENPATICO,ALL MEDICAID CENPATICO,14217.00,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $14,217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12084.45,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $12,084.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,CIGNA,ALL COMMERCIAL CIGNA,9951.90,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $9,951.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,COFINITY,COFINITY,14217.00,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $14,217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1065.36,,,,,,,1065.3600,14217.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 57155 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1065.36,,,,,,,1065.3600,14217.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 57155 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13506.15,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $13,506.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,11942.28,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $11,942.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10094.07,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $10,094.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10378.41,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $10,378.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,6909.46,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $6,909.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12084.45,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $12,084.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HUMANA,HUMANA CHOICE CARE HMO,5023.00,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HUMANA,HUMANA CHOICE CARE PPO,12084.45,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $12,084.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,4859.04,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,HUMANA,HUMANA NATIIONAL POS HMO,5023.00,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10378.41,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $10,378.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,14217.00,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $14,217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1065.36,,,,,,,1065.3600,14217.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 57155 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,4859.04,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1065.36,,,,,,,1065.3600,14217.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 57155 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,1129.28,,,,,,,1065.3600,14217.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 57155 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36... $1,065.36 at 106% = $1,129.28 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,4859.04,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7108.50,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $7,108.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11942.28,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $11,942.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,10932.84,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10662.75,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $10,662.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13079.64,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $13,079.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3002.55,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3002.55,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,PREVEA HEALTH NETWORK,PREVEA360,3002.55,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3002.55,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9074.71,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $9,074.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,4907.63,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10236.24,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $10,236.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,TRIOLOGY,TRILOGY MEDICAID,1129.29,,,,,,,1065.3600,14217.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 57155 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 106% = $1,129.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3110.50,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,3110.50,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,4859.04,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,3110.50,,,,,,,1065.3600,14217.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 57155 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,UNITY HEALTH PLAN,UNITY HOSPICE,4859.04,,,,,,,1065.3600,14217.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10236.24,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $10,236.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8814.54,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $8,814.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10236.24,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $10,236.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10236.24,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $10,236.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL,57155,CPT,361,RC,36100506,CDM,,,,both,,,14217.0000,9383.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8530.20,,,,,,,1065.3600,14217.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $14,217.00 in Billed Charges for Rev 361 Proc 57155 = $8,530.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,AETNA,AETNA HSHS,534.24,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,AETNA,AETNA MEDICARE,239.60,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,AETNA,ALL COMMERCIAL AETNA,827.00,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $827.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,ANTHEM,ANTEHM MEDICAID,210.86,,,,,,,210.8600,827.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00041 Proc 28899 at $125.60 (Base Rate) * 1.6788 (Relative Weight) = $210.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $210.86 at 100% = $210.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,239.60,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,ANTHEM,ANTHEM POS/HMO,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $19,430.00 at 100% of $19,430.00 = $19,430.00 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,ANTHEM,ANTHEM PPO,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $22,500.00 at 100% of $22,500.00 = $22,500.00 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,827.00,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $827.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,CENPATICO,ALL MEDICAID CENPATICO,827.00,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $827.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,702.95,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $702.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,CIGNA,ALL COMMERCIAL CIGNA,578.90,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $578.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,COFINITY,COFINITY,827.00,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $827.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,210.86,,,,,,,210.8600,827.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00041 Proc 28899 at $125.60 (Base Rate) * 1.6788 (Relative Weight) = $210.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $210.86 at 100% = $210.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,210.86,,,,,,,210.8600,827.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00041 Proc 28899 at $125.60 (Base Rate) * 1.6788 (Relative Weight) = $210.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $210.86 at 100% = $210.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,785.65,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $785.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,694.68,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $694.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,587.17,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $587.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,603.71,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $603.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,401.92,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $401.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,702.95,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $702.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HUMANA,HUMANA CHOICE CARE HMO,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HUMANA,HUMANA CHOICE CARE PPO,702.95,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $702.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,239.60,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,HUMANA,HUMANA NATIIONAL POS HMO,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,603.71,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $603.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,827.00,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $827.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,210.86,,,,,,,210.8600,827.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00041 Proc 28899 at $125.60 (Base Rate) * 1.6788 (Relative Weight) = $210.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $210.86 at 100% = $210.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,239.60,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,210.86,,,,,,,210.8600,827.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00041 Proc 28899 at $125.60 (Base Rate) * 1.6788 (Relative Weight) = $210.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $210.86 at 100% = $210.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,223.51,,,,,,,210.8600,827.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00041 Proc 28899 at $125.60 (Base Rate) * 1.6788 (Relative Weight) = $210.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $210.86 at 100% = $210.86... $210.86 at 106% = $223.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,239.60,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,413.50,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $413.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,694.68,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $694.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,539.09,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,620.25,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $620.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,760.84,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $760.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,PREVEA HEALTH NETWORK,PREVEA360,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,527.87,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $527.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,242.00,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,595.44,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $595.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,TRIOLOGY,TRILOGY MEDICAID,223.51,,,,,,,210.8600,827.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00041 Proc 28899 at $125.60 (Base Rate) * 1.6788 (Relative Weight) = $210.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $210.86 at 106% = $223.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,239.60,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,827.00,,,,,,,210.8600,827.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 28899 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $827.00 in Billed Charges - $0.00 in ASG Allowed Amount = $827.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,UNITY HEALTH PLAN,UNITY HOSPICE,239.60,,,,,,,210.8600,827.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,595.44,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $595.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,512.74,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $512.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,595.44,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $595.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,595.44,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $595.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PX FOOT/TOES,28899,CPT,361,RC,36100513,CDM,,,,both,,,827.0000,545.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,496.20,,,,,,,210.8600,827.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $827.00 in Billed Charges for Rev 361 Proc 28899 = $496.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,AETNA,AETNA HSHS,1006.47,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,006.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,AETNA,AETNA MEDICARE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,AETNA,ALL COMMERCIAL AETNA,1558.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,ANTHEM,ANTEHM MEDICAID,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64448 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,ANTHEM,ANTHEM POS/HMO,1059.44,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,059.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,ANTHEM,ANTHEM PPO,1059.44,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,059.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1558.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,CENPATICO,ALL MEDICAID CENPATICO,1558.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1324.30,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,324.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,CIGNA,ALL COMMERCIAL CIGNA,1090.60,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,090.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,COFINITY,COFINITY,1558.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64448 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64448 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1480.10,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,480.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,1308.72,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,308.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1106.18,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,106.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1137.34,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,137.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,757.19,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $757.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1324.30,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,324.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,HUMANA CHOICE CARE HMO,989.33,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $989.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,HUMANA CHOICE CARE PPO,1324.30,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,324.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,HUMANA,HUMANA NATIIONAL POS HMO,989.33,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $989.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1137.34,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,137.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1558.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64448 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64448 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,621.74,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64448 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55... $586.55 at 106% = $621.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,779.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $779.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1308.72,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,308.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,1933.01,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1168.50,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,168.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1433.36,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,433.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,934.80,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $934.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,934.80,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $934.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,PREVEA HEALTH NETWORK,PREVEA360,934.80,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $934.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,934.80,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $934.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,994.47,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $994.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,867.71,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1121.76,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,TRIOLOGY,TRILOGY MEDICAID,621.75,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64448 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 106% = $621.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,861.57,,,,,,,586.5500,1933.0100,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $861.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,861.57,,,,,,,586.5500,1933.0100,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $861.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,861.57,,,,,,,586.5500,1933.0100,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $861.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,UNITY HEALTH PLAN,UNITY HOSPICE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1121.76,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,965.96,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $965.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1121.76,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1121.76,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $1,121.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK CONTINUOUS,64448,CPT,370,RC,37000014,CDM,,,,both,,,1558.0000,1028.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,934.80,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,558.00 in Billed Charges for Rev 370 Proc 64448 = $934.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,AETNA,AETNA HSHS,73.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,AETNA,ALL COMMERCIAL AETNA,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,ANTHEM,ANTEHM MEDICAID,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99157 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,ANTHEM,ANTHEM POS/HMO,76.84,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $76.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,ANTHEM,ANTHEM PPO,76.84,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $76.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,CENPATICO,ALL MEDICAID CENPATICO,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,96.05,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $96.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,CIGNA,ALL COMMERCIAL CIGNA,79.10,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $79.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,COFINITY,COFINITY,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99157 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99157 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,107.35,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $107.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,94.92,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $94.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.23,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $80.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,82.49,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $82.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,54.92,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $54.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,96.05,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $96.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,HUMANA,HUMANA CHOICE CARE HMO,71.76,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $71.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,HUMANA,HUMANA CHOICE CARE PPO,96.05,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $96.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,HUMANA,HUMANA NATIIONAL POS HMO,71.76,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $71.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,82.49,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $82.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99157 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99157 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,MOLINA HEALTHCARE,MOLINA MEDICAID,11.05,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99157 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42... $10.42 at 106% = $11.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,56.50,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $56.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,94.92,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $94.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,84.75,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $84.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,103.96,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $103.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,PREVEA HEALTH NETWORK,PREVEA360,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,72.13,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $72.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,81.36,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $81.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,TRIOLOGY,TRILOGY MEDICAID,11.05,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99157 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 106% = $11.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,62.49,,,,,,,10.4200,113.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $62.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,62.49,,,,,,,10.4200,113.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $62.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,62.49,,,,,,,10.4200,113.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $62.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,81.36,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $81.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,70.06,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $70.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,81.36,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $81.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,81.36,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $81.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY EA ADDL 15MIN,99157,CPT,370,RC,37000020,CDM,,,,both,,,113.0000,74.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99157 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,AETNA,AETNA HSHS,692.51,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,072.00 in Billed Charges for Rev 370 = $692.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,AETNA,ALL COMMERCIAL AETNA,1072.00,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,072.00 in Billed Charges for Rev 370 = $1,072.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,ANTHEM,ANTHEM POS/HMO,728.96,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,072.00 in Billed Charges for Rev 370 = $728.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,ANTHEM,ANTHEM PPO,728.96,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,072.00 in Billed Charges for Rev 370 = $728.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1072.00,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,072.00 in Billed Charges for Rev 370 = $1,072.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,CENPATICO,ALL MEDICAID CENPATICO,1072.00,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,072.00 in Billed Charges for Rev 370 = $1,072.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,911.20,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,072.00 in Billed Charges for Rev 370 = $911.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,CIGNA,ALL COMMERCIAL CIGNA,750.40,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,072.00 in Billed Charges for Rev 370 = $750.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,COFINITY,COFINITY,1072.00,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,072.00 in Billed Charges for Rev 370 = $1,072.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1018.40,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,072.00 in Billed Charges for Rev 370 = $1,018.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,900.48,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,072.00 in Billed Charges for Rev 370 = $900.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,761.12,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,072.00 in Billed Charges for Rev 370 = $761.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,782.56,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,072.00 in Billed Charges for Rev 370 = $782.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,520.99,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,072.00 in Billed Charges for Rev 370 = $520.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,911.20,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,072.00 in Billed Charges for Rev 370 = $911.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,HUMANA,HUMANA CHOICE CARE HMO,680.72,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,072.00 in Billed Charges for Rev 370 = $680.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,HUMANA,HUMANA CHOICE CARE PPO,911.20,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,072.00 in Billed Charges for Rev 370 = $911.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,HUMANA,HUMANA NATIIONAL POS HMO,680.72,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,072.00 in Billed Charges for Rev 370 = $680.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,782.56,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,072.00 in Billed Charges for Rev 370 = $782.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1072.00,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,072.00 in Billed Charges for Rev 370 = $1,072.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,536.00,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,072.00 in Billed Charges for Rev 370 = $536.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,900.48,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,072.00 in Billed Charges for Rev 370 = $900.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,804.00,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,072.00 in Billed Charges for Rev 370 = $804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,986.24,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,072.00 in Billed Charges for Rev 370 = $986.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,643.20,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,072.00 in Billed Charges for Rev 370 = $643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,643.20,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,072.00 in Billed Charges for Rev 370 = $643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,PREVEA HEALTH NETWORK,PREVEA360,643.20,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,072.00 in Billed Charges for Rev 370 = $643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,643.20,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,072.00 in Billed Charges for Rev 370 = $643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,684.26,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,072.00 in Billed Charges for Rev 370 = $684.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,771.84,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,072.00 in Billed Charges for Rev 370 = $771.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,592.82,,,,,,,520.9900,1072.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,072.00 in Billed Charges for Rev 370 = $592.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,592.82,,,,,,,520.9900,1072.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,072.00 in Billed Charges for Rev 370 = $592.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,592.82,,,,,,,520.9900,1072.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,072.00 in Billed Charges for Rev 370 = $592.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,771.84,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,072.00 in Billed Charges for Rev 370 = $771.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,664.64,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,072.00 in Billed Charges for Rev 370 = $664.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,771.84,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,072.00 in Billed Charges for Rev 370 = $771.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,771.84,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,072.00 in Billed Charges for Rev 370 = $771.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES INIT,370,RC,37000050,CDM,,,,,,both,,,1072.0000,707.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,643.20,,,,,,,520.9900,1072.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,072.00 in Billed Charges for Rev 370 = $643.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,AETNA,AETNA HSHS,128.55,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $199.00 in Billed Charges for Rev 370 = $128.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,AETNA,ALL COMMERCIAL AETNA,199.00,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $199.00 in Billed Charges for Rev 370 = $199.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,ANTHEM,ANTHEM POS/HMO,135.32,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $199.00 in Billed Charges for Rev 370 = $135.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,ANTHEM,ANTHEM PPO,135.32,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $199.00 in Billed Charges for Rev 370 = $135.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,199.00,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $199.00 in Billed Charges for Rev 370 = $199.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,CENPATICO,ALL MEDICAID CENPATICO,199.00,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $199.00 in Billed Charges for Rev 370 = $199.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,169.15,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $199.00 in Billed Charges for Rev 370 = $169.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,CIGNA,ALL COMMERCIAL CIGNA,139.30,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $199.00 in Billed Charges for Rev 370 = $139.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,COFINITY,COFINITY,199.00,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $199.00 in Billed Charges for Rev 370 = $199.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,189.05,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $199.00 in Billed Charges for Rev 370 = $189.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,167.16,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $199.00 in Billed Charges for Rev 370 = $167.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,141.29,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $199.00 in Billed Charges for Rev 370 = $141.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,145.27,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $199.00 in Billed Charges for Rev 370 = $145.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,96.71,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $199.00 in Billed Charges for Rev 370 = $96.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,169.15,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $199.00 in Billed Charges for Rev 370 = $169.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,HUMANA,HUMANA CHOICE CARE HMO,126.37,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $199.00 in Billed Charges for Rev 370 = $126.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,HUMANA,HUMANA CHOICE CARE PPO,169.15,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $199.00 in Billed Charges for Rev 370 = $169.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,HUMANA,HUMANA NATIIONAL POS HMO,126.37,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $199.00 in Billed Charges for Rev 370 = $126.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,145.27,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $199.00 in Billed Charges for Rev 370 = $145.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,199.00,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $199.00 in Billed Charges for Rev 370 = $199.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,99.50,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $199.00 in Billed Charges for Rev 370 = $99.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,167.16,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $199.00 in Billed Charges for Rev 370 = $167.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,149.25,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $199.00 in Billed Charges for Rev 370 = $149.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,183.08,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $199.00 in Billed Charges for Rev 370 = $183.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,119.40,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $199.00 in Billed Charges for Rev 370 = $119.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,119.40,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $199.00 in Billed Charges for Rev 370 = $119.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,PREVEA HEALTH NETWORK,PREVEA360,119.40,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $199.00 in Billed Charges for Rev 370 = $119.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,119.40,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $199.00 in Billed Charges for Rev 370 = $119.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,127.02,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $199.00 in Billed Charges for Rev 370 = $127.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,143.28,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $199.00 in Billed Charges for Rev 370 = $143.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,110.05,,,,,,,96.7100,199.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $199.00 in Billed Charges for Rev 370 = $110.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,110.05,,,,,,,96.7100,199.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $199.00 in Billed Charges for Rev 370 = $110.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,110.05,,,,,,,96.7100,199.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $199.00 in Billed Charges for Rev 370 = $110.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,143.28,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $199.00 in Billed Charges for Rev 370 = $143.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,123.38,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $199.00 in Billed Charges for Rev 370 = $123.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,143.28,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $199.00 in Billed Charges for Rev 370 = $143.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,143.28,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $199.00 in Billed Charges for Rev 370 = $143.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIER BLOCK ANES ADDL,370,RC,37000051,CDM,,,,,,both,,,199.0000,131.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,119.40,,,,,,,96.7100,199.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $199.00 in Billed Charges for Rev 370 = $119.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,AETNA,AETNA HSHS,1299.75,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,012.00 in Billed Charges for Rev 370 = $1,299.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,AETNA,ALL COMMERCIAL AETNA,2012.00,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,012.00 in Billed Charges for Rev 370 = $2,012.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,ANTHEM,ANTHEM POS/HMO,1368.16,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,012.00 in Billed Charges for Rev 370 = $1,368.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,ANTHEM,ANTHEM PPO,1368.16,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,012.00 in Billed Charges for Rev 370 = $1,368.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2012.00,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,012.00 in Billed Charges for Rev 370 = $2,012.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,CENPATICO,ALL MEDICAID CENPATICO,2012.00,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,012.00 in Billed Charges for Rev 370 = $2,012.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1710.20,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,012.00 in Billed Charges for Rev 370 = $1,710.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,CIGNA,ALL COMMERCIAL CIGNA,1408.40,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,012.00 in Billed Charges for Rev 370 = $1,408.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,COFINITY,COFINITY,2012.00,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,012.00 in Billed Charges for Rev 370 = $2,012.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1911.40,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,012.00 in Billed Charges for Rev 370 = $1,911.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,1690.08,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,012.00 in Billed Charges for Rev 370 = $1,690.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1428.52,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,012.00 in Billed Charges for Rev 370 = $1,428.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1468.76,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,012.00 in Billed Charges for Rev 370 = $1,468.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,977.83,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,012.00 in Billed Charges for Rev 370 = $977.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1710.20,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,012.00 in Billed Charges for Rev 370 = $1,710.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,HUMANA,HUMANA CHOICE CARE HMO,1277.62,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,012.00 in Billed Charges for Rev 370 = $1,277.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,HUMANA,HUMANA CHOICE CARE PPO,1710.20,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,012.00 in Billed Charges for Rev 370 = $1,710.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,HUMANA,HUMANA NATIIONAL POS HMO,1277.62,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,012.00 in Billed Charges for Rev 370 = $1,277.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1468.76,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,012.00 in Billed Charges for Rev 370 = $1,468.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2012.00,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,012.00 in Billed Charges for Rev 370 = $2,012.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1006.00,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,012.00 in Billed Charges for Rev 370 = $1,006.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1690.08,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,012.00 in Billed Charges for Rev 370 = $1,690.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1509.00,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,012.00 in Billed Charges for Rev 370 = $1,509.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1851.04,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,012.00 in Billed Charges for Rev 370 = $1,851.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1207.20,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,012.00 in Billed Charges for Rev 370 = $1,207.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1207.20,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,012.00 in Billed Charges for Rev 370 = $1,207.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,PREVEA HEALTH NETWORK,PREVEA360,1207.20,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,012.00 in Billed Charges for Rev 370 = $1,207.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1207.20,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,012.00 in Billed Charges for Rev 370 = $1,207.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1284.26,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,012.00 in Billed Charges for Rev 370 = $1,284.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1448.64,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,012.00 in Billed Charges for Rev 370 = $1,448.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1112.64,,,,,,,977.8300,2012.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,012.00 in Billed Charges for Rev 370 = $1,112.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,1112.64,,,,,,,977.8300,2012.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,012.00 in Billed Charges for Rev 370 = $1,112.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,1112.64,,,,,,,977.8300,2012.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,012.00 in Billed Charges for Rev 370 = $1,112.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1448.64,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,012.00 in Billed Charges for Rev 370 = $1,448.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1247.44,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,012.00 in Billed Charges for Rev 370 = $1,247.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1448.64,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,012.00 in Billed Charges for Rev 370 = $1,448.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1448.64,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,012.00 in Billed Charges for Rev 370 = $1,448.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENERAL ANESTHESIA INITIAL 15 MIN,370,RC,37000052,CDM,,,,,,both,,,2012.0000,1327.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1207.20,,,,,,,977.8300,2012.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,012.00 in Billed Charges for Rev 370 = $1,207.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,AETNA,AETNA HSHS,550.39,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $852.00 in Billed Charges for Rev 370 = $550.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,AETNA,ALL COMMERCIAL AETNA,852.00,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.00 in Billed Charges for Rev 370 = $852.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,ANTHEM,ANTHEM POS/HMO,579.36,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $852.00 in Billed Charges for Rev 370 = $579.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,ANTHEM,ANTHEM PPO,579.36,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $852.00 in Billed Charges for Rev 370 = $579.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,852.00,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.00 in Billed Charges for Rev 370 = $852.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,CENPATICO,ALL MEDICAID CENPATICO,852.00,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.00 in Billed Charges for Rev 370 = $852.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,724.20,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $852.00 in Billed Charges for Rev 370 = $724.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,CIGNA,ALL COMMERCIAL CIGNA,596.40,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $852.00 in Billed Charges for Rev 370 = $596.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,COFINITY,COFINITY,852.00,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.00 in Billed Charges for Rev 370 = $852.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,809.40,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $852.00 in Billed Charges for Rev 370 = $809.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,715.68,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $852.00 in Billed Charges for Rev 370 = $715.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,604.92,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $852.00 in Billed Charges for Rev 370 = $604.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,621.96,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $852.00 in Billed Charges for Rev 370 = $621.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,414.07,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $852.00 in Billed Charges for Rev 370 = $414.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,724.20,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $852.00 in Billed Charges for Rev 370 = $724.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,HUMANA,HUMANA CHOICE CARE HMO,541.02,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $852.00 in Billed Charges for Rev 370 = $541.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,HUMANA,HUMANA CHOICE CARE PPO,724.20,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $852.00 in Billed Charges for Rev 370 = $724.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,HUMANA,HUMANA NATIIONAL POS HMO,541.02,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $852.00 in Billed Charges for Rev 370 = $541.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,621.96,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $852.00 in Billed Charges for Rev 370 = $621.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,852.00,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $852.00 in Billed Charges for Rev 370 = $852.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,426.00,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $852.00 in Billed Charges for Rev 370 = $426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,715.68,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $852.00 in Billed Charges for Rev 370 = $715.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,639.00,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $852.00 in Billed Charges for Rev 370 = $639.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,783.84,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $852.00 in Billed Charges for Rev 370 = $783.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,511.20,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $852.00 in Billed Charges for Rev 370 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,511.20,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $852.00 in Billed Charges for Rev 370 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,PREVEA HEALTH NETWORK,PREVEA360,511.20,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $852.00 in Billed Charges for Rev 370 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,511.20,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $852.00 in Billed Charges for Rev 370 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,543.83,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $852.00 in Billed Charges for Rev 370 = $543.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,613.44,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $852.00 in Billed Charges for Rev 370 = $613.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,471.16,,,,,,,414.0700,852.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $852.00 in Billed Charges for Rev 370 = $471.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,471.16,,,,,,,414.0700,852.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $852.00 in Billed Charges for Rev 370 = $471.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,471.16,,,,,,,414.0700,852.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $852.00 in Billed Charges for Rev 370 = $471.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,613.44,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $852.00 in Billed Charges for Rev 370 = $613.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,528.24,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $852.00 in Billed Charges for Rev 370 = $528.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,613.44,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $852.00 in Billed Charges for Rev 370 = $613.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,613.44,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $852.00 in Billed Charges for Rev 370 = $613.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MONITORED ANES INIT,370,RC,37000054,CDM,,,,,,both,,,852.0000,562.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,511.20,,,,,,,414.0700,852.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $852.00 in Billed Charges for Rev 370 = $511.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,AETNA,AETNA HSHS,3643.44,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,640.00 in Billed Charges for Rev 370 = $3,643.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,AETNA,ALL COMMERCIAL AETNA,5640.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,640.00 in Billed Charges for Rev 370 = $5,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,ANTHEM,ANTHEM POS/HMO,3835.20,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $5,640.00 in Billed Charges for Rev 370 = $3,835.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,ANTHEM,ANTHEM PPO,3835.20,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $5,640.00 in Billed Charges for Rev 370 = $3,835.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5640.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,640.00 in Billed Charges for Rev 370 = $5,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,CENPATICO,ALL MEDICAID CENPATICO,5640.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,640.00 in Billed Charges for Rev 370 = $5,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4794.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,640.00 in Billed Charges for Rev 370 = $4,794.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,CIGNA,ALL COMMERCIAL CIGNA,3948.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,640.00 in Billed Charges for Rev 370 = $3,948.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,COFINITY,COFINITY,5640.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,640.00 in Billed Charges for Rev 370 = $5,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5358.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,640.00 in Billed Charges for Rev 370 = $5,358.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,4737.60,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,640.00 in Billed Charges for Rev 370 = $4,737.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4004.40,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,640.00 in Billed Charges for Rev 370 = $4,004.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4117.20,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,640.00 in Billed Charges for Rev 370 = $4,117.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,2741.04,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,640.00 in Billed Charges for Rev 370 = $2,741.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4794.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,640.00 in Billed Charges for Rev 370 = $4,794.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,HUMANA,HUMANA CHOICE CARE HMO,3581.40,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $5,640.00 in Billed Charges for Rev 370 = $3,581.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,HUMANA,HUMANA CHOICE CARE PPO,4794.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,640.00 in Billed Charges for Rev 370 = $4,794.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,HUMANA,HUMANA NATIIONAL POS HMO,3581.40,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $5,640.00 in Billed Charges for Rev 370 = $3,581.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4117.20,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,640.00 in Billed Charges for Rev 370 = $4,117.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,5640.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,640.00 in Billed Charges for Rev 370 = $5,640.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2820.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,640.00 in Billed Charges for Rev 370 = $2,820.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4737.60,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,640.00 in Billed Charges for Rev 370 = $4,737.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4230.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,640.00 in Billed Charges for Rev 370 = $4,230.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5188.80,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,640.00 in Billed Charges for Rev 370 = $5,188.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3384.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,640.00 in Billed Charges for Rev 370 = $3,384.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3384.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,640.00 in Billed Charges for Rev 370 = $3,384.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,PREVEA HEALTH NETWORK,PREVEA360,3384.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,640.00 in Billed Charges for Rev 370 = $3,384.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3384.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,640.00 in Billed Charges for Rev 370 = $3,384.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3600.01,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,640.00 in Billed Charges for Rev 370 = $3,600.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4060.80,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,640.00 in Billed Charges for Rev 370 = $4,060.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3118.92,,,,,,,2741.0400,5640.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $5,640.00 in Billed Charges for Rev 370 = $3,118.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,3118.92,,,,,,,2741.0400,5640.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $5,640.00 in Billed Charges for Rev 370 = $3,118.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,3118.92,,,,,,,2741.0400,5640.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $5,640.00 in Billed Charges for Rev 370 = $3,118.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4060.80,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,640.00 in Billed Charges for Rev 370 = $4,060.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3496.80,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,640.00 in Billed Charges for Rev 370 = $3,496.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4060.80,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,640.00 in Billed Charges for Rev 370 = $4,060.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4060.80,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,640.00 in Billed Charges for Rev 370 = $4,060.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES INIT,370,RC,37000058,CDM,,,,,,both,,,5640.0000,3722.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3384.00,,,,,,,2741.0400,5640.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,640.00 in Billed Charges for Rev 370 = $3,384.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,AETNA,AETNA HSHS,250.65,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $388.00 in Billed Charges for Rev 370 = $250.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,AETNA,ALL COMMERCIAL AETNA,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 370 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,ANTHEM,ANTHEM POS/HMO,263.84,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $388.00 in Billed Charges for Rev 370 = $263.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,ANTHEM,ANTHEM PPO,263.84,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $388.00 in Billed Charges for Rev 370 = $263.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 370 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,CENPATICO,ALL MEDICAID CENPATICO,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 370 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,329.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $388.00 in Billed Charges for Rev 370 = $329.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,CIGNA,ALL COMMERCIAL CIGNA,271.60,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $388.00 in Billed Charges for Rev 370 = $271.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,COFINITY,COFINITY,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 370 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,368.60,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $388.00 in Billed Charges for Rev 370 = $368.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,325.92,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $388.00 in Billed Charges for Rev 370 = $325.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,275.48,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $388.00 in Billed Charges for Rev 370 = $275.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,283.24,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $388.00 in Billed Charges for Rev 370 = $283.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,188.57,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $388.00 in Billed Charges for Rev 370 = $188.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,329.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $388.00 in Billed Charges for Rev 370 = $329.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,HUMANA,HUMANA CHOICE CARE HMO,246.38,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $388.00 in Billed Charges for Rev 370 = $246.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,HUMANA,HUMANA CHOICE CARE PPO,329.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $388.00 in Billed Charges for Rev 370 = $329.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,HUMANA,HUMANA NATIIONAL POS HMO,246.38,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $388.00 in Billed Charges for Rev 370 = $246.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,283.24,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $388.00 in Billed Charges for Rev 370 = $283.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,388.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $388.00 in Billed Charges for Rev 370 = $388.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,194.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $388.00 in Billed Charges for Rev 370 = $194.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,325.92,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $388.00 in Billed Charges for Rev 370 = $325.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,291.00,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $388.00 in Billed Charges for Rev 370 = $291.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,356.96,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $388.00 in Billed Charges for Rev 370 = $356.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 370 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 370 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,PREVEA HEALTH NETWORK,PREVEA360,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 370 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 370 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,247.66,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $388.00 in Billed Charges for Rev 370 = $247.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,279.36,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $388.00 in Billed Charges for Rev 370 = $279.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,214.56,,,,,,,188.5700,388.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $388.00 in Billed Charges for Rev 370 = $214.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,214.56,,,,,,,188.5700,388.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $388.00 in Billed Charges for Rev 370 = $214.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,214.56,,,,,,,188.5700,388.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $388.00 in Billed Charges for Rev 370 = $214.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,279.36,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $388.00 in Billed Charges for Rev 370 = $279.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,240.56,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $388.00 in Billed Charges for Rev 370 = $240.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,279.36,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $388.00 in Billed Charges for Rev 370 = $279.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,279.36,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $388.00 in Billed Charges for Rev 370 = $279.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CARDIAC ANES ADDL,370,RC,37000059,CDM,,,,,,both,,,388.0000,256.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,232.80,,,,,,,188.5700,388.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $388.00 in Billed Charges for Rev 370 = $232.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,AETNA,AETNA HSHS,343.67,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $343.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,AETNA,ALL COMMERCIAL AETNA,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTEHM MEDICAID,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99151 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM POS/HMO,361.76,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM PPO,361.76,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,CENPATICO,ALL MEDICAID CENPATICO,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,CIGNA,ALL COMMERCIAL CIGNA,372.40,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $372.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,COFINITY,COFINITY,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99151 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99151 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,505.40,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $505.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,446.88,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,377.72,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $377.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,388.36,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,258.55,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $258.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE HMO,337.82,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $337.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE PPO,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA NATIIONAL POS HMO,337.82,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $337.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,388.36,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99151 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99151 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,11.05,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99151 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42... $10.42 at 106% = $11.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,266.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $266.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,446.88,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,399.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $399.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,489.44,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $489.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,339.58,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $339.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,TRILOGY MEDICAID,11.05,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99151 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 106% = $11.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,329.84,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $329.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY <5YR 1ST 15MIN,99151,CPT,370,RC,37000072,CDM,,,,both,,,532.0000,351.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99151 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,AETNA,AETNA HSHS,483.85,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $749.00 in Billed Charges for Rev 370 = $483.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,AETNA,ALL COMMERCIAL AETNA,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 370 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,ANTHEM,ANTHEM POS/HMO,509.32,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $749.00 in Billed Charges for Rev 370 = $509.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,ANTHEM,ANTHEM PPO,509.32,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $749.00 in Billed Charges for Rev 370 = $509.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 370 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,CENPATICO,ALL MEDICAID CENPATICO,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 370 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,636.65,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.00 in Billed Charges for Rev 370 = $636.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,CIGNA,ALL COMMERCIAL CIGNA,524.30,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $749.00 in Billed Charges for Rev 370 = $524.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,COFINITY,COFINITY,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 370 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,711.55,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $749.00 in Billed Charges for Rev 370 = $711.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,629.16,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $749.00 in Billed Charges for Rev 370 = $629.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,531.79,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $749.00 in Billed Charges for Rev 370 = $531.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,546.77,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $749.00 in Billed Charges for Rev 370 = $546.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,364.01,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $749.00 in Billed Charges for Rev 370 = $364.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,636.65,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.00 in Billed Charges for Rev 370 = $636.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,HUMANA,HUMANA CHOICE CARE HMO,475.62,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $749.00 in Billed Charges for Rev 370 = $475.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,HUMANA,HUMANA CHOICE CARE PPO,636.65,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.00 in Billed Charges for Rev 370 = $636.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,HUMANA,HUMANA NATIIONAL POS HMO,475.62,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $749.00 in Billed Charges for Rev 370 = $475.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,546.77,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $749.00 in Billed Charges for Rev 370 = $546.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 370 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,374.50,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $749.00 in Billed Charges for Rev 370 = $374.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,629.16,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $749.00 in Billed Charges for Rev 370 = $629.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,561.75,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $749.00 in Billed Charges for Rev 370 = $561.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,689.08,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $749.00 in Billed Charges for Rev 370 = $689.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 370 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 370 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,PREVEA HEALTH NETWORK,PREVEA360,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 370 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 370 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.09,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $749.00 in Billed Charges for Rev 370 = $478.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,539.28,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.00 in Billed Charges for Rev 370 = $539.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,414.20,,,,,,,364.0100,749.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $749.00 in Billed Charges for Rev 370 = $414.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,414.20,,,,,,,364.0100,749.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $749.00 in Billed Charges for Rev 370 = $414.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,414.20,,,,,,,364.0100,749.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $749.00 in Billed Charges for Rev 370 = $414.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,539.28,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.00 in Billed Charges for Rev 370 = $539.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,464.38,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $749.00 in Billed Charges for Rev 370 = $464.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,539.28,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.00 in Billed Charges for Rev 370 = $539.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,539.28,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.00 in Billed Charges for Rev 370 = $539.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SEDATION DEEP/INTENSIVE,370,RC,37000079,CDM,,,,,,both,,,749.0000,494.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 370 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,AETNA,AETNA HSHS,714.48,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $714.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,AETNA,ALL COMMERCIAL AETNA,1106.00,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $1,106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,ANTHEM,ANTEHM MEDICAID,10.42,,,,,,,10.4200,1106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 01967 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,ANTHEM,ANTHEM POS/HMO,752.08,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $752.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,ANTHEM,ANTHEM PPO,752.08,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $752.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1106.00,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $1,106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,CENPATICO,ALL MEDICAID CENPATICO,1106.00,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $1,106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,940.10,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $940.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,CIGNA,ALL COMMERCIAL CIGNA,774.20,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $774.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,COFINITY,COFINITY,1106.00,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $1,106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.42,,,,,,,10.4200,1106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 01967 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.42,,,,,,,10.4200,1106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 01967 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1050.70,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $1,050.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,929.04,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $929.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,785.26,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $785.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,807.38,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $807.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,537.52,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $537.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,940.10,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $940.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,HUMANA,HUMANA CHOICE CARE HMO,702.31,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $702.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,HUMANA,HUMANA CHOICE CARE PPO,940.10,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $940.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,HUMANA,HUMANA NATIIONAL POS HMO,702.31,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $702.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,807.38,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $807.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1106.00,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $1,106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.42,,,,,,,10.4200,1106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 01967 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.42,,,,,,,10.4200,1106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 01967 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,11.05,,,,,,,10.4200,1106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 01967 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42... $10.42 at 106% = $11.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,553.00,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $553.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,929.04,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $929.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,829.50,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $829.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1017.52,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $1,017.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,663.60,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $663.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,663.60,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $663.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,PREVEA HEALTH NETWORK,PREVEA360,663.60,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $663.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,663.60,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $663.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,705.96,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $705.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,796.32,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $796.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,TRIOLOGY,TRILOGY MEDICAID,11.05,,,,,,,10.4200,1106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 01967 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 106% = $11.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,611.62,,,,,,,10.4200,1106.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $611.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,611.62,,,,,,,10.4200,1106.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $611.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,611.62,,,,,,,10.4200,1106.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $611.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,796.32,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $796.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,685.72,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $685.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,796.32,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $796.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,796.32,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $796.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL/SPINAL FOR LABOR,01967,CPT,370,RC,37001000,CDM,,,,both,,,1106.0000,729.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,663.60,,,,,,,10.4200,1106.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,106.00 in Billed Charges for Rev 370 Proc 01967 = $663.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,AETNA,AETNA HSHS,45.22,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $70.00 in Billed Charges for Rev 390 = $45.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,AETNA,ALL COMMERCIAL AETNA,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 390 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,ANTHEM,ANTHEM POS/HMO,47.60,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $70.00 in Billed Charges for Rev 390 = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,ANTHEM,ANTHEM PPO,47.60,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $70.00 in Billed Charges for Rev 390 = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 390 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,CENPATICO,ALL MEDICAID CENPATICO,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 390 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,59.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.00 in Billed Charges for Rev 390 = $59.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,CIGNA,ALL COMMERCIAL CIGNA,49.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $70.00 in Billed Charges for Rev 390 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,COFINITY,COFINITY,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 390 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,66.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $70.00 in Billed Charges for Rev 390 = $66.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,58.80,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.00 in Billed Charges for Rev 390 = $58.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,49.70,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $70.00 in Billed Charges for Rev 390 = $49.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,51.10,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.00 in Billed Charges for Rev 390 = $51.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,34.02,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $70.00 in Billed Charges for Rev 390 = $34.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,59.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.00 in Billed Charges for Rev 390 = $59.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,HUMANA,HUMANA CHOICE CARE HMO,44.45,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $70.00 in Billed Charges for Rev 390 = $44.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,HUMANA,HUMANA CHOICE CARE PPO,59.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.00 in Billed Charges for Rev 390 = $59.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,HUMANA,HUMANA NATIIONAL POS HMO,44.45,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $70.00 in Billed Charges for Rev 390 = $44.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,51.10,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.00 in Billed Charges for Rev 390 = $51.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 390 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $70.00 in Billed Charges for Rev 390 = $35.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,58.80,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.00 in Billed Charges for Rev 390 = $58.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,52.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $70.00 in Billed Charges for Rev 390 = $52.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,64.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $70.00 in Billed Charges for Rev 390 = $64.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 390 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 390 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,PREVEA HEALTH NETWORK,PREVEA360,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 390 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 390 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44.68,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $70.00 in Billed Charges for Rev 390 = $44.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,50.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.00 in Billed Charges for Rev 390 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,70.00,,,,,,,34.0200,70.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $70.00, claim capped at $70.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,70.00,,,,,,,34.0200,70.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $70.00, claim capped at $70.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,70.00,,,,,,,34.0200,70.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $70.00, claim capped at $70.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,50.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.00 in Billed Charges for Rev 390 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,43.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $70.00 in Billed Charges for Rev 390 = $43.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,50.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.00 in Billed Charges for Rev 390 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,50.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.00 in Billed Charges for Rev 390 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CROSS CMV TESTED PRD,390,RC,39000001,CDM,,,,,,both,,,70.0000,46.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 390 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,AETNA,AETNA HSHS,959.31,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $959.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,AETNA,AETNA MEDICARE,189.84,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,AETNA,ALL COMMERCIAL AETNA,1485.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,485.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,189.84,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,ANTHEM,ANTHEM POS/HMO,1009.80,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,009.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,ANTHEM,ANTHEM PPO,1009.80,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,009.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1485.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,485.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,CENPATICO,ALL MEDICAID CENPATICO,1485.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,485.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1262.25,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,262.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,CIGNA,ALL COMMERCIAL CIGNA,1039.50,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,039.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,COFINITY,COFINITY,1485.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,485.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1410.75,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,410.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,1247.40,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,247.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1054.35,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,054.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1084.05,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,084.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,721.71,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $721.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1262.25,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,262.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HUMANA,HUMANA CHOICE CARE HMO,942.98,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $942.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HUMANA,HUMANA CHOICE CARE PPO,1262.25,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,262.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,189.84,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,HUMANA,HUMANA NATIIONAL POS HMO,942.98,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $942.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1084.05,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,084.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1485.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,485.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,189.84,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,189.84,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,742.50,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $742.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1247.40,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,247.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,427.14,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1113.75,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,113.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1366.20,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,366.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,891.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $891.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,891.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $891.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,PREVEA HEALTH NETWORK,PREVEA360,891.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $891.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,891.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $891.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,947.88,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $947.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,191.74,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1069.20,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,069.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,57.4200,1485.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9010 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,57.4200,1485.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9010 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,189.84,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,57.4200,1485.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9010 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,UNITY HEALTH PLAN,UNITY HOSPICE,189.84,,,,,,,57.4200,1485.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1069.20,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,069.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,920.70,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $920.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1069.20,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,069.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1069.20,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $1,069.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO,P9010,HCPCS,390,RC,39000101,CDM,,,,both,,,1485.0000,980.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,891.00,,,,,,,57.4200,1485.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,485.00 in Billed Charges for Rev 390 Proc P9010 = $891.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,AETNA,AETNA HSHS,387.60,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $387.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,AETNA,AETNA MEDICARE,189.84,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,AETNA,ALL COMMERCIAL AETNA,600.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,189.84,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,ANTHEM,ANTHEM POS/HMO,408.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,ANTHEM,ANTHEM PPO,408.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,600.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,CENPATICO,ALL MEDICAID CENPATICO,600.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,510.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,CIGNA,ALL COMMERCIAL CIGNA,420.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,COFINITY,COFINITY,600.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,570.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $570.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,504.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,426.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,438.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,291.60,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $291.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,510.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HUMANA,HUMANA CHOICE CARE HMO,381.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HUMANA,HUMANA CHOICE CARE PPO,510.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,189.84,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,HUMANA,HUMANA NATIIONAL POS HMO,381.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,438.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,600.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,189.84,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,189.84,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,300.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,504.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,427.14,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,450.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,552.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $552.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,360.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,360.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,PREVEA HEALTH NETWORK,PREVEA360,360.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,360.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,382.98,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $382.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,191.74,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,432.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9010 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,57.4200,600.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9010 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,57.4200,600.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9010 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,189.84,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,57.4200,600.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9010 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,UNITY HEALTH PLAN,UNITY HOSPICE,189.84,,,,,,,57.4200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,432.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,372.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,432.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,432.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE BLOOD EA AUTO (RC),P9010,HCPCS,390,RC,39000102,CDM,,,,both,,,600.0000,396.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,360.00,,,,,,,57.4200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9010 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,AETNA,AETNA HSHS,151.81,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $151.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,AETNA,AETNA MEDICARE,71.95,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,AETNA,ALL COMMERCIAL AETNA,235.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9012 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,71.95,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,ANTHEM,ANTHEM POS/HMO,159.80,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $159.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,ANTHEM,ANTHEM PPO,159.80,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $159.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,235.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,CENPATICO,ALL MEDICAID CENPATICO,235.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,199.75,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $199.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,CIGNA,ALL COMMERCIAL CIGNA,164.50,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $164.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,COFINITY,COFINITY,235.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9012 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9012 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,223.25,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $223.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,197.40,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $197.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,166.85,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $166.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,171.55,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $171.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,114.21,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $114.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,199.75,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $199.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HUMANA,HUMANA CHOICE CARE HMO,149.23,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $149.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HUMANA,HUMANA CHOICE CARE PPO,199.75,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $199.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,71.95,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,HUMANA,HUMANA NATIIONAL POS HMO,149.23,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $149.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,171.55,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $171.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,235.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9012 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,71.95,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9012 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9012 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,71.95,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,117.50,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $117.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,197.40,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $197.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,161.89,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,176.25,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $176.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,216.20,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $216.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,141.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,141.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,PREVEA HEALTH NETWORK,PREVEA360,141.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,141.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,150.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,72.67,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,169.20,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $169.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9012 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,235.00,,,,,,,71.9500,235.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9012 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $235.00, claim capped at $235.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,235.00,,,,,,,71.9500,235.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9012 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $235.00, claim capped at $235.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,71.95,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,235.00,,,,,,,71.9500,235.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9012 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $235.00, claim capped at $235.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,UNITY HEALTH PLAN,UNITY HOSPICE,71.95,,,,,,,71.9500,235.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,169.20,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $169.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,145.70,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $145.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,169.20,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $169.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,169.20,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $169.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CRYOPRECIPITATE EACH UNIT,P9012,HCPCS,390,RC,39000104,CDM,,,,both,,,235.0000,155.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,141.00,,,,,,,71.9500,235.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $235.00 in Billed Charges for Rev 390 Proc P9012 = $141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,AETNA,AETNA HSHS,455.43,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $455.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,AETNA,AETNA MEDICARE,184.91,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,AETNA,ALL COMMERCIAL AETNA,705.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,ANTHEM,ANTEHM MEDICAID,449.49,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,184.91,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,ANTHEM,ANTHEM POS/HMO,479.40,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $479.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,ANTHEM,ANTHEM PPO,479.40,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $479.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,705.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,CENPATICO,ALL MEDICAID CENPATICO,705.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,599.25,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $599.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,CIGNA,ALL COMMERCIAL CIGNA,493.50,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $493.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,COFINITY,COFINITY,705.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,449.49,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,449.49,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,669.75,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $669.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,592.20,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $592.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,500.55,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $500.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,514.65,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $514.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,342.63,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $342.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,599.25,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $599.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HUMANA,HUMANA CHOICE CARE HMO,447.68,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $447.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HUMANA,HUMANA CHOICE CARE PPO,599.25,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $599.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,184.91,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,HUMANA,HUMANA NATIIONAL POS HMO,447.68,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $447.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,514.65,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $514.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,705.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $705.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,449.49,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,184.91,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,449.49,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,476.46,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49... $449.49 at 106% = $476.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,184.91,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,352.50,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $352.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,592.20,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $592.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,416.05,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,528.75,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $528.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,648.60,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $648.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,423.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,423.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,PREVEA HEALTH NETWORK,PREVEA360,423.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,423.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,450.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,186.76,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,507.60,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $507.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,TRIOLOGY,TRILOGY MEDICAID,476.46,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 106% = $476.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,184.9100,705.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,184.9100,705.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,184.91,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,184.9100,705.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,UNITY HEALTH PLAN,UNITY HOSPICE,184.91,,,,,,,184.9100,705.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,507.60,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $507.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,437.10,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $437.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,507.60,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $507.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,507.60,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $507.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,39000108,CDM,,,,both,,,705.0000,465.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,423.00,,,,,,,184.9100,705.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $705.00 in Billed Charges for Rev 390 Proc P9016 = $423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,AETNA,AETNA HSHS,184.76,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $184.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,AETNA,AETNA MEDICARE,85.98,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,AETNA,ALL COMMERCIAL AETNA,286.00,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $286.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,ANTHEM,ANTEHM MEDICAID,38.65,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9017 at $38.65 (Fee Schedule) = $38.65 (Total Line Payment) at 100% = $38.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,85.98,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,ANTHEM,ANTHEM POS/HMO,194.48,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $194.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,ANTHEM,ANTHEM PPO,194.48,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $194.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,286.00,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $286.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,CENPATICO,ALL MEDICAID CENPATICO,286.00,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $286.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,243.10,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $243.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,CIGNA,ALL COMMERCIAL CIGNA,200.20,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $200.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,COFINITY,COFINITY,286.00,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $286.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,38.65,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9017 at $38.65 (Fee Schedule) = $38.65 (Total Line Payment) at 100% = $38.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,38.65,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9017 at $38.65 (Fee Schedule) = $38.65 (Total Line Payment) at 100% = $38.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,271.70,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $271.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,240.24,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $240.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,203.06,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $203.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,208.78,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $208.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,139.00,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $139.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,243.10,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $243.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HUMANA,HUMANA CHOICE CARE HMO,181.61,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $181.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HUMANA,HUMANA CHOICE CARE PPO,243.10,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $243.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,85.98,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,HUMANA,HUMANA NATIIONAL POS HMO,181.61,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $181.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,208.78,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $208.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,286.00,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $286.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,38.65,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9017 at $38.65 (Fee Schedule) = $38.65 (Total Line Payment) at 100% = $38.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,85.98,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,38.65,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9017 at $38.65 (Fee Schedule) = $38.65 (Total Line Payment) at 100% = $38.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,40.97,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9017 at $38.65 (Fee Schedule) = $38.65 (Total Line Payment) at 100% = $38.65... $38.65 at 106% = $40.97 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,85.98,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,143.00,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $143.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,240.24,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $240.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,193.46,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,214.50,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $214.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,263.12,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $263.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,171.60,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $171.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,171.60,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $171.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,PREVEA HEALTH NETWORK,PREVEA360,171.60,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $171.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,171.60,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $171.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,182.55,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $182.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,86.84,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,205.92,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $205.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,TRIOLOGY,TRILOGY MEDICAID,40.97,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9017 at $38.65 (Fee Schedule) = $38.65 (Total Line Payment) at 106% = $40.97. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,286.00,,,,,,,38.6500,286.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9017 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $286.00, claim capped at $286.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,286.00,,,,,,,38.6500,286.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9017 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $286.00, claim capped at $286.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,85.98,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,286.00,,,,,,,38.6500,286.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9017 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $286.00, claim capped at $286.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,UNITY HEALTH PLAN,UNITY HOSPICE,85.98,,,,,,,38.6500,286.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,205.92,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $205.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,177.32,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $177.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,205.92,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $205.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,205.92,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $205.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,39000112,CDM,,,,both,,,286.0000,188.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,171.60,,,,,,,38.6500,286.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $286.00 in Billed Charges for Rev 390 Proc P9017 = $171.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,AETNA,AETNA HSHS,265.51,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $265.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,AETNA,AETNA MEDICARE,144.26,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,AETNA,ALL COMMERCIAL AETNA,411.00,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9031 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,144.26,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,ANTHEM,ANTHEM POS/HMO,279.48,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $279.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,ANTHEM,ANTHEM PPO,279.48,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $279.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,411.00,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,CENPATICO,ALL MEDICAID CENPATICO,411.00,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,349.35,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $349.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,CIGNA,ALL COMMERCIAL CIGNA,287.70,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $287.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,COFINITY,COFINITY,411.00,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9031 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9031 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,390.45,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $390.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,345.24,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $345.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,291.81,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $291.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,300.03,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $300.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,199.75,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $199.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,349.35,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $349.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HUMANA,HUMANA CHOICE CARE HMO,260.99,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $260.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HUMANA,HUMANA CHOICE CARE PPO,349.35,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $349.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,144.26,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,HUMANA,HUMANA NATIIONAL POS HMO,260.99,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $260.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,300.03,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $300.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,411.00,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $411.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9031 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,144.26,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9031 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9031 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,144.26,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,205.50,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $205.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,345.24,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $345.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,324.59,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,308.25,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $308.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,378.12,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $378.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,246.60,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $246.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,246.60,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $246.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,PREVEA HEALTH NETWORK,PREVEA360,246.60,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $246.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,246.60,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $246.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,262.34,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $262.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,145.70,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,295.92,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $295.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9031 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,411.00,,,,,,,126.6200,411.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9031 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $411.00, claim capped at $411.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,411.00,,,,,,,126.6200,411.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9031 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $411.00, claim capped at $411.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,144.26,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,411.00,,,,,,,126.6200,411.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9031 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $411.00, claim capped at $411.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,UNITY HEALTH PLAN,UNITY HOSPICE,144.26,,,,,,,126.6200,411.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,295.92,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $295.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,254.82,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $254.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,295.92,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $295.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,295.92,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $295.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,39000117,CDM,,,,both,,,411.0000,271.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,246.60,,,,,,,126.6200,411.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $411.00 in Billed Charges for Rev 390 Proc P9031 = $246.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,AETNA,AETNA HSHS,387.60,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $387.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,AETNA,AETNA MEDICARE,189.59,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,AETNA,ALL COMMERCIAL AETNA,600.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9033 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,189.59,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,ANTHEM,ANTHEM POS/HMO,408.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,ANTHEM,ANTHEM PPO,408.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $408.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,600.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,CENPATICO,ALL MEDICAID CENPATICO,600.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,510.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,CIGNA,ALL COMMERCIAL CIGNA,420.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,COFINITY,COFINITY,600.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9033 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9033 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,570.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $570.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,504.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,426.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,438.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,291.60,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $291.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,510.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HUMANA,HUMANA CHOICE CARE HMO,381.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HUMANA,HUMANA CHOICE CARE PPO,510.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $510.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,189.59,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,HUMANA,HUMANA NATIIONAL POS HMO,381.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,438.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,600.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $600.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9033 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,189.59,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9033 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9033 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,189.59,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,300.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,504.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $504.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,426.58,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,450.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,552.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $552.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,360.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,360.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,PREVEA HEALTH NETWORK,PREVEA360,360.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,360.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,382.98,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $382.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,191.49,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,432.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9033 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,600.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9033 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,600.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9033 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,189.59,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,600.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9033 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,UNITY HEALTH PLAN,UNITY HOSPICE,189.59,,,,,,,126.6200,600.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,432.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,372.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,432.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,432.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS L/R IRR EA,P9033,HCPCS,390,RC,39000119,CDM,,,,both,,,600.0000,396.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,360.00,,,,,,,126.6200,600.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $600.00 in Billed Charges for Rev 390 Proc P9033 = $360.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,AETNA,AETNA HSHS,1164.09,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,164.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,AETNA,AETNA MEDICARE,255.05,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,AETNA,ALL COMMERCIAL AETNA,1802.00,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,ANTHEM,ANTEHM MEDICAID,61.22,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81313 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,255.05,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,ANTHEM,ANTHEM POS/HMO,892.68,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $892.68 from Fee Schedule WII28_25 for Rev 310 Proc 81313 Mod TC * Qty 1 = $892.68 at 100% = $892.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,ANTHEM,ANTHEM PPO,892.68,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $892.68 from Fee Schedule WII28_25 for Rev 310 Proc 81313 Mod TC * Qty 1 = $892.68 at 100% = $892.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1802.00,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,CENPATICO,ALL MEDICAID CENPATICO,1802.00,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1531.70,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,531.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,CIGNA,ALL COMMERCIAL CIGNA,1261.40,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,261.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,COFINITY,COFINITY,1802.00,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,61.22,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81313 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,61.22,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81313 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1711.90,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,711.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,1513.68,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,513.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1279.42,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,279.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1315.46,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,315.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,875.77,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $875.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1531.70,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,531.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,HUMANA CHOICE CARE HMO,433.59,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $433.59 from Fee Schedule 005543_170 for Rev 310 Proc 81313 * Qty 1 = $433.59 at 100% = $433.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,HUMANA CHOICE CARE PPO,1531.70,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,531.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,255.05,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,HUMANA,HUMANA NATIIONAL POS HMO,433.59,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $433.59 from Fee Schedule 005543_170 for Rev 310 Proc 81313 * Qty 1 = $433.59 at 100% = $433.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1315.46,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,315.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1802.00,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,802.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,61.22,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81313 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,255.05,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,61.22,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81313 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,64.89,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81313 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22... $61.22 at 106% = $64.89 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,255.05,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,901.00,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1513.68,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,513.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,573.86,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1351.50,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,351.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1657.84,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,657.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,331.57,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,331.57,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,PREVEA HEALTH NETWORK,PREVEA360,331.57,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,331.57,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1150.22,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,150.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,257.60,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1297.44,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,297.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,TRIOLOGY,TRILOGY MEDICAID,64.89,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81313 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 106% = $64.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,306.06,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $306.06 from Fee Schedule UHC_98227C for Rev 310 Proc 81313 * Qty 1 = $306.06 at 100% = $306.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,306.06,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $306.06 from Fee Schedule UHC_98227C for Rev 310 Proc 81313 * Qty 1 = $306.06 at 100% = $306.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,255.05,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,306.06,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $306.06 from Fee Schedule UHC_98227C for Rev 310 Proc 81313 * Qty 1 = $306.06 at 100% = $306.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,UNITY HEALTH PLAN,UNITY HOSPICE,255.05,,,,,,,61.2200,1802.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1297.44,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,297.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1117.24,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,117.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1297.44,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,297.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1297.44,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,297.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PROSTATE CANCER ANTIGEN 3,81313,CPT,310,RC,31000105,CDM,,,,both,,,1802.0000,1189.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1081.20,,,,,,,61.2200,1802.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,802.00 in Billed Charges for Rev 310 Proc 81313 = $1,081.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,AETNA,AETNA HSHS,1115.64,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,115.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,AETNA,AETNA MEDICARE,137.00,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,AETNA,ALL COMMERCIAL AETNA,1727.00,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,ANTHEM,ANTEHM MEDICAID,109.60,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,137.00,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,ANTHEM,ANTHEM POS/HMO,479.50,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81401 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,ANTHEM,ANTHEM PPO,479.50,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81401 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1727.00,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,CENPATICO,ALL MEDICAID CENPATICO,1727.00,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1467.95,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,467.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,CIGNA,ALL COMMERCIAL CIGNA,1208.90,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,208.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,COFINITY,COFINITY,1727.00,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,109.60,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,109.60,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1640.65,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,640.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,1450.68,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,450.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1226.17,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,226.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1260.71,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,260.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,839.32,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $839.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1467.95,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,467.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HUMANA,HUMANA CHOICE CARE HMO,232.90,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81401 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HUMANA,HUMANA CHOICE CARE PPO,1467.95,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,467.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,137.00,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,HUMANA,HUMANA NATIIONAL POS HMO,232.90,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81401 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1260.71,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,260.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1727.00,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,109.60,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,137.00,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,109.60,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,116.18,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60... $109.60 at 106% = $116.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,137.00,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,863.50,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $863.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1450.68,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,450.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,308.25,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1295.25,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,295.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1588.84,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,588.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,178.10,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,178.10,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,PREVEA HEALTH NETWORK,PREVEA360,178.10,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,178.10,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1102.34,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,102.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,138.37,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1243.44,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,243.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,TRIOLOGY,TRILOGY MEDICAID,116.18,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81401 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 106% = $116.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,164.40,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81401 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,164.40,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81401 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,137.00,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,164.40,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81401 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,UNITY HEALTH PLAN,UNITY HOSPICE,137.00,,,,,,,109.6000,1727.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1243.44,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,243.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1070.74,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,070.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1243.44,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,243.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1243.44,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,243.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOPATH PROC L2,81401,CPT,310,RC,31000106,CDM,,,,both,,,1727.0000,1139.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1036.20,,,,,,,109.6000,1727.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,727.00 in Billed Charges for Rev 310 Proc 81401 = $1,036.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,AETNA,AETNA HSHS,523.91,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $523.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,AETNA,AETNA MEDICARE,450.91,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,AETNA,ALL COMMERCIAL AETNA,811.00,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,ANTHEM,ANTEHM MEDICAID,133.58,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,450.91,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,ANTHEM,ANTHEM POS/HMO,811.00,,,,,,,133.5800,1014.5500,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,578.19 from Fee Schedule WII28_25 for Rev 310 Proc 81226 Mod TC * Qty 1 = $1,578.19 at 100% = $1,578.19 (Limited to $811.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,ANTHEM,ANTHEM PPO,811.00,,,,,,,133.5800,1014.5500,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,578.19 from Fee Schedule WII28_25 for Rev 310 Proc 81226 Mod TC * Qty 1 = $1,578.19 at 100% = $1,578.19 (Limited to $811.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,811.00,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,CENPATICO,ALL MEDICAID CENPATICO,811.00,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,689.35,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $689.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,CIGNA,ALL COMMERCIAL CIGNA,567.70,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $567.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,COFINITY,COFINITY,811.00,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,133.58,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,133.58,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,770.45,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $770.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,681.24,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $681.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,575.81,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $575.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,592.03,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $592.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,394.15,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $394.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,689.35,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $689.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HUMANA,HUMANA CHOICE CARE HMO,766.55,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $766.55 from Fee Schedule 005543_170 for Rev 310 Proc 81226 * Qty 1 = $766.55 at 100% = $766.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HUMANA,HUMANA CHOICE CARE PPO,689.35,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $689.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,450.91,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,HUMANA,HUMANA NATIIONAL POS HMO,766.55,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $766.55 from Fee Schedule 005543_170 for Rev 310 Proc 81226 * Qty 1 = $766.55 at 100% = $766.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,592.03,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $592.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,811.00,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $811.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,133.58,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,450.91,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,133.58,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,141.59,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58... $133.58 at 106% = $141.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,450.91,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,405.50,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $405.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,681.24,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $681.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,1014.55,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,608.25,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $608.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,746.12,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $746.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,586.18,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,586.18,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,PREVEA HEALTH NETWORK,PREVEA360,586.18,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,586.18,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,517.66,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $517.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,455.42,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,583.92,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $583.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,TRIOLOGY,TRILOGY MEDICAID,141.59,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81226 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 106% = $141.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,541.09,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $541.09 from Fee Schedule UHC_98227C for Rev 310 Proc 81226 * Qty 1 = $541.09 at 100% = $541.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,541.09,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $541.09 from Fee Schedule UHC_98227C for Rev 310 Proc 81226 * Qty 1 = $541.09 at 100% = $541.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,450.91,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,541.09,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $541.09 from Fee Schedule UHC_98227C for Rev 310 Proc 81226 * Qty 1 = $541.09 at 100% = $541.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,UNITY HEALTH PLAN,UNITY HOSPICE,450.91,,,,,,,133.5800,1014.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,583.92,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $583.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,502.82,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $502.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,583.92,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $583.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,583.92,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $583.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,81226,CPT,310,RC,31000112,CDM,,,,both,,,811.0000,535.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,486.60,,,,,,,133.5800,1014.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $811.00 in Billed Charges for Rev 310 Proc 81226 = $486.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,AETNA,AETNA HSHS,242.25,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $242.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,AETNA,AETNA MEDICARE,165.51,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,AETNA,ALL COMMERCIAL AETNA,375.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,ANTHEM,ANTEHM MEDICAID,132.74,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81245 at $132.74 (Fee Schedule) = $132.74 (Total Line Payment) at 100% = $132.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,165.51,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,ANTHEM,ANTHEM POS/HMO,375.00,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $579.29 from Fee Schedule WII28_25 for Rev 310 Proc 81245 Mod TC * Qty 1 = $579.29 at 100% = $579.29 (Limited to $375.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,ANTHEM,ANTHEM PPO,375.00,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $579.29 from Fee Schedule WII28_25 for Rev 310 Proc 81245 Mod TC * Qty 1 = $579.29 at 100% = $579.29 (Limited to $375.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,375.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,CENPATICO,ALL MEDICAID CENPATICO,375.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,318.75,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $318.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,CIGNA,ALL COMMERCIAL CIGNA,262.50,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $262.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,COFINITY,COFINITY,375.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,132.74,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81245 at $132.74 (Fee Schedule) = $132.74 (Total Line Payment) at 100% = $132.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,132.74,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81245 at $132.74 (Fee Schedule) = $132.74 (Total Line Payment) at 100% = $132.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,356.25,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $356.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,315.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,266.25,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $266.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,273.75,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $273.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,182.25,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $182.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,318.75,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $318.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HUMANA,HUMANA CHOICE CARE HMO,281.37,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $281.37 from Fee Schedule 005543_170 for Rev 310 Proc 81245 * Qty 1 = $281.37 at 100% = $281.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HUMANA,HUMANA CHOICE CARE PPO,318.75,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $318.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,165.51,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,HUMANA,HUMANA NATIIONAL POS HMO,281.37,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $281.37 from Fee Schedule 005543_170 for Rev 310 Proc 81245 * Qty 1 = $281.37 at 100% = $281.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,273.75,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $273.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,375.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,132.74,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81245 at $132.74 (Fee Schedule) = $132.74 (Total Line Payment) at 100% = $132.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,165.51,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,132.74,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81245 at $132.74 (Fee Schedule) = $132.74 (Total Line Payment) at 100% = $132.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,140.70,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81245 at $132.74 (Fee Schedule) = $132.74 (Total Line Payment) at 100% = $132.74... $132.74 at 106% = $140.70 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,165.51,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,187.50,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $187.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,315.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,372.40,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,281.25,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $281.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,345.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $345.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,215.16,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,215.16,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,PREVEA HEALTH NETWORK,PREVEA360,215.16,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,215.16,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,239.36,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $239.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,167.17,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,270.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,TRIOLOGY,TRILOGY MEDICAID,140.70,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81245 at $132.74 (Fee Schedule) = $132.74 (Total Line Payment) at 106% = $140.70. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,198.61,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $198.61 from Fee Schedule UHC_98227C for Rev 310 Proc 81245 * Qty 1 = $198.61 at 100% = $198.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,198.61,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $198.61 from Fee Schedule UHC_98227C for Rev 310 Proc 81245 * Qty 1 = $198.61 at 100% = $198.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,165.51,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,198.61,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $198.61 from Fee Schedule UHC_98227C for Rev 310 Proc 81245 * Qty 1 = $198.61 at 100% = $198.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,UNITY HEALTH PLAN,UNITY HOSPICE,165.51,,,,,,,132.7400,375.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,270.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,232.50,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $232.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,270.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,270.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FLT3 GENE ANALYSIS INT TANDEM DUP VARIANTS,81245,CPT,310,RC,31000113,CDM,,,,both,,,375.0000,247.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,225.00,,,,,,,132.7400,375.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $375.00 in Billed Charges for Rev 310 Proc 81245 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,AETNA,AETNA HSHS,203.49,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $203.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,AETNA,AETNA MEDICARE,83.00,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,AETNA,ALL COMMERCIAL AETNA,315.00,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,ANTHEM,ANTEHM MEDICAID,85.76,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81246 at $85.76 (Fee Schedule) = $85.76 (Total Line Payment) at 100% = $85.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,83.00,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,ANTHEM,ANTHEM POS/HMO,290.50,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $290.50 from Fee Schedule WII28_25 for Rev 310 Proc 81246 Mod TC * Qty 1 = $290.50 at 100% = $290.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,ANTHEM,ANTHEM PPO,290.50,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $290.50 from Fee Schedule WII28_25 for Rev 310 Proc 81246 Mod TC * Qty 1 = $290.50 at 100% = $290.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,315.00,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,CENPATICO,ALL MEDICAID CENPATICO,315.00,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,267.75,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,CIGNA,ALL COMMERCIAL CIGNA,220.50,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $220.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,COFINITY,COFINITY,315.00,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,85.76,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81246 at $85.76 (Fee Schedule) = $85.76 (Total Line Payment) at 100% = $85.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,85.76,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81246 at $85.76 (Fee Schedule) = $85.76 (Total Line Payment) at 100% = $85.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,299.25,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $299.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,264.60,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $264.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,223.65,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $223.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,229.95,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $229.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,153.09,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $153.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,267.75,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HUMANA,HUMANA CHOICE CARE HMO,141.10,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $141.10 from Fee Schedule 005543_170 for Rev 310 Proc 81246 * Qty 1 = $141.10 at 100% = $141.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HUMANA,HUMANA CHOICE CARE PPO,267.75,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $267.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,83.00,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,HUMANA,HUMANA NATIIONAL POS HMO,141.10,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $141.10 from Fee Schedule 005543_170 for Rev 310 Proc 81246 * Qty 1 = $141.10 at 100% = $141.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,229.95,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $229.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,315.00,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,85.76,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81246 at $85.76 (Fee Schedule) = $85.76 (Total Line Payment) at 100% = $85.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,83.00,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,85.76,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81246 at $85.76 (Fee Schedule) = $85.76 (Total Line Payment) at 100% = $85.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,90.91,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81246 at $85.76 (Fee Schedule) = $85.76 (Total Line Payment) at 100% = $85.76... $85.76 at 106% = $90.91 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,83.00,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,157.50,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,264.60,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $264.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,186.75,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,236.25,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $236.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,289.80,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,107.90,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,107.90,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,PREVEA HEALTH NETWORK,PREVEA360,107.90,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,107.90,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,201.06,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $201.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,83.83,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,226.80,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,TRIOLOGY,TRILOGY MEDICAID,90.91,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81246 at $85.76 (Fee Schedule) = $85.76 (Total Line Payment) at 106% = $90.91. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,99.60,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $99.60 from Fee Schedule UHC_98227C for Rev 310 Proc 81246 * Qty 1 = $99.60 at 100% = $99.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,99.60,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $99.60 from Fee Schedule UHC_98227C for Rev 310 Proc 81246 * Qty 1 = $99.60 at 100% = $99.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,83.00,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,99.60,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $99.60 from Fee Schedule UHC_98227C for Rev 310 Proc 81246 * Qty 1 = $99.60 at 100% = $99.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,UNITY HEALTH PLAN,UNITY HOSPICE,83.00,,,,,,,83.0000,315.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,226.80,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,195.30,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $195.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,226.80,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,226.80,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $226.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FL53 GENE ANALYSIS TYROSINE KINASE VARIANTS,81246,CPT,310,RC,31000114,CDM,,,,both,,,315.0000,207.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,189.00,,,,,,,83.0000,315.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $315.00 in Billed Charges for Rev 310 Proc 81246 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,AETNA,AETNA HSHS,515.51,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $515.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,AETNA,AETNA MEDICARE,197.99,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,AETNA,ALL COMMERCIAL AETNA,798.00,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,ANTHEM,ANTEHM MEDICAID,204.58,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,197.99,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,ANTHEM,ANTHEM POS/HMO,692.97,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $692.97 from Fee Schedule WII28_25 for Rev 310 Proc 81261 Mod TC * Qty 1 = $692.97 at 100% = $692.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,ANTHEM,ANTHEM PPO,692.97,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $692.97 from Fee Schedule WII28_25 for Rev 310 Proc 81261 Mod TC * Qty 1 = $692.97 at 100% = $692.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,798.00,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,CENPATICO,ALL MEDICAID CENPATICO,798.00,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,678.30,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $678.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,CIGNA,ALL COMMERCIAL CIGNA,558.60,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $558.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,COFINITY,COFINITY,798.00,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,204.58,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,204.58,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,758.10,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $758.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,670.32,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $670.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,566.58,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $566.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,582.54,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $582.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,387.83,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $387.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,678.30,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $678.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HUMANA,HUMANA CHOICE CARE HMO,336.58,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $336.58 from Fee Schedule 005543_170 for Rev 310 Proc 81261 * Qty 1 = $336.58 at 100% = $336.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HUMANA,HUMANA CHOICE CARE PPO,678.30,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $678.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,197.99,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,HUMANA,HUMANA NATIIONAL POS HMO,336.58,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $336.58 from Fee Schedule 005543_170 for Rev 310 Proc 81261 * Qty 1 = $336.58 at 100% = $336.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,582.54,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $582.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,798.00,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,204.58,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,197.99,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,204.58,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,216.85,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 100% = $204.58... $204.58 at 106% = $216.85 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,197.99,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,399.00,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $399.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,670.32,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $670.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,445.48,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,598.50,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $598.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,734.16,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $734.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,257.39,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,257.39,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,PREVEA HEALTH NETWORK,PREVEA360,257.39,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,257.39,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,509.36,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $509.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,199.97,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,574.56,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $574.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,TRIOLOGY,TRILOGY MEDICAID,216.85,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81261 at $204.58 (Fee Schedule) = $204.58 (Total Line Payment) at 106% = $216.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,237.59,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,237.59,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,197.99,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,237.59,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $237.59 from Fee Schedule UHC_98227C for Rev 310 Proc 81261 * Qty 1 = $237.59 at 100% = $237.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,UNITY HEALTH PLAN,UNITY HOSPICE,197.99,,,,,,,197.9900,798.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,574.56,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $574.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,494.76,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $494.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,574.56,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $574.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,574.56,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $574.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH GENE ANALYSIS REARRANGEMENT AMP,81261,CPT,310,RC,31000116,CDM,,,,both,,,798.0000,526.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,478.80,,,,,,,197.9900,798.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $798.00 in Billed Charges for Rev 310 Proc 81261 = $478.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,AETNA,AETNA HSHS,669.26,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $669.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,AETNA,AETNA MEDICARE,294.52,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,AETNA,ALL COMMERCIAL AETNA,1036.00,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $1,036.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,ANTHEM,ANTEHM MEDICAID,304.33,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81263 at $304.33 (Fee Schedule) = $304.33 (Total Line Payment) at 100% = $304.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,294.52,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,ANTHEM,ANTHEM POS/HMO,1030.82,,,,,,,294.5200,1036.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,030.82 from Fee Schedule WII28_25 for Rev 310 Proc 81263 Mod TC * Qty 1 = $1,030.82 at 100% = $1,030.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,ANTHEM,ANTHEM PPO,1030.82,,,,,,,294.5200,1036.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,030.82 from Fee Schedule WII28_25 for Rev 310 Proc 81263 Mod TC * Qty 1 = $1,030.82 at 100% = $1,030.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1036.00,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $1,036.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,CENPATICO,ALL MEDICAID CENPATICO,1036.00,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $1,036.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,880.60,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $880.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,CIGNA,ALL COMMERCIAL CIGNA,725.20,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $725.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,COFINITY,COFINITY,1036.00,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $1,036.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,304.33,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81263 at $304.33 (Fee Schedule) = $304.33 (Total Line Payment) at 100% = $304.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,304.33,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81263 at $304.33 (Fee Schedule) = $304.33 (Total Line Payment) at 100% = $304.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,984.20,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $984.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,870.24,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $870.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,735.56,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $735.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,756.28,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $756.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,503.50,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $503.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,880.60,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $880.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HUMANA,HUMANA CHOICE CARE HMO,500.68,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.68 from Fee Schedule 005543_170 for Rev 310 Proc 81263 * Qty 1 = $500.68 at 100% = $500.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HUMANA,HUMANA CHOICE CARE PPO,880.60,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $880.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,294.52,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,HUMANA,HUMANA NATIIONAL POS HMO,500.68,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $500.68 from Fee Schedule 005543_170 for Rev 310 Proc 81263 * Qty 1 = $500.68 at 100% = $500.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,756.28,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $756.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1036.00,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $1,036.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,304.33,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81263 at $304.33 (Fee Schedule) = $304.33 (Total Line Payment) at 100% = $304.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,294.52,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,304.33,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81263 at $304.33 (Fee Schedule) = $304.33 (Total Line Payment) at 100% = $304.33. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,322.59,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81263 at $304.33 (Fee Schedule) = $304.33 (Total Line Payment) at 100% = $304.33... $304.33 at 106% = $322.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,294.52,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,518.00,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $518.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,870.24,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $870.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,662.67,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,777.00,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $777.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,953.12,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $953.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,382.88,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,382.88,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,PREVEA HEALTH NETWORK,PREVEA360,382.88,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,382.88,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,661.28,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $661.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,297.47,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,745.92,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $745.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,TRIOLOGY,TRILOGY MEDICAID,322.59,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81263 at $304.33 (Fee Schedule) = $304.33 (Total Line Payment) at 106% = $322.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,353.42,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $353.42 from Fee Schedule UHC_98227C for Rev 310 Proc 81263 * Qty 1 = $353.42 at 100% = $353.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,353.42,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $353.42 from Fee Schedule UHC_98227C for Rev 310 Proc 81263 * Qty 1 = $353.42 at 100% = $353.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,294.52,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,353.42,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $353.42 from Fee Schedule UHC_98227C for Rev 310 Proc 81263 * Qty 1 = $353.42 at 100% = $353.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,UNITY HEALTH PLAN,UNITY HOSPICE,294.52,,,,,,,294.5200,1036.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,745.92,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $745.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,642.32,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $642.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,745.92,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $745.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,745.92,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $745.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IGH VAR REG SOMATIC MUTATION ANALYSIS,81263,CPT,310,RC,31000117,CDM,,,,both,,,1036.0000,683.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,621.60,,,,,,,294.5200,1036.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,036.00 in Billed Charges for Rev 310 Proc 81263 = $621.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA HSHS,484.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $484.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,AETNA,AETNA MEDICARE,329.51,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,AETNA,ALL COMMERCIAL AETNA,750.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTEHM MEDICAID,195.07,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81272 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,329.51,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM POS/HMO,750.00,,,,,,,195.0700,750.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,153.29 from Fee Schedule WII28_25 for Rev 310 Proc 81272 Mod TC * Qty 1 = $1,153.29 at 100% = $1,153.29 (Limited to $750.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,ANTHEM,ANTHEM PPO,750.00,,,,,,,195.0700,750.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,153.29 from Fee Schedule WII28_25 for Rev 310 Proc 81272 Mod TC * Qty 1 = $1,153.29 at 100% = $1,153.29 (Limited to $750.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,750.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,CENPATICO,ALL MEDICAID CENPATICO,750.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,637.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,CIGNA,ALL COMMERCIAL CIGNA,525.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $525.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,COFINITY,COFINITY,750.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,195.07,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81272 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,195.07,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81272 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,712.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $712.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,630.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,532.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $532.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,547.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,364.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $364.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,637.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE HMO,560.17,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $560.17 from Fee Schedule 005543_170 for Rev 310 Proc 81272 * Qty 1 = $560.17 at 100% = $560.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA CHOICE CARE PPO,637.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $637.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,329.51,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,HUMANA,HUMANA NATIIONAL POS HMO,560.17,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $560.17 from Fee Schedule 005543_170 for Rev 310 Proc 81272 * Qty 1 = $560.17 at 100% = $560.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,547.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $547.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,750.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,195.07,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81272 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,329.51,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,195.07,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81272 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,206.77,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81272 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 100% = $195.07... $195.07 at 106% = $206.77 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,329.51,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,375.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $375.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,630.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,741.40,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,562.50,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $562.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,690.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $690.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,428.36,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,428.36,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360,428.36,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,428.36,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.73,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $478.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,332.81,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,540.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,TRIOLOGY,TRILOGY MEDICAID,206.77,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81272 at $195.07 (Fee Schedule) = $195.07 (Total Line Payment) at 106% = $206.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,395.41,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $395.41 from Fee Schedule UHC_98227C for Rev 310 Proc 81272 * Qty 1 = $395.41 at 100% = $395.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,395.41,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $395.41 from Fee Schedule UHC_98227C for Rev 310 Proc 81272 * Qty 1 = $395.41 at 100% = $395.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,329.51,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,395.41,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $395.41 from Fee Schedule UHC_98227C for Rev 310 Proc 81272 * Qty 1 = $395.41 at 100% = $395.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,UNITY HEALTH PLAN,UNITY HOSPICE,329.51,,,,,,,195.0700,750.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,540.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,465.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,540.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,540.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC V KIT GENE ANALYSIS TARGETED SEQ,81272,CPT,310,RC,31000118,CDM,,,,both,,,750.0000,495.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,450.00,,,,,,,195.0700,750.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $750.00 in Billed Charges for Rev 310 Proc 81272 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,AETNA,AETNA HSHS,605.95,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $605.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,AETNA,AETNA MEDICARE,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,AETNA,ALL COMMERCIAL AETNA,938.00,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,ANTHEM,ANTEHM MEDICAID,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81350 at $234.00 (Fee Schedule) = $234.00 (Total Line Payment) at 100% = $234.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,ANTHEM,ANTHEM POS/HMO,819.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $819.00 from Fee Schedule WII28_25 for Rev 310 Proc 81350 Mod TC * Qty 1 = $819.00 at 100% = $819.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,ANTHEM,ANTHEM PPO,819.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $819.00 from Fee Schedule WII28_25 for Rev 310 Proc 81350 Mod TC * Qty 1 = $819.00 at 100% = $819.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,938.00,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,CENPATICO,ALL MEDICAID CENPATICO,938.00,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,797.30,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $797.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,CIGNA,ALL COMMERCIAL CIGNA,656.60,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $656.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,COFINITY,COFINITY,938.00,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81350 at $234.00 (Fee Schedule) = $234.00 (Total Line Payment) at 100% = $234.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81350 at $234.00 (Fee Schedule) = $234.00 (Total Line Payment) at 100% = $234.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,891.10,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $891.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,787.92,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $787.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,665.98,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $665.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,684.74,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $684.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,455.87,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $455.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,797.30,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $797.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HUMANA,HUMANA CHOICE CARE HMO,397.80,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $397.80 from Fee Schedule 005543_170 for Rev 310 Proc 81350 * Qty 1 = $397.80 at 100% = $397.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HUMANA,HUMANA CHOICE CARE PPO,797.30,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $797.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HUMANA,HUMANA MEDICARE ADVANTAGE,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,HUMANA,HUMANA NATIIONAL POS HMO,397.80,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $397.80 from Fee Schedule 005543_170 for Rev 310 Proc 81350 * Qty 1 = $397.80 at 100% = $397.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,684.74,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $684.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,938.00,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81350 at $234.00 (Fee Schedule) = $234.00 (Total Line Payment) at 100% = $234.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81350 at $234.00 (Fee Schedule) = $234.00 (Total Line Payment) at 100% = $234.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,248.04,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81350 at $234.00 (Fee Schedule) = $234.00 (Total Line Payment) at 100% = $234.00... $234.00 at 106% = $248.04 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,MOLINA HEALTHCARE,MOLINA MEDICARE,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,469.00,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $469.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,787.92,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $787.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,NAPHCARE,ALL COMMERICAL NAPHCARE,526.50,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,703.50,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $703.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,862.96,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $862.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,304.20,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,304.20,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,PREVEA HEALTH NETWORK,PREVEA360,304.20,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,304.20,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,598.73,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $598.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,236.34,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,675.36,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $675.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,TRIOLOGY,TRILOGY MEDICAID,248.04,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81350 at $234.00 (Fee Schedule) = $234.00 (Total Line Payment) at 106% = $248.04. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,280.80,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $280.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81350 * Qty 1 = $280.80 at 100% = $280.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,280.80,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $280.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81350 * Qty 1 = $280.80 at 100% = $280.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,280.80,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $280.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81350 * Qty 1 = $280.80 at 100% = $280.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,UNITY HEALTH PLAN,UNITY HOSPICE,234.00,,,,,,,234.0000,938.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,675.36,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $675.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,581.56,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $581.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,675.36,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $675.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,675.36,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $675.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UGT1A1 GENE ANALYSIS COM VARIANTS,81350,CPT,310,RC,31000120,CDM,,,,both,,,938.0000,619.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,562.80,,,,,,,234.0000,938.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $938.00 in Billed Charges for Rev 310 Proc 81350 = $562.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,AETNA,AETNA HSHS,1843.04,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $1,843.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,AETNA,AETNA MEDICARE,1160.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,AETNA,ALL COMMERCIAL AETNA,2853.00,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,853.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,ANTHEM,ANTEHM MEDICAID,608.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1160.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,ANTHEM,ANTHEM POS/HMO,2853.00,,,,,,,608.0000,2853.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,060.00 from Fee Schedule WII28_25 for Rev 310 Proc 81229 Mod TC * Qty 1 = $4,060.00 at 100% = $4,060.00 (Limited to $2,853.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,ANTHEM,ANTHEM PPO,2853.00,,,,,,,608.0000,2853.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,060.00 from Fee Schedule WII28_25 for Rev 310 Proc 81229 Mod TC * Qty 1 = $4,060.00 at 100% = $4,060.00 (Limited to $2,853.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2853.00,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,853.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,CENPATICO,ALL MEDICAID CENPATICO,2853.00,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,853.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2425.05,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,425.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,CIGNA,ALL COMMERCIAL CIGNA,1997.10,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $1,997.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,COFINITY,COFINITY,2853.00,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,853.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,608.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,608.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2710.35,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,710.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,2396.52,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,396.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2025.63,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,025.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2082.69,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,082.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,1386.56,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $1,386.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2425.05,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,425.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HUMANA,HUMANA CHOICE CARE HMO,1972.00,,,,,,,608.0000,2853.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,972.00 from Fee Schedule 005543_170 for Rev 310 Proc 81229 * Qty 1 = $1,972.00 at 100% = $1,972.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HUMANA,HUMANA CHOICE CARE PPO,2425.05,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,425.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HUMANA,HUMANA MEDICARE ADVANTAGE,1160.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,HUMANA,HUMANA NATIIONAL POS HMO,1972.00,,,,,,,608.0000,2853.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,972.00 from Fee Schedule 005543_170 for Rev 310 Proc 81229 * Qty 1 = $1,972.00 at 100% = $1,972.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2082.69,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,082.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2853.00,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,853.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,608.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1160.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,608.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,MOLINA HEALTHCARE,MOLINA MEDICAID,644.48,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 100% = $608.00... $608.00 at 106% = $644.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,MOLINA HEALTHCARE,MOLINA MEDICARE,1160.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1426.50,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $1,426.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2396.52,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,396.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,NAPHCARE,ALL COMMERICAL NAPHCARE,2610.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2139.75,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,139.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2624.76,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,624.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1508.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1508.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,PREVEA HEALTH NETWORK,PREVEA360,1508.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1508.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1821.07,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $1,821.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1171.60,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2054.16,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,054.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,TRIOLOGY,TRILOGY MEDICAID,644.48,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81229 at $608.00 (Fee Schedule) = $608.00 (Total Line Payment) at 106% = $644.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1392.00,,,,,,,608.0000,2853.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,392.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81229 * Qty 1 = $1,392.00 at 100% = $1,392.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,UNITED HEALTHCARE,UHC ONEIDA NATION,1392.00,,,,,,,608.0000,2853.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,392.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81229 * Qty 1 = $1,392.00 at 100% = $1,392.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1160.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,UNITED HEALTHCARE,UNITED HEALTHCARE,1392.00,,,,,,,608.0000,2853.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,392.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81229 * Qty 1 = $1,392.00 at 100% = $1,392.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,UNITY HEALTH PLAN,UNITY HOSPICE,1160.00,,,,,,,608.0000,2853.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2054.16,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,054.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1768.86,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $1,768.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2054.16,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,054.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2054.16,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $2,054.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYTOGENOMIC MICROARRAY ASSAY,81229,CPT,310,RC,31000202,CDM,,,,both,,,2853.0000,1882.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1711.80,,,,,,,608.0000,2853.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,853.00 in Billed Charges for Rev 310 Proc 81229 = $1,711.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,AETNA,AETNA HSHS,1939.94,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $1,939.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,AETNA,AETNA MEDICARE,896.87,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,AETNA,ALL COMMERCIAL AETNA,3003.00,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $3,003.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,ANTHEM,ANTEHM MEDICAID,133.58,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,896.87,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,ANTHEM,ANTHEM POS/HMO,2042.04,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81457 $3,003.00 in Billed Charges at 68% = $2,042.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,ANTHEM,ANTHEM PPO,2042.04,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81457 $3,003.00 in Billed Charges at 68% = $2,042.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3003.00,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $3,003.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,CENPATICO,ALL MEDICAID CENPATICO,3003.00,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $3,003.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2552.55,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,552.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,CIGNA,ALL COMMERCIAL CIGNA,2102.10,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,102.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,COFINITY,COFINITY,3003.00,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $3,003.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,133.58,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,133.58,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2852.85,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,852.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,2522.52,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,522.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2132.13,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,132.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2192.19,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,192.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,1459.46,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $1,459.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2552.55,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,552.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,HUMANA,HUMANA CHOICE CARE PPO,2552.55,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,552.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,HUMANA,HUMANA MEDICARE ADVANTAGE,896.87,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2192.19,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,192.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3003.00,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $3,003.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,133.58,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,896.87,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,133.58,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,MOLINA HEALTHCARE,MOLINA MEDICAID,141.59,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 100% = $133.58... $133.58 at 106% = $141.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,MOLINA HEALTHCARE,MOLINA MEDICARE,896.87,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1501.50,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $1,501.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2522.52,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,522.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,NAPHCARE,ALL COMMERICAL NAPHCARE,2017.96,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2252.25,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,252.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2762.76,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,762.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1165.93,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1165.93,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,PREVEA HEALTH NETWORK,PREVEA360,1165.93,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1165.93,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1916.81,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $1,916.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,905.84,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2162.16,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,162.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,TRIOLOGY,TRILOGY MEDICAID,141.59,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81457 at $125.60 (Base Rate) * 1.0635 (Relative Weight) = $133.58 (Total Line Payment) at 106% = $141.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1076.24,,,,,,,133.5800,3003.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,UNITED HEALTHCARE,UHC ONEIDA NATION,1076.24,,,,,,,133.5800,3003.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,896.87,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,UNITED HEALTHCARE,UNITED HEALTHCARE,1076.24,,,,,,,133.5800,3003.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,076.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81457 * Qty 1 = $1,076.24 at 100% = $1,076.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,UNITY HEALTH PLAN,UNITY HOSPICE,896.87,,,,,,,133.5800,3003.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2162.16,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,162.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1861.86,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $1,861.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2162.16,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,162.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2162.16,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $2,162.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENE SEQ SOLID ORGAN NEOPLASM 5-50 GENES,81457,CPT,310,RC,31000212,CDM,,,,both,,,3003.0000,1981.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1801.80,,,,,,,133.5800,3003.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,003.00 in Billed Charges for Rev 310 Proc 81457 = $1,801.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,AETNA,AETNA HSHS,697.68,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $697.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,AETNA,AETNA MEDICARE,193.25,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,AETNA,ALL COMMERCIAL AETNA,1080.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,ANTHEM,ANTEHM MEDICAID,154.60,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81120 at $154.60 (Fee Schedule) = $154.60 (Total Line Payment) at 100% = $154.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,193.25,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,ANTHEM,ANTHEM POS/HMO,676.38,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $676.38 from Fee Schedule WII28_25 for Rev 310 Proc 81120 Mod TC * Qty 1 = $676.38 at 100% = $676.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,ANTHEM,ANTHEM PPO,676.38,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $676.38 from Fee Schedule WII28_25 for Rev 310 Proc 81120 Mod TC * Qty 1 = $676.38 at 100% = $676.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1080.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,CENPATICO,ALL MEDICAID CENPATICO,1080.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,918.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $918.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,CIGNA,ALL COMMERCIAL CIGNA,756.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,COFINITY,COFINITY,1080.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,154.60,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81120 at $154.60 (Fee Schedule) = $154.60 (Total Line Payment) at 100% = $154.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,154.60,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81120 at $154.60 (Fee Schedule) = $154.60 (Total Line Payment) at 100% = $154.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1026.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $1,026.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,907.20,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $907.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,766.80,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $766.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,788.40,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $788.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,524.88,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $524.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,918.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $918.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HUMANA,HUMANA CHOICE CARE HMO,328.53,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $328.53 from Fee Schedule 005543_170 for Rev 310 Proc 81120 * Qty 1 = $328.53 at 100% = $328.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HUMANA,HUMANA CHOICE CARE PPO,918.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $918.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,193.25,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,HUMANA,HUMANA NATIIONAL POS HMO,328.53,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $328.53 from Fee Schedule 005543_170 for Rev 310 Proc 81120 * Qty 1 = $328.53 at 100% = $328.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,788.40,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $788.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1080.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $1,080.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,154.60,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81120 at $154.60 (Fee Schedule) = $154.60 (Total Line Payment) at 100% = $154.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,193.25,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,154.60,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81120 at $154.60 (Fee Schedule) = $154.60 (Total Line Payment) at 100% = $154.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,163.88,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81120 at $154.60 (Fee Schedule) = $154.60 (Total Line Payment) at 100% = $154.60... $154.60 at 106% = $163.88 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,193.25,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,540.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $540.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,907.20,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $907.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,434.81,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,810.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $810.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,993.60,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $993.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,251.23,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,251.23,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,PREVEA HEALTH NETWORK,PREVEA360,251.23,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,251.23,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,689.36,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $689.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,195.18,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,777.60,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $777.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,TRIOLOGY,TRILOGY MEDICAID,163.88,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81120 at $154.60 (Fee Schedule) = $154.60 (Total Line Payment) at 106% = $163.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,231.90,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $231.90 from Fee Schedule UHC_98227C for Rev 310 Proc 81120 * Qty 1 = $231.90 at 100% = $231.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,231.90,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $231.90 from Fee Schedule UHC_98227C for Rev 310 Proc 81120 * Qty 1 = $231.90 at 100% = $231.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,193.25,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,231.90,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $231.90 from Fee Schedule UHC_98227C for Rev 310 Proc 81120 * Qty 1 = $231.90 at 100% = $231.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,UNITY HEALTH PLAN,UNITY HOSPICE,193.25,,,,,,,154.6000,1080.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,777.60,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $777.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,669.60,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $669.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,777.60,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $777.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,777.60,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $777.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC IDH1 COMMON VARIANTS,81120,CPT,310,RC,31000222,CDM,,,,both,,,1080.0000,712.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,648.00,,,,,,,154.6000,1080.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,080.00 in Billed Charges for Rev 310 Proc 81120 = $648.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,AETNA,AETNA HSHS,388.25,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $388.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,AETNA,AETNA MEDICARE,185.20,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,AETNA,ALL COMMERCIAL AETNA,601.00,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,ANTHEM,ANTEHM MEDICAID,148.16,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81403 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,185.20,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,ANTHEM,ANTHEM POS/HMO,601.00,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $648.20 from Fee Schedule WII28_25 for Rev 310 Proc 81403 Mod TC * Qty 1 = $648.20 at 100% = $648.20 (Limited to $601.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,ANTHEM,ANTHEM PPO,601.00,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $648.20 from Fee Schedule WII28_25 for Rev 310 Proc 81403 Mod TC * Qty 1 = $648.20 at 100% = $648.20 (Limited to $601.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,601.00,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,CENPATICO,ALL MEDICAID CENPATICO,601.00,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,510.85,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $510.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,CIGNA,ALL COMMERCIAL CIGNA,420.70,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $420.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,COFINITY,COFINITY,601.00,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,148.16,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81403 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,148.16,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81403 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,570.95,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $570.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,504.84,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $504.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,426.71,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $426.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,438.73,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $438.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,292.09,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $292.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,510.85,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $510.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HUMANA,HUMANA CHOICE CARE HMO,314.84,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $314.84 from Fee Schedule 005543_170 for Rev 310 Proc 81403 * Qty 1 = $314.84 at 100% = $314.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HUMANA,HUMANA CHOICE CARE PPO,510.85,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $510.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,185.20,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,HUMANA,HUMANA NATIIONAL POS HMO,314.84,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $314.84 from Fee Schedule 005543_170 for Rev 310 Proc 81403 * Qty 1 = $314.84 at 100% = $314.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,438.73,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $438.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,601.00,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,148.16,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81403 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,185.20,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,148.16,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81403 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,157.05,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81403 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 100% = $148.16... $148.16 at 106% = $157.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,185.20,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,300.50,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $300.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,504.84,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $504.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,416.70,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,450.75,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $450.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,552.92,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $552.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,240.76,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,240.76,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,PREVEA HEALTH NETWORK,PREVEA360,240.76,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,240.76,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,383.62,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $383.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,187.05,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,432.72,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $432.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,TRIOLOGY,TRILOGY MEDICAID,157.05,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81403 at $148.16 (Fee Schedule) = $148.16 (Total Line Payment) at 106% = $157.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,222.24,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81403 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,222.24,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81403 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,185.20,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,222.24,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $222.24 from Fee Schedule UHC_98227C for Rev 310 Proc 81403 * Qty 1 = $222.24 at 100% = $222.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,UNITY HEALTH PLAN,UNITY HOSPICE,185.20,,,,,,,148.1600,601.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,432.72,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $432.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,372.62,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $372.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,432.72,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $432.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,432.72,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $432.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATH MUTATION ANALYSIS EXON 12,81403,CPT,310,RC,31000236,CDM,,,,both,,,601.0000,396.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,360.60,,,,,,,148.1600,601.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $601.00 in Billed Charges for Rev 310 Proc 81403 = $360.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,AETNA,AETNA HSHS,382.43,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $382.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,AETNA,AETNA MEDICARE,137.00,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,AETNA,ALL COMMERCIAL AETNA,592.00,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,ANTHEM,ANTEHM MEDICAID,109.60,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81271 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,137.00,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,ANTHEM,ANTHEM POS/HMO,479.50,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81271 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,ANTHEM,ANTHEM PPO,479.50,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81271 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,592.00,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,CENPATICO,ALL MEDICAID CENPATICO,592.00,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,503.20,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $503.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,CIGNA,ALL COMMERCIAL CIGNA,414.40,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $414.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,COFINITY,COFINITY,592.00,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,109.60,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81271 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,109.60,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81271 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,562.40,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $562.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,497.28,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $497.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,420.32,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $420.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,432.16,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $432.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,287.71,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $287.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,503.20,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $503.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HUMANA,HUMANA CHOICE CARE HMO,232.90,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81271 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HUMANA,HUMANA CHOICE CARE PPO,503.20,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $503.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,137.00,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,HUMANA,HUMANA NATIIONAL POS HMO,232.90,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81271 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,432.16,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $432.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,592.00,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $592.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,109.60,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81271 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,137.00,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,109.60,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81271 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,116.18,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81271 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60... $109.60 at 106% = $116.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,137.00,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,296.00,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $296.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,497.28,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $497.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,308.25,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,444.00,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $444.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,544.64,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $544.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,178.10,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,178.10,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,PREVEA HEALTH NETWORK,PREVEA360,178.10,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,178.10,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,377.87,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $377.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,138.37,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,426.24,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $426.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,TRIOLOGY,TRILOGY MEDICAID,116.18,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81271 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 106% = $116.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,164.40,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81271 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,164.40,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81271 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,137.00,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,164.40,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81271 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,UNITY HEALTH PLAN,UNITY HOSPICE,137.00,,,,,,,109.6000,592.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,426.24,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $426.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,367.04,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $367.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,426.24,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $426.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,426.24,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $426.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HTT GENE ANALYSIS DETECT ABNORMAL ALLELES,81271,CPT,310,RC,31000244,CDM,,,,both,,,592.0000,390.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,355.20,,,,,,,109.6000,592.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $592.00 in Billed Charges for Rev 310 Proc 81271 = $355.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,AETNA,AETNA HSHS,357.88,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $357.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,AETNA,AETNA MEDICARE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,AETNA,ALL COMMERCIAL AETNA,554.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,ANTHEM,ANTEHM MEDICAID,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81309 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,ANTHEM,ANTHEM POS/HMO,554.00,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $961.91 from Fee Schedule WII28_25 for Rev 310 Proc 81309 Mod TC * Qty 1 = $961.91 at 100% = $961.91 (Limited to $554.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,ANTHEM,ANTHEM PPO,554.00,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $961.91 from Fee Schedule WII28_25 for Rev 310 Proc 81309 Mod TC * Qty 1 = $961.91 at 100% = $961.91 (Limited to $554.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,554.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,CENPATICO,ALL MEDICAID CENPATICO,554.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,470.90,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $470.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,CIGNA,ALL COMMERCIAL CIGNA,387.80,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $387.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,COFINITY,COFINITY,554.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81309 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81309 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,526.30,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $526.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,465.36,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $465.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,393.34,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $393.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,404.42,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $404.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,269.24,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $269.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,470.90,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $470.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HUMANA,HUMANA CHOICE CARE HMO,467.21,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $467.21 from Fee Schedule 005543_170 for Rev 310 Proc 81309 * Qty 1 = $467.21 at 100% = $467.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HUMANA,HUMANA CHOICE CARE PPO,470.90,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $470.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,HUMANA,HUMANA NATIIONAL POS HMO,467.21,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $467.21 from Fee Schedule 005543_170 for Rev 310 Proc 81309 * Qty 1 = $467.21 at 100% = $467.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,404.42,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $404.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,554.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $554.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81309 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,219.86,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81309 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,233.05,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81309 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86... $219.86 at 106% = $233.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,277.00,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $277.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,465.36,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $465.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,618.37,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,415.50,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $415.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,509.68,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $509.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,357.28,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,357.28,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,PREVEA HEALTH NETWORK,PREVEA360,357.28,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,357.28,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,353.62,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $353.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,277.58,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,398.88,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $398.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,TRIOLOGY,TRILOGY MEDICAID,233.05,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81309 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 106% = $233.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,329.80,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81309 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,329.80,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81309 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,329.80,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81309 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,UNITY HEALTH PLAN,UNITY HOSPICE,274.83,,,,,,,219.8600,618.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,398.88,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $398.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,343.48,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $343.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,398.88,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $398.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,398.88,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $398.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR MUTATION ANALYSIS PIK3CA,81309,CPT,310,RC,31000252,CDM,,,,both,,,554.0000,365.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,332.40,,,,,,,219.8600,618.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $554.00 in Billed Charges for Rev 310 Proc 81309 = $332.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,AETNA,AETNA HSHS,369.51,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $369.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,AETNA,AETNA MEDICARE,91.66,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,AETNA,ALL COMMERCIAL AETNA,572.00,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,ANTHEM,ANTEHM MEDICAID,94.71,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,91.66,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,ANTHEM,ANTHEM POS/HMO,320.81,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $320.81 from Fee Schedule WII28_25 for Rev 310 Proc 81270 Mod TC * Qty 1 = $320.81 at 100% = $320.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,ANTHEM,ANTHEM PPO,320.81,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $320.81 from Fee Schedule WII28_25 for Rev 310 Proc 81270 Mod TC * Qty 1 = $320.81 at 100% = $320.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,572.00,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,CENPATICO,ALL MEDICAID CENPATICO,572.00,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,486.20,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,CIGNA,ALL COMMERCIAL CIGNA,400.40,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $400.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,COFINITY,COFINITY,572.00,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,94.71,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,94.71,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,543.40,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $543.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,480.48,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $480.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,406.12,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $406.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,417.56,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $417.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,277.99,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $277.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,486.20,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HUMANA,HUMANA CHOICE CARE HMO,155.82,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $155.82 from Fee Schedule 005543_170 for Rev 310 Proc 81270 * Qty 1 = $155.82 at 100% = $155.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HUMANA,HUMANA CHOICE CARE PPO,486.20,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,91.66,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,HUMANA,HUMANA NATIIONAL POS HMO,155.82,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $155.82 from Fee Schedule 005543_170 for Rev 310 Proc 81270 * Qty 1 = $155.82 at 100% = $155.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,417.56,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $417.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,572.00,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,94.71,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,91.66,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,94.71,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,100.39,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 100% = $94.71... $94.71 at 106% = $100.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,91.66,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,286.00,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $286.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,480.48,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $480.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,206.24,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,429.00,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $429.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,526.24,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $526.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,119.16,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,119.16,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,PREVEA HEALTH NETWORK,PREVEA360,119.16,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,119.16,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,365.11,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $365.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,92.58,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,411.84,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $411.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,TRIOLOGY,TRILOGY MEDICAID,100.39,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81270 at $94.71 (Fee Schedule) = $94.71 (Total Line Payment) at 106% = $100.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,109.99,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,109.99,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,91.66,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,109.99,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $109.99 from Fee Schedule UHC_98227C for Rev 310 Proc 81270 * Qty 1 = $109.99 at 100% = $109.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,UNITY HEALTH PLAN,UNITY HOSPICE,91.66,,,,,,,91.6600,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,411.84,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $411.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,354.64,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $354.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,411.84,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $411.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,411.84,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $411.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC JAK2 V617F MUTATION DETECTION B/BM,81270,CPT,310,RC,31000273,CDM,,,,both,,,572.0000,377.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,343.20,,,,,,,91.6600,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $572.00 in Billed Charges for Rev 310 Proc 81270 = $343.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,AETNA,AETNA HSHS,2224.18,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,224.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,AETNA,AETNA MEDICARE,1287.00,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,AETNA,ALL COMMERCIAL AETNA,3443.00,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $3,443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,ANTHEM,ANTEHM MEDICAID,1029.60,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81460 at $1,029.60 (Fee Schedule) = $1,029.60 (Total Line Payment) at 100% = $1,029.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1287.00,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,ANTHEM,ANTHEM POS/HMO,3443.00,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,504.50 from Fee Schedule WII28_25 for Rev 310 Proc 81460 Mod TC * Qty 1 = $4,504.50 at 100% = $4,504.50 (Limited to $3,443.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,ANTHEM,ANTHEM PPO,3443.00,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,504.50 from Fee Schedule WII28_25 for Rev 310 Proc 81460 Mod TC * Qty 1 = $4,504.50 at 100% = $4,504.50 (Limited to $3,443.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3443.00,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $3,443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,CENPATICO,ALL MEDICAID CENPATICO,3443.00,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $3,443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2926.55,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,926.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,CIGNA,ALL COMMERCIAL CIGNA,2410.10,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,410.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,COFINITY,COFINITY,3443.00,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $3,443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1029.60,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81460 at $1,029.60 (Fee Schedule) = $1,029.60 (Total Line Payment) at 100% = $1,029.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1029.60,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81460 at $1,029.60 (Fee Schedule) = $1,029.60 (Total Line Payment) at 100% = $1,029.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3270.85,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $3,270.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,2892.12,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,892.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2444.53,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,444.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2513.39,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,513.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,1673.30,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $1,673.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2926.55,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,926.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HUMANA,HUMANA CHOICE CARE HMO,2187.90,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,187.90 from Fee Schedule 005543_170 for Rev 310 Proc 81460 * Qty 1 = $2,187.90 at 100% = $2,187.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HUMANA,HUMANA CHOICE CARE PPO,2926.55,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,926.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HUMANA,HUMANA MEDICARE ADVANTAGE,1287.00,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,HUMANA,HUMANA NATIIONAL POS HMO,2187.90,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,187.90 from Fee Schedule 005543_170 for Rev 310 Proc 81460 * Qty 1 = $2,187.90 at 100% = $2,187.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2513.39,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,513.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3443.00,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $3,443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1029.60,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81460 at $1,029.60 (Fee Schedule) = $1,029.60 (Total Line Payment) at 100% = $1,029.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1287.00,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1029.60,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81460 at $1,029.60 (Fee Schedule) = $1,029.60 (Total Line Payment) at 100% = $1,029.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,MOLINA HEALTHCARE,MOLINA MEDICAID,1091.38,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81460 at $1,029.60 (Fee Schedule) = $1,029.60 (Total Line Payment) at 100% = $1,029.60... $1,029.60 at 106% = $1,091.38 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,MOLINA HEALTHCARE,MOLINA MEDICARE,1287.00,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1721.50,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $1,721.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2892.12,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,892.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,NAPHCARE,ALL COMMERICAL NAPHCARE,2895.75,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2582.25,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,582.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3167.56,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $3,167.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1673.10,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1673.10,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,PREVEA HEALTH NETWORK,PREVEA360,1673.10,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1673.10,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2197.67,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,197.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1299.87,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2478.96,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,478.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,TRIOLOGY,TRILOGY MEDICAID,1091.38,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81460 at $1,029.60 (Fee Schedule) = $1,029.60 (Total Line Payment) at 106% = $1,091.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1544.40,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,544.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81460 * Qty 1 = $1,544.40 at 100% = $1,544.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,UNITED HEALTHCARE,UHC ONEIDA NATION,1544.40,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,544.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81460 * Qty 1 = $1,544.40 at 100% = $1,544.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1287.00,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,UNITED HEALTHCARE,UNITED HEALTHCARE,1544.40,,,,,,,1029.6000,3443.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,544.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81460 * Qty 1 = $1,544.40 at 100% = $1,544.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,UNITY HEALTH PLAN,UNITY HOSPICE,1287.00,,,,,,,1029.6000,3443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2478.96,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,478.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2134.66,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,134.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2478.96,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,478.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2478.96,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,478.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC WHOLE MITOCHONDRIAL GENOME,81460,CPT,310,RC,31000309,CDM,,,,both,,,3443.0000,2272.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2065.80,,,,,,,1029.6000,3443.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,443.00 in Billed Charges for Rev 310 Proc 81460 = $2,065.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,AETNA,AETNA HSHS,366.93,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $366.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,AETNA,AETNA MEDICARE,324.58,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,AETNA,ALL COMMERCIAL AETNA,568.00,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $568.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,ANTHEM,ANTEHM MEDICAID,259.66,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81364 at $259.66 (Fee Schedule) = $259.66 (Total Line Payment) at 100% = $259.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,324.58,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,ANTHEM,ANTHEM POS/HMO,568.00,,,,,,,259.6600,730.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,136.03 from Fee Schedule WII28_25 for Rev 310 Proc 81364 Mod TC * Qty 1 = $1,136.03 at 100% = $1,136.03 (Limited to $568.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,ANTHEM,ANTHEM PPO,568.00,,,,,,,259.6600,730.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,136.03 from Fee Schedule WII28_25 for Rev 310 Proc 81364 Mod TC * Qty 1 = $1,136.03 at 100% = $1,136.03 (Limited to $568.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,568.00,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $568.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,CENPATICO,ALL MEDICAID CENPATICO,568.00,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $568.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,482.80,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $482.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,CIGNA,ALL COMMERCIAL CIGNA,397.60,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $397.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,COFINITY,COFINITY,568.00,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $568.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,259.66,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81364 at $259.66 (Fee Schedule) = $259.66 (Total Line Payment) at 100% = $259.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,259.66,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81364 at $259.66 (Fee Schedule) = $259.66 (Total Line Payment) at 100% = $259.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,539.60,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $539.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,477.12,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $477.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,403.28,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $403.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,414.64,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $414.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,276.05,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $276.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,482.80,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $482.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HUMANA,HUMANA CHOICE CARE HMO,551.79,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $551.79 from Fee Schedule 005543_170 for Rev 310 Proc 81364 * Qty 1 = $551.79 at 100% = $551.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HUMANA,HUMANA CHOICE CARE PPO,482.80,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $482.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,324.58,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,HUMANA,HUMANA NATIIONAL POS HMO,551.79,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $551.79 from Fee Schedule 005543_170 for Rev 310 Proc 81364 * Qty 1 = $551.79 at 100% = $551.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,414.64,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $414.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,568.00,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $568.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,259.66,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81364 at $259.66 (Fee Schedule) = $259.66 (Total Line Payment) at 100% = $259.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,324.58,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,259.66,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81364 at $259.66 (Fee Schedule) = $259.66 (Total Line Payment) at 100% = $259.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,275.24,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81364 at $259.66 (Fee Schedule) = $259.66 (Total Line Payment) at 100% = $259.66... $259.66 at 106% = $275.24 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,324.58,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,284.00,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $284.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,477.12,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $477.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,730.31,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,426.00,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $426.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,522.56,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $522.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,421.95,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,421.95,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,PREVEA HEALTH NETWORK,PREVEA360,421.95,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,421.95,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,362.55,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $362.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,327.83,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,408.96,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $408.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,TRIOLOGY,TRILOGY MEDICAID,275.24,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81364 at $259.66 (Fee Schedule) = $259.66 (Total Line Payment) at 106% = $275.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,389.50,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $389.50 from Fee Schedule UHC_98227C for Rev 310 Proc 81364 * Qty 1 = $389.50 at 100% = $389.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,389.50,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $389.50 from Fee Schedule UHC_98227C for Rev 310 Proc 81364 * Qty 1 = $389.50 at 100% = $389.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,324.58,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,389.50,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $389.50 from Fee Schedule UHC_98227C for Rev 310 Proc 81364 * Qty 1 = $389.50 at 100% = $389.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,UNITY HEALTH PLAN,UNITY HOSPICE,324.58,,,,,,,259.6600,730.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,408.96,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $408.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,352.16,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $352.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,408.96,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $408.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,408.96,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $408.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB FULL GENE SEQUENCE,81364,CPT,310,RC,31000315,CDM,,,,both,,,568.0000,374.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,340.80,,,,,,,259.6600,730.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $568.00 in Billed Charges for Rev 310 Proc 81364 = $340.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,AETNA,AETNA HSHS,956.73,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $956.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,AETNA,AETNA MEDICARE,846.27,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,AETNA,ALL COMMERCIAL AETNA,1481.00,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,ANTHEM,ANTEHM MEDICAID,677.02,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81407 at $677.02 (Fee Schedule) = $677.02 (Total Line Payment) at 100% = $677.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,846.27,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,ANTHEM,ANTHEM POS/HMO,1481.00,,,,,,,677.0200,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,961.95 from Fee Schedule WII28_25 for Rev 310 Proc 81407 Mod TC * Qty 1 = $2,961.95 at 100% = $2,961.95 (Limited to $1,481.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,ANTHEM,ANTHEM PPO,1481.00,,,,,,,677.0200,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,961.95 from Fee Schedule WII28_25 for Rev 310 Proc 81407 Mod TC * Qty 1 = $2,961.95 at 100% = $2,961.95 (Limited to $1,481.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1481.00,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,CENPATICO,ALL MEDICAID CENPATICO,1481.00,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1258.85,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,258.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,CIGNA,ALL COMMERCIAL CIGNA,1036.70,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,036.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,COFINITY,COFINITY,1481.00,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,677.02,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81407 at $677.02 (Fee Schedule) = $677.02 (Total Line Payment) at 100% = $677.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,677.02,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81407 at $677.02 (Fee Schedule) = $677.02 (Total Line Payment) at 100% = $677.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1406.95,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,406.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,1244.04,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,244.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1051.51,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,051.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1081.13,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,081.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,719.77,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $719.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1258.85,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,258.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HUMANA,HUMANA CHOICE CARE HMO,1438.66,,,,,,,677.0200,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,438.66 from Fee Schedule 005543_170 for Rev 310 Proc 81407 * Qty 1 = $1,438.66 at 100% = $1,438.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HUMANA,HUMANA CHOICE CARE PPO,1258.85,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,258.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,846.27,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,HUMANA,HUMANA NATIIONAL POS HMO,1438.66,,,,,,,677.0200,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,438.66 from Fee Schedule 005543_170 for Rev 310 Proc 81407 * Qty 1 = $1,438.66 at 100% = $1,438.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1081.13,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,081.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1481.00,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,481.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,677.02,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81407 at $677.02 (Fee Schedule) = $677.02 (Total Line Payment) at 100% = $677.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,846.27,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,677.02,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81407 at $677.02 (Fee Schedule) = $677.02 (Total Line Payment) at 100% = $677.02. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,717.64,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81407 at $677.02 (Fee Schedule) = $677.02 (Total Line Payment) at 100% = $677.02... $677.02 at 106% = $717.64 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,846.27,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,740.50,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $740.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1244.04,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,244.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,1904.11,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1110.75,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,110.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1362.52,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,362.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1100.15,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1100.15,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,PREVEA HEALTH NETWORK,PREVEA360,1100.15,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1100.15,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,945.32,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $945.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,854.73,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1066.32,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,TRIOLOGY,TRILOGY MEDICAID,717.64,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81407 at $677.02 (Fee Schedule) = $677.02 (Total Line Payment) at 106% = $717.64. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1015.52,,,,,,,677.0200,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,015.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81407 * Qty 1 = $1,015.52 at 100% = $1,015.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,1015.52,,,,,,,677.0200,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,015.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81407 * Qty 1 = $1,015.52 at 100% = $1,015.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,846.27,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,1015.52,,,,,,,677.0200,1904.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,015.52 from Fee Schedule UHC_98227C for Rev 310 Proc 81407 * Qty 1 = $1,015.52 at 100% = $1,015.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,UNITY HEALTH PLAN,UNITY HOSPICE,846.27,,,,,,,677.0200,1904.1100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1066.32,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,918.22,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $918.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1066.32,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1066.32,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $1,066.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 8,81407,CPT,310,RC,31000316,CDM,,,,both,,,1481.0000,977.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,888.60,,,,,,,677.0200,1904.1100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,481.00 in Billed Charges for Rev 310 Proc 81407 = $888.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,AETNA,AETNA HSHS,2261.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,261.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,AETNA,AETNA MEDICARE,2000.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,AETNA,ALL COMMERCIAL AETNA,3500.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $3,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,ANTHEM,ANTEHM MEDICAID,1600.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81408 at $1,600.00 (Fee Schedule) = $1,600.00 (Total Line Payment) at 100% = $1,600.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2000.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,ANTHEM,ANTHEM POS/HMO,3500.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $7,000.00 from Fee Schedule WII28_25 for Rev 310 Proc 81408 Mod TC * Qty 1 = $7,000.00 at 100% = $7,000.00 (Limited to $3,500.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,ANTHEM,ANTHEM PPO,3500.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $7,000.00 from Fee Schedule WII28_25 for Rev 310 Proc 81408 Mod TC * Qty 1 = $7,000.00 at 100% = $7,000.00 (Limited to $3,500.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3500.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $3,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,CENPATICO,ALL MEDICAID CENPATICO,3500.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $3,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2975.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,975.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,CIGNA,ALL COMMERCIAL CIGNA,2450.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,COFINITY,COFINITY,3500.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $3,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1600.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81408 at $1,600.00 (Fee Schedule) = $1,600.00 (Total Line Payment) at 100% = $1,600.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1600.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81408 at $1,600.00 (Fee Schedule) = $1,600.00 (Total Line Payment) at 100% = $1,600.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3325.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $3,325.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,2940.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,940.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2485.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,485.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2555.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,555.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,1701.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $1,701.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2975.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,975.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HUMANA,HUMANA CHOICE CARE HMO,3400.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,400.00 from Fee Schedule 005543_170 for Rev 310 Proc 81408 * Qty 1 = $3,400.00 at 100% = $3,400.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HUMANA,HUMANA CHOICE CARE PPO,2975.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,975.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,2000.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,HUMANA,HUMANA NATIIONAL POS HMO,3400.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,400.00 from Fee Schedule 005543_170 for Rev 310 Proc 81408 * Qty 1 = $3,400.00 at 100% = $3,400.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2555.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,555.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3500.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $3,500.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1600.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81408 at $1,600.00 (Fee Schedule) = $1,600.00 (Total Line Payment) at 100% = $1,600.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2000.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1600.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81408 at $1,600.00 (Fee Schedule) = $1,600.00 (Total Line Payment) at 100% = $1,600.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,1696.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81408 at $1,600.00 (Fee Schedule) = $1,600.00 (Total Line Payment) at 100% = $1,600.00... $1,600.00 at 106% = $1,696.00 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,2000.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1750.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $1,750.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2940.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,940.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,4500.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2625.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,625.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3220.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $3,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2600.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2600.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,PREVEA HEALTH NETWORK,PREVEA360,2600.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2600.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2234.05,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,234.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2020.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2520.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,TRIOLOGY,TRILOGY MEDICAID,1696.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81408 at $1,600.00 (Fee Schedule) = $1,600.00 (Total Line Payment) at 106% = $1,696.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2400.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,400.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81408 * Qty 1 = $2,400.00 at 100% = $2,400.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,2400.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,400.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81408 * Qty 1 = $2,400.00 at 100% = $2,400.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2000.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,2400.00,,,,,,,1600.0000,4500.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,400.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81408 * Qty 1 = $2,400.00 at 100% = $2,400.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,UNITY HEALTH PLAN,UNITY HOSPICE,2000.00,,,,,,,1600.0000,4500.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2520.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2170.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,170.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2520.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2520.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,520.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,81408,CPT,310,RC,31000317,CDM,,,,both,,,3500.0000,2310.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2100.00,,,,,,,1600.0000,4500.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,500.00 in Billed Charges for Rev 310 Proc 81408 = $2,100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,AETNA,AETNA HSHS,510.34,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $510.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,AETNA,AETNA MEDICARE,124.64,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,AETNA,ALL COMMERCIAL AETNA,790.00,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $790.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,ANTHEM,ANTEHM MEDICAID,83.09,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81287 at $83.09 (Fee Schedule) = $83.09 (Total Line Payment) at 100% = $83.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,124.64,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,ANTHEM,ANTHEM POS/HMO,436.24,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $436.24 from Fee Schedule WII28_25 for Rev 310 Proc 81287 Mod TC * Qty 1 = $436.24 at 100% = $436.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,ANTHEM,ANTHEM PPO,436.24,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $436.24 from Fee Schedule WII28_25 for Rev 310 Proc 81287 Mod TC * Qty 1 = $436.24 at 100% = $436.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,790.00,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $790.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,CENPATICO,ALL MEDICAID CENPATICO,790.00,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $790.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,671.50,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $671.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,CIGNA,ALL COMMERCIAL CIGNA,553.00,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $553.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,COFINITY,COFINITY,790.00,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $790.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,83.09,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81287 at $83.09 (Fee Schedule) = $83.09 (Total Line Payment) at 100% = $83.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,83.09,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81287 at $83.09 (Fee Schedule) = $83.09 (Total Line Payment) at 100% = $83.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,750.50,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $750.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,663.60,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $663.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,560.90,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $560.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,576.70,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $576.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,383.94,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $383.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,671.50,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $671.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HUMANA,HUMANA CHOICE CARE HMO,211.89,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $211.89 from Fee Schedule 005543_170 for Rev 310 Proc 81287 * Qty 1 = $211.89 at 100% = $211.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HUMANA,HUMANA CHOICE CARE PPO,671.50,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $671.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HUMANA,HUMANA MEDICARE ADVANTAGE,124.64,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,HUMANA,HUMANA NATIIONAL POS HMO,211.89,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $211.89 from Fee Schedule 005543_170 for Rev 310 Proc 81287 * Qty 1 = $211.89 at 100% = $211.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,576.70,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $576.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,790.00,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $790.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,83.09,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81287 at $83.09 (Fee Schedule) = $83.09 (Total Line Payment) at 100% = $83.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,124.64,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,83.09,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81287 at $83.09 (Fee Schedule) = $83.09 (Total Line Payment) at 100% = $83.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,MOLINA HEALTHCARE,MOLINA MEDICAID,88.08,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81287 at $83.09 (Fee Schedule) = $83.09 (Total Line Payment) at 100% = $83.09... $83.09 at 106% = $88.08 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,MOLINA HEALTHCARE,MOLINA MEDICARE,124.64,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,395.00,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $395.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,663.60,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $663.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,NAPHCARE,ALL COMMERICAL NAPHCARE,280.44,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,592.50,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $592.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,726.80,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $726.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,162.03,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,162.03,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,PREVEA HEALTH NETWORK,PREVEA360,162.03,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,162.03,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,504.26,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $504.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,125.89,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,568.80,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $568.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,TRIOLOGY,TRILOGY MEDICAID,88.08,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81287 at $83.09 (Fee Schedule) = $83.09 (Total Line Payment) at 106% = $88.08. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,149.57,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.57 from Fee Schedule UHC_98227C for Rev 310 Proc 81287 * Qty 1 = $149.57 at 100% = $149.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,149.57,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.57 from Fee Schedule UHC_98227C for Rev 310 Proc 81287 * Qty 1 = $149.57 at 100% = $149.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,124.64,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,149.57,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $149.57 from Fee Schedule UHC_98227C for Rev 310 Proc 81287 * Qty 1 = $149.57 at 100% = $149.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,UNITY HEALTH PLAN,UNITY HOSPICE,124.64,,,,,,,83.0900,790.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,568.80,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $568.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,489.80,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $489.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,568.80,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $568.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,568.80,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $568.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MGMT GENE METHYLATION ANALYSIS,81287,CPT,310,RC,31000322,CDM,,,,both,,,790.0000,521.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,474.00,,,,,,,83.0900,790.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $790.00 in Billed Charges for Rev 310 Proc 81287 = $474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,AETNA,AETNA HSHS,684.11,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $684.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,AETNA,AETNA MEDICARE,600.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,AETNA,ALL COMMERCIAL AETNA,1059.00,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $1,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,ANTHEM,ANTEHM MEDICAID,480.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81259 at $480.00 (Fee Schedule) = $480.00 (Total Line Payment) at 100% = $480.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,600.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,ANTHEM,ANTHEM POS/HMO,1059.00,,,,,,,480.0000,1350.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,100.00 from Fee Schedule WII28_25 for Rev 310 Proc 81259 Mod TC * Qty 1 = $2,100.00 at 100% = $2,100.00 (Limited to $1,059.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,ANTHEM,ANTHEM PPO,1059.00,,,,,,,480.0000,1350.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,100.00 from Fee Schedule WII28_25 for Rev 310 Proc 81259 Mod TC * Qty 1 = $2,100.00 at 100% = $2,100.00 (Limited to $1,059.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1059.00,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $1,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,CENPATICO,ALL MEDICAID CENPATICO,1059.00,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $1,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,900.15,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $900.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,CIGNA,ALL COMMERCIAL CIGNA,741.30,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $741.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,COFINITY,COFINITY,1059.00,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $1,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,480.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81259 at $480.00 (Fee Schedule) = $480.00 (Total Line Payment) at 100% = $480.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,480.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81259 at $480.00 (Fee Schedule) = $480.00 (Total Line Payment) at 100% = $480.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1006.05,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $1,006.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,889.56,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $889.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,751.89,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $751.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,773.07,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $773.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,514.67,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $514.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,900.15,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $900.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HUMANA,HUMANA CHOICE CARE HMO,1020.00,,,,,,,480.0000,1350.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,020.00 from Fee Schedule 005543_170 for Rev 310 Proc 81259 * Qty 1 = $1,020.00 at 100% = $1,020.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HUMANA,HUMANA CHOICE CARE PPO,900.15,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $900.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,600.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,HUMANA,HUMANA NATIIONAL POS HMO,1020.00,,,,,,,480.0000,1350.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,020.00 from Fee Schedule 005543_170 for Rev 310 Proc 81259 * Qty 1 = $1,020.00 at 100% = $1,020.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,773.07,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $773.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1059.00,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $1,059.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,480.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81259 at $480.00 (Fee Schedule) = $480.00 (Total Line Payment) at 100% = $480.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,600.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,480.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81259 at $480.00 (Fee Schedule) = $480.00 (Total Line Payment) at 100% = $480.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,508.80,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81259 at $480.00 (Fee Schedule) = $480.00 (Total Line Payment) at 100% = $480.00... $480.00 at 106% = $508.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,600.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,529.50,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $529.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,889.56,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $889.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,1350.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,794.25,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $794.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,974.28,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $974.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,780.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,780.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,PREVEA HEALTH NETWORK,PREVEA360,780.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,780.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,675.96,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $675.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,606.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,762.48,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $762.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,TRIOLOGY,TRILOGY MEDICAID,508.80,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81259 at $480.00 (Fee Schedule) = $480.00 (Total Line Payment) at 106% = $508.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,720.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $720.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81259 * Qty 1 = $720.00 at 100% = $720.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,720.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $720.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81259 * Qty 1 = $720.00 at 100% = $720.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,600.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,720.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $720.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81259 * Qty 1 = $720.00 at 100% = $720.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,UNITY HEALTH PLAN,UNITY HOSPICE,600.00,,,,,,,480.0000,1350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,762.48,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $762.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,656.58,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $656.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,762.48,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $762.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,762.48,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $762.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1 / HBA2 FULL GENE SEQ,81259,CPT,310,RC,31000326,CDM,,,,both,,,1059.0000,698.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,635.40,,,,,,,480.0000,1350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,059.00 in Billed Charges for Rev 310 Proc 81259 = $635.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,AETNA,AETNA HSHS,669.90,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $669.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,AETNA,AETNA MEDICARE,202.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,AETNA,ALL COMMERCIAL AETNA,1037.00,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,ANTHEM,ANTEHM MEDICAID,161.92,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81269 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,202.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,ANTHEM,ANTHEM POS/HMO,708.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.40 from Fee Schedule WII28_25 for Rev 310 Proc 81269 Mod TC * Qty 1 = $708.40 at 100% = $708.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,ANTHEM,ANTHEM PPO,708.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.40 from Fee Schedule WII28_25 for Rev 310 Proc 81269 Mod TC * Qty 1 = $708.40 at 100% = $708.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1037.00,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,CENPATICO,ALL MEDICAID CENPATICO,1037.00,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,881.45,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $881.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,CIGNA,ALL COMMERCIAL CIGNA,725.90,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $725.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,COFINITY,COFINITY,1037.00,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,161.92,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81269 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,161.92,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81269 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,985.15,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $985.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,871.08,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $871.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,736.27,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $736.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,757.01,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $757.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,503.98,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $503.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,881.45,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $881.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HUMANA,HUMANA CHOICE CARE HMO,344.08,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $344.08 from Fee Schedule 005543_170 for Rev 310 Proc 81269 * Qty 1 = $344.08 at 100% = $344.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HUMANA,HUMANA CHOICE CARE PPO,881.45,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $881.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HUMANA,HUMANA MEDICARE ADVANTAGE,202.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,HUMANA,HUMANA NATIIONAL POS HMO,344.08,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $344.08 from Fee Schedule 005543_170 for Rev 310 Proc 81269 * Qty 1 = $344.08 at 100% = $344.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,757.01,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $757.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1037.00,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,161.92,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81269 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,202.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,161.92,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81269 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,MOLINA HEALTHCARE,MOLINA MEDICAID,171.64,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81269 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92... $161.92 at 106% = $171.64 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,MOLINA HEALTHCARE,MOLINA MEDICARE,202.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,518.50,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $518.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,871.08,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $871.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,NAPHCARE,ALL COMMERICAL NAPHCARE,455.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,777.75,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $777.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,954.04,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $954.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,263.12,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,263.12,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,PREVEA HEALTH NETWORK,PREVEA360,263.12,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,263.12,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,661.92,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $661.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,204.42,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,746.64,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $746.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,TRIOLOGY,TRILOGY MEDICAID,171.64,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81269 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 106% = $171.64. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,242.88,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81269 * Qty 1 = $242.88 at 100% = $242.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,242.88,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81269 * Qty 1 = $242.88 at 100% = $242.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,202.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,242.88,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81269 * Qty 1 = $242.88 at 100% = $242.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,UNITY HEALTH PLAN,UNITY HOSPICE,202.40,,,,,,,161.9200,1037.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,746.64,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $746.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,642.94,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $642.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,746.64,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $746.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,746.64,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $746.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,81269,CPT,310,RC,31000328,CDM,,,,both,,,1037.0000,684.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,622.20,,,,,,,161.9200,1037.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,037.00 in Billed Charges for Rev 310 Proc 81269 = $622.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,AETNA,AETNA HSHS,1366.29,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,366.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,AETNA,AETNA MEDICARE,320.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,AETNA,ALL COMMERCIAL AETNA,2115.00,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $2,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,ANTHEM,ANTEHM MEDICAID,61.22,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81417 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,320.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,ANTHEM,ANTHEM POS/HMO,1120.00,,,,,,,61.2200,2115.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,120.00 from Fee Schedule WII28_25 for Rev 310 Proc 81417 Mod TC * Qty 1 = $1,120.00 at 100% = $1,120.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,ANTHEM,ANTHEM PPO,1120.00,,,,,,,61.2200,2115.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,120.00 from Fee Schedule WII28_25 for Rev 310 Proc 81417 Mod TC * Qty 1 = $1,120.00 at 100% = $1,120.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2115.00,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $2,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,CENPATICO,ALL MEDICAID CENPATICO,2115.00,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $2,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1797.75,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,797.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,CIGNA,ALL COMMERCIAL CIGNA,1480.50,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,480.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,COFINITY,COFINITY,2115.00,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $2,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,61.22,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81417 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,61.22,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81417 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2009.25,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $2,009.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,1776.60,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,776.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1501.65,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,501.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1543.95,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,543.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,1027.89,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,027.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1797.75,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,797.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HUMANA,HUMANA CHOICE CARE HMO,544.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $544.00 from Fee Schedule 005543_170 for Rev 310 Proc 81417 * Qty 1 = $544.00 at 100% = $544.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HUMANA,HUMANA CHOICE CARE PPO,1797.75,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,797.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,320.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,HUMANA,HUMANA NATIIONAL POS HMO,544.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $544.00 from Fee Schedule 005543_170 for Rev 310 Proc 81417 * Qty 1 = $544.00 at 100% = $544.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1543.95,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,543.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2115.00,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $2,115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,61.22,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81417 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,320.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,61.22,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81417 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,64.89,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81417 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 100% = $61.22... $61.22 at 106% = $64.89 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,320.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1057.50,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,057.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1776.60,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,776.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,720.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1586.25,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,586.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1945.80,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,945.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,416.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,416.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,PREVEA HEALTH NETWORK,PREVEA360,416.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,416.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1350.00,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,323.20,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1522.80,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,522.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,TRIOLOGY,TRILOGY MEDICAID,64.89,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81417 at $125.60 (Base Rate) * 0.4874 (Relative Weight) = $61.22 (Total Line Payment) at 106% = $64.89. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,384.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $384.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81417 * Qty 1 = $384.00 at 100% = $384.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,384.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $384.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81417 * Qty 1 = $384.00 at 100% = $384.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,320.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,384.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $384.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81417 * Qty 1 = $384.00 at 100% = $384.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,UNITY HEALTH PLAN,UNITY HOSPICE,320.00,,,,,,,61.2200,2115.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1522.80,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,522.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1311.30,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,311.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1522.80,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,522.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1522.80,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,522.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ,81417,CPT,310,RC,31000330,CDM,,,,both,,,2115.0000,1395.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1269.00,,,,,,,61.2200,2115.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,115.00 in Billed Charges for Rev 310 Proc 81417 = $1,269.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,126.29,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81376 at $126.29 (Fee Schedule) = $126.29 (Total Line Payment) at 100% = $126.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81376 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81376 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.29,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81376 at $126.29 (Fee Schedule) = $126.29 (Total Line Payment) at 100% = $126.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.29,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81376 at $126.29 (Fee Schedule) = $126.29 (Total Line Payment) at 100% = $126.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81376 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81376 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.29,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81376 at $126.29 (Fee Schedule) = $126.29 (Total Line Payment) at 100% = $126.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.29,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81376 at $126.29 (Fee Schedule) = $126.29 (Total Line Payment) at 100% = $126.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,133.87,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81376 at $126.29 (Fee Schedule) = $126.29 (Total Line Payment) at 100% = $126.29... $126.29 at 106% = $133.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,133.87,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81376 at $126.29 (Fee Schedule) = $126.29 (Total Line Payment) at 106% = $133.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81376 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81376 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81376 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,122.2200,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 TYPE LOW RESOLUTION 1 LOCUS,81376,CPT,310,RC,31000331,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,122.2200,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81376 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,AETNA,AETNA HSHS,278.43,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $278.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,AETNA,AETNA MEDICARE,123.68,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,AETNA,ALL COMMERCIAL AETNA,431.00,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,ANTHEM,ANTEHM MEDICAID,127.80,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81382 at $127.80 (Fee Schedule) = $127.80 (Total Line Payment) at 100% = $127.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,123.68,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,ANTHEM,ANTHEM POS/HMO,431.00,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $432.88 from Fee Schedule WII28_25 for Rev 310 Proc 81382 Mod TC * Qty 1 = $432.88 at 100% = $432.88 (Limited to $431.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,ANTHEM,ANTHEM PPO,431.00,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $432.88 from Fee Schedule WII28_25 for Rev 310 Proc 81382 Mod TC * Qty 1 = $432.88 at 100% = $432.88 (Limited to $431.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,431.00,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,CENPATICO,ALL MEDICAID CENPATICO,431.00,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,366.35,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $366.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,CIGNA,ALL COMMERCIAL CIGNA,301.70,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $301.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,COFINITY,COFINITY,431.00,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,127.80,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81382 at $127.80 (Fee Schedule) = $127.80 (Total Line Payment) at 100% = $127.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,127.80,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81382 at $127.80 (Fee Schedule) = $127.80 (Total Line Payment) at 100% = $127.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,409.45,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $409.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,362.04,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $362.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,306.01,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $306.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,314.63,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $314.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,209.47,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $209.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,366.35,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $366.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HUMANA,HUMANA CHOICE CARE HMO,210.26,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.26 from Fee Schedule 005543_170 for Rev 310 Proc 81382 * Qty 1 = $210.26 at 100% = $210.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HUMANA,HUMANA CHOICE CARE PPO,366.35,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $366.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,123.68,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,HUMANA,HUMANA NATIIONAL POS HMO,210.26,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.26 from Fee Schedule 005543_170 for Rev 310 Proc 81382 * Qty 1 = $210.26 at 100% = $210.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,314.63,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $314.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,431.00,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $431.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,127.80,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81382 at $127.80 (Fee Schedule) = $127.80 (Total Line Payment) at 100% = $127.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,123.68,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,127.80,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81382 at $127.80 (Fee Schedule) = $127.80 (Total Line Payment) at 100% = $127.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,135.47,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81382 at $127.80 (Fee Schedule) = $127.80 (Total Line Payment) at 100% = $127.80... $127.80 at 106% = $135.47 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,123.68,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,215.50,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $215.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,362.04,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $362.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,278.28,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,323.25,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $323.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,396.52,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $396.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,160.78,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,160.78,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,PREVEA HEALTH NETWORK,PREVEA360,160.78,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,160.78,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,275.11,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $275.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,124.92,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,310.32,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $310.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,TRIOLOGY,TRILOGY MEDICAID,135.47,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81382 at $127.80 (Fee Schedule) = $127.80 (Total Line Payment) at 106% = $135.47. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,148.42,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $148.42 from Fee Schedule UHC_98227C for Rev 310 Proc 81382 * Qty 1 = $148.42 at 100% = $148.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,148.42,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $148.42 from Fee Schedule UHC_98227C for Rev 310 Proc 81382 * Qty 1 = $148.42 at 100% = $148.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,123.68,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,148.42,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $148.42 from Fee Schedule UHC_98227C for Rev 310 Proc 81382 * Qty 1 = $148.42 at 100% = $148.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,UNITY HEALTH PLAN,UNITY HOSPICE,123.68,,,,,,,123.6800,431.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,310.32,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $310.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,267.22,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $267.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,310.32,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $310.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,310.32,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $310.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA CLASS 2 HIGH RESOLUTION ONE LOCUS EA,81382,CPT,310,RC,31000332,CDM,,,,both,,,431.0000,284.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,258.60,,,,,,,123.6800,431.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $431.00 in Billed Charges for Rev 310 Proc 81382 = $258.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81105 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81105 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81105 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81105 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81105 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81105 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81105 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81105 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81105 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81105 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71... $120.71 at 106% = $127.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81105 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 106% = $127.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81105 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81105 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81105 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-1 GENOTYPING ANALYSIS COMM VAR,81105,CPT,310,RC,31000333,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81105 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81106 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81106 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81106 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81106 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81106 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81106 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81106 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81106 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81106 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81106 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71... $120.71 at 106% = $127.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81106 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 106% = $127.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81106 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81106 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81106 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-2 GENOTYPING GENE ANALYSIS COMMON VAR,81106,CPT,310,RC,31000334,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81106 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81109 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81109 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81109 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81109 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81109 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81109 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81109 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81109 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81109 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81109 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71... $120.71 at 106% = $127.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81109 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 106% = $127.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81109 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81109 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81109 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-5 GENOTYPING GENE ANALYSIS COMMON VAR,81109,CPT,310,RC,31000337,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81109 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA HSHS,275.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $275.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,AETNA,AETNA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,AETNA,ALL COMMERCIAL AETNA,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTEHM MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81110 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM POS/HMO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81110 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,ANTHEM,ANTHEM PPO,427.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $427.77 from Fee Schedule WII28_25 for Rev 310 Proc 81110 Mod TC * Qty 1 = $427.77 at 100% = $427.77 (Limited to $427.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,CENPATICO,ALL MEDICAID CENPATICO,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,CIGNA,ALL COMMERCIAL CIGNA,298.90,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $298.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,COFINITY,COFINITY,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81110 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81110 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,405.65,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $405.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,303.17,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $303.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,207.52,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $207.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81110 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA CHOICE CARE PPO,362.95,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $362.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,HUMANA,HUMANA NATIIONAL POS HMO,207.77,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $207.77 from Fee Schedule 005543_170 for Rev 310 Proc 81110 * Qty 1 = $207.77 at 100% = $207.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,311.71,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $311.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,427.00,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81110 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,120.71,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81110 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81110 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 100% = $120.71... $120.71 at 106% = $127.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,213.50,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $213.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,358.68,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $358.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,275.00,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,320.25,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $320.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,392.84,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $392.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.89,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,272.55,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $272.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,123.44,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,TRIOLOGY,TRILOGY MEDICAID,127.95,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81110 at $120.71 (Fee Schedule) = $120.71 (Total Line Payment) at 106% = $127.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81110 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81110 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,146.66,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $146.66 from Fee Schedule UHC_98227C for Rev 310 Proc 81110 * Qty 1 = $146.66 at 100% = $146.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,UNITY HEALTH PLAN,UNITY HOSPICE,122.22,,,,,,,120.7100,427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,264.74,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $264.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,307.44,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $307.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HPA-6 GENOTYPING GENE ANALYSIS COMMON VAR,81110,CPT,310,RC,31000338,CDM,,,,both,,,427.0000,281.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,256.20,,,,,,,120.7100,427.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $427.00 in Billed Charges for Rev 310 Proc 81110 = $256.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,AETNA,AETNA HSHS,5688.03,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $5,688.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,AETNA,AETNA MEDICARE,5031.20,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,AETNA,ALL COMMERCIAL AETNA,8805.00,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $8,805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,ANTHEM,ANTEHM MEDICAID,866.06,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81425 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5031.20,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,ANTHEM,ANTHEM POS/HMO,8805.00,,,,,,,866.0600,11320.2000,fee schedule,"ST VINCENT HOSPITAL (ACU). $17,609.20 from Fee Schedule WII28_25 for Rev 310 Proc 81425 Mod TC * Qty 1 = $17,609.20 at 100% = $17,609.20 (Limited to $8,805.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,ANTHEM,ANTHEM PPO,8805.00,,,,,,,866.0600,11320.2000,fee schedule,"ST VINCENT HOSPITAL (ACU). $17,609.20 from Fee Schedule WII28_25 for Rev 310 Proc 81425 Mod TC * Qty 1 = $17,609.20 at 100% = $17,609.20 (Limited to $8,805.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8805.00,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $8,805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,CENPATICO,ALL MEDICAID CENPATICO,8805.00,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $8,805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7484.25,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $7,484.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,CIGNA,ALL COMMERCIAL CIGNA,6163.50,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,163.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,COFINITY,COFINITY,8805.00,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $8,805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,866.06,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81425 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,866.06,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81425 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8364.75,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $8,364.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,7396.20,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $7,396.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6251.55,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,251.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6427.65,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,427.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,4279.23,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $4,279.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7484.25,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $7,484.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HUMANA,HUMANA CHOICE CARE HMO,8553.04,,,,,,,866.0600,11320.2000,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,553.04 from Fee Schedule 005543_170 for Rev 310 Proc 81425 * Qty 1 = $8,553.04 at 100% = $8,553.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HUMANA,HUMANA CHOICE CARE PPO,7484.25,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $7,484.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,5031.20,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,HUMANA,HUMANA NATIIONAL POS HMO,8553.04,,,,,,,866.0600,11320.2000,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,553.04 from Fee Schedule 005543_170 for Rev 310 Proc 81425 * Qty 1 = $8,553.04 at 100% = $8,553.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6427.65,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,427.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,8805.00,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $8,805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,866.06,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81425 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5031.20,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,866.06,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81425 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,918.02,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81425 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06... $866.06 at 106% = $918.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,5031.20,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4402.50,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $4,402.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7396.20,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $7,396.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,11320.20,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6603.75,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,603.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8100.60,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $8,100.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6540.56,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6540.56,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,PREVEA HEALTH NETWORK,PREVEA360,6540.56,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6540.56,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5620.23,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $5,620.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5081.51,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6339.60,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,339.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,TRIOLOGY,TRILOGY MEDICAID,918.03,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81425 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 106% = $918.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6037.44,,,,,,,866.0600,11320.2000,fee schedule,"ST VINCENT HOSPITAL (ACU). $6,037.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81425 * Qty 1 = $6,037.44 at 100% = $6,037.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,6037.44,,,,,,,866.0600,11320.2000,fee schedule,"ST VINCENT HOSPITAL (ACU). $6,037.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81425 * Qty 1 = $6,037.44 at 100% = $6,037.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5031.20,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,6037.44,,,,,,,866.0600,11320.2000,fee schedule,"ST VINCENT HOSPITAL (ACU). $6,037.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81425 * Qty 1 = $6,037.44 at 100% = $6,037.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,UNITY HEALTH PLAN,UNITY HOSPICE,5031.20,,,,,,,866.0600,11320.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6339.60,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,339.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5459.10,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $5,459.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6339.60,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,339.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6339.60,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $6,339.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GENOME; SEQUENCE ANALSYS,81425,CPT,310,RC,31000344,CDM,,,,both,,,8805.0000,5811.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5283.00,,,,,,,866.0600,11320.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,805.00 in Billed Charges for Rev 310 Proc 81425 = $5,283.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,AETNA,AETNA HSHS,361.11,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $361.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,AETNA,AETNA MEDICARE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,AETNA,ALL COMMERCIAL AETNA,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,ANTHEM,ANTEHM MEDICAID,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81187 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,ANTHEM,ANTHEM POS/HMO,479.50,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81187 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,ANTHEM,ANTHEM PPO,479.50,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $479.50 from Fee Schedule WII28_25 for Rev 310 Proc 81187 Mod TC * Qty 1 = $479.50 at 100% = $479.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,CENPATICO,ALL MEDICAID CENPATICO,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,475.15,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $475.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,CIGNA,ALL COMMERCIAL CIGNA,391.30,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $391.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,COFINITY,COFINITY,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81187 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81187 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,531.05,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $531.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,469.56,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $469.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,396.89,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $396.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,408.07,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $408.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,271.67,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $271.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,475.15,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $475.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HUMANA,HUMANA CHOICE CARE HMO,232.90,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81187 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HUMANA,HUMANA CHOICE CARE PPO,475.15,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $475.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,HUMANA,HUMANA NATIIONAL POS HMO,232.90,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $232.90 from Fee Schedule 005543_170 for Rev 310 Proc 81187 * Qty 1 = $232.90 at 100% = $232.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,408.07,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $408.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,559.00,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $559.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81187 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,109.60,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81187 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,116.18,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81187 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 100% = $109.60... $109.60 at 106% = $116.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,279.50,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $279.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,469.56,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $469.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,308.25,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,419.25,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $419.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,514.28,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $514.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,178.10,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,178.10,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,PREVEA HEALTH NETWORK,PREVEA360,178.10,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,178.10,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,356.81,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $356.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,138.37,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,402.48,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $402.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,TRIOLOGY,TRILOGY MEDICAID,116.18,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81187 at $109.60 (Fee Schedule) = $109.60 (Total Line Payment) at 106% = $116.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,164.40,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81187 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,164.40,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81187 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,164.40,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.40 from Fee Schedule UHC_98227C for Rev 310 Proc 81187 * Qty 1 = $164.40 at 100% = $164.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,UNITY HEALTH PLAN,UNITY HOSPICE,137.00,,,,,,,109.6000,559.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,402.48,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $402.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,346.58,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $346.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,402.48,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $402.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,402.48,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $402.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CNBP GENE DETC ABNOR ALLELE,81187,CPT,310,RC,31000352,CDM,,,,both,,,559.0000,368.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,335.40,,,,,,,109.6000,559.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $559.00 in Billed Charges for Rev 310 Proc 81187 = $335.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,AETNA,AETNA HSHS,892.77,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $892.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,AETNA,ALL COMMERCIAL AETNA,1382.00,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,ANTHEM,ANTEHM MEDICAID,17.32,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,ANTHEM,ANTHEM POS/HMO,939.76,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81479 $1,382.00 in Billed Charges at 68% = $939.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,ANTHEM,ANTHEM PPO,939.76,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 310 Proc 81479 $1,382.00 in Billed Charges at 68% = $939.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1382.00,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,CENPATICO,ALL MEDICAID CENPATICO,1382.00,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1174.70,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,174.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,CIGNA,ALL COMMERCIAL CIGNA,967.40,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $967.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,COFINITY,COFINITY,1382.00,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,17.32,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,17.32,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1312.90,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,312.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,1160.88,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,160.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,981.22,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $981.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1008.86,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,008.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,671.65,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $671.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1174.70,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,174.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,HUMANA,HUMANA CHOICE CARE PPO,1174.70,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,174.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1008.86,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,008.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1382.00,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,382.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,17.32,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,17.32,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,18.36,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 100% = $17.32... $17.32 at 106% = $18.36 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,967.40,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $967.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,691.00,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $691.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1160.88,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,160.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,829.20,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $829.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1036.50,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,036.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1271.44,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $1,271.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,829.20,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,829.20,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,PREVEA HEALTH NETWORK,PREVEA360,829.20,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,829.20,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,882.13,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $882.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,995.04,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $995.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,TRIOLOGY,TRILOGY MEDICAID,18.36,,,,,,,17.3200,1382.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81479 at $125.60 (Base Rate) * 0.1379 (Relative Weight) = $17.32 (Total Line Payment) at 106% = $18.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,995.04,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $995.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,856.84,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $856.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,995.04,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $995.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,995.04,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $995.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SERPINE1 SINGLE GENE TEST,81479,CPT,310,RC,31000356,CDM,,,,both,,,1382.0000,912.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,829.20,,,,,,,17.3200,1382.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,382.00 in Billed Charges for Rev 310 Proc 81479 = $829.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,AETNA,AETNA HSHS,1758.41,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,758.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,AETNA,AETNA MEDICARE,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,AETNA,ALL COMMERCIAL AETNA,2722.00,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,722.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,ANTHEM,ANTEHM MEDICAID,866.06,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81416 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,ANTHEM,ANTHEM POS/HMO,2722.00,,,,,,,866.0600,6124.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $42,000.00 from Fee Schedule WII28_25 for Rev 310 Proc 81416 Mod TC * Qty 1 = $42,000.00 at 100% = $42,000.00 (Limited to $2,722.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,ANTHEM,ANTHEM PPO,2722.00,,,,,,,866.0600,6124.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $42,000.00 from Fee Schedule WII28_25 for Rev 310 Proc 81416 Mod TC * Qty 1 = $42,000.00 at 100% = $42,000.00 (Limited to $2,722.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2722.00,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,722.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,CENPATICO,ALL MEDICAID CENPATICO,2722.00,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,722.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2313.70,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,313.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,CIGNA,ALL COMMERCIAL CIGNA,1905.40,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,905.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,COFINITY,COFINITY,2722.00,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,722.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,866.06,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81416 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,866.06,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81416 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2585.90,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,585.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,2286.48,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,286.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1932.62,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,932.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1987.06,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,987.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,1322.89,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,322.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2313.70,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,313.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HUMANA,HUMANA CHOICE CARE HMO,2722.00,,,,,,,866.0600,6124.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $20,400.00 from Fee Schedule 005543_170 for Rev 310 Proc 81416 * Qty 1 = $20,400.00 at 100% = $20,400.00 (Limited to $2,722.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HUMANA,HUMANA CHOICE CARE PPO,2313.70,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,313.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,HUMANA,HUMANA NATIIONAL POS HMO,2722.00,,,,,,,866.0600,6124.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $20,400.00 from Fee Schedule 005543_170 for Rev 310 Proc 81416 * Qty 1 = $20,400.00 at 100% = $20,400.00 (Limited to $2,722.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1987.06,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,987.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2722.00,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,722.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,866.06,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81416 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,866.06,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81416 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,918.02,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81416 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06... $866.06 at 106% = $918.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1361.00,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,361.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2286.48,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,286.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,6124.50,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2041.50,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,041.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2504.24,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $2,504.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,PREVEA HEALTH NETWORK,PREVEA360,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1737.45,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,737.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2749.22,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1959.84,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,959.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,TRIOLOGY,TRILOGY MEDICAID,918.03,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 81416 at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 106% = $918.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2722.00,,,,,,,866.0600,6124.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $14,400.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81416 * Qty 1 = $14,400.00 at 100% = $14,400.00 (Service Line reduced to $2,722.00, claim capped at $2,722.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,2722.00,,,,,,,866.0600,6124.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $14,400.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81416 * Qty 1 = $14,400.00 at 100% = $14,400.00 (Service Line reduced to $2,722.00, claim capped at $2,722.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,2722.00,,,,,,,866.0600,6124.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $14,400.00 from Fee Schedule UHC_98227C for Rev 310 Proc 81416 * Qty 1 = $14,400.00 at 100% = $14,400.00 (Service Line reduced to $2,722.00, claim capped at $2,722.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,UNITY HEALTH PLAN,UNITY HOSPICE,2722.00,,,,,,,866.0600,6124.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1959.84,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,959.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1687.64,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,687.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1959.84,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,959.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1959.84,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,959.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME,81416,CPT,310,RC,31000357,CDM,,,,both,,,2722.0000,1796.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1633.20,,,,,,,866.0600,6124.5000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,722.00 in Billed Charges for Rev 310 Proc 81416 = $1,633.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,AETNA,AETNA HSHS,627.91,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $627.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,AETNA,AETNA MEDICARE,202.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,AETNA,ALL COMMERCIAL AETNA,972.00,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,ANTHEM,ANTEHM MEDICAID,161.92,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81363 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,202.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,ANTHEM,ANTHEM POS/HMO,708.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.40 from Fee Schedule WII28_25 for Rev 310 Proc 81363 Mod TC * Qty 1 = $708.40 at 100% = $708.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,ANTHEM,ANTHEM PPO,708.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $708.40 from Fee Schedule WII28_25 for Rev 310 Proc 81363 Mod TC * Qty 1 = $708.40 at 100% = $708.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,972.00,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,CENPATICO,ALL MEDICAID CENPATICO,972.00,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,826.20,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $826.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,CIGNA,ALL COMMERCIAL CIGNA,680.40,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $680.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,COFINITY,COFINITY,972.00,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,161.92,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81363 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,161.92,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81363 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,923.40,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $923.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,816.48,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $816.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,690.12,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $690.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,709.56,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $709.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,472.39,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $472.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,826.20,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $826.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HUMANA,HUMANA CHOICE CARE HMO,344.08,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $344.08 from Fee Schedule 005543_170 for Rev 310 Proc 81363 * Qty 1 = $344.08 at 100% = $344.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HUMANA,HUMANA CHOICE CARE PPO,826.20,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $826.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,202.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,HUMANA,HUMANA NATIIONAL POS HMO,344.08,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $344.08 from Fee Schedule 005543_170 for Rev 310 Proc 81363 * Qty 1 = $344.08 at 100% = $344.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,709.56,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $709.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,972.00,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,161.92,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81363 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,202.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,161.92,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81363 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,171.64,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81363 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 100% = $161.92... $161.92 at 106% = $171.64 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,202.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,486.00,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $486.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,816.48,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $816.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,455.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,729.00,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $729.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,894.24,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $894.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,263.12,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,263.12,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,PREVEA HEALTH NETWORK,PREVEA360,263.12,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,263.12,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,620.43,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $620.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,204.42,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,699.84,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $699.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,TRIOLOGY,TRILOGY MEDICAID,171.64,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81363 at $161.92 (Fee Schedule) = $161.92 (Total Line Payment) at 106% = $171.64. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,242.88,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81363 * Qty 1 = $242.88 at 100% = $242.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,242.88,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81363 * Qty 1 = $242.88 at 100% = $242.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,202.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,242.88,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $242.88 from Fee Schedule UHC_98227C for Rev 310 Proc 81363 * Qty 1 = $242.88 at 100% = $242.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,UNITY HEALTH PLAN,UNITY HOSPICE,202.40,,,,,,,161.9200,972.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,699.84,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $699.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,602.64,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,699.84,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $699.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,699.84,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $699.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HBB GENE DUP/DEL,81363,CPT,310,RC,31000361,CDM,,,,both,,,972.0000,641.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,583.20,,,,,,,161.9200,972.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $972.00 in Billed Charges for Rev 310 Proc 81363 = $583.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,AETNA,AETNA HSHS,1441.87,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,441.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,AETNA,AETNA MEDICARE,676.50,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,AETNA,ALL COMMERCIAL AETNA,2232.00,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $2,232.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,ANTHEM,ANTEHM MEDICAID,565.61,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81175 at $565.61 (Fee Schedule) = $565.61 (Total Line Payment) at 100% = $565.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,676.50,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,ANTHEM,ANTHEM POS/HMO,2232.00,,,,,,,565.6100,2232.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,367.75 from Fee Schedule WII28_25 for Rev 310 Proc 81175 Mod TC * Qty 1 = $2,367.75 at 100% = $2,367.75 (Limited to $2,232.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,ANTHEM,ANTHEM PPO,2232.00,,,,,,,565.6100,2232.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,367.75 from Fee Schedule WII28_25 for Rev 310 Proc 81175 Mod TC * Qty 1 = $2,367.75 at 100% = $2,367.75 (Limited to $2,232.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2232.00,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $2,232.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,CENPATICO,ALL MEDICAID CENPATICO,2232.00,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $2,232.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1897.20,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,897.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,CIGNA,ALL COMMERCIAL CIGNA,1562.40,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,562.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,COFINITY,COFINITY,2232.00,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $2,232.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,565.61,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81175 at $565.61 (Fee Schedule) = $565.61 (Total Line Payment) at 100% = $565.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,565.61,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81175 at $565.61 (Fee Schedule) = $565.61 (Total Line Payment) at 100% = $565.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2120.40,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $2,120.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,1874.88,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,874.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1584.72,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,584.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1629.36,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,629.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,1084.75,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,084.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1897.20,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,897.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HUMANA,HUMANA CHOICE CARE HMO,1150.05,,,,,,,565.6100,2232.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,150.05 from Fee Schedule 005543_170 for Rev 310 Proc 81175 * Qty 1 = $1,150.05 at 100% = $1,150.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HUMANA,HUMANA CHOICE CARE PPO,1897.20,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,897.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,676.50,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,HUMANA,HUMANA NATIIONAL POS HMO,1150.05,,,,,,,565.6100,2232.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,150.05 from Fee Schedule 005543_170 for Rev 310 Proc 81175 * Qty 1 = $1,150.05 at 100% = $1,150.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1629.36,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,629.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2232.00,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $2,232.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,565.61,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81175 at $565.61 (Fee Schedule) = $565.61 (Total Line Payment) at 100% = $565.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,676.50,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,565.61,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81175 at $565.61 (Fee Schedule) = $565.61 (Total Line Payment) at 100% = $565.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,599.55,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81175 at $565.61 (Fee Schedule) = $565.61 (Total Line Payment) at 100% = $565.61... $565.61 at 106% = $599.55 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,676.50,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1116.00,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,116.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1874.88,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,874.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,1522.13,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1674.00,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,674.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2053.44,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $2,053.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,879.45,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,879.45,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,PREVEA HEALTH NETWORK,PREVEA360,879.45,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,879.45,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1424.69,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,424.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,683.27,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1607.04,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,607.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,TRIOLOGY,TRILOGY MEDICAID,599.55,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81175 at $565.61 (Fee Schedule) = $565.61 (Total Line Payment) at 106% = $599.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,811.80,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $811.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81175 * Qty 1 = $811.80 at 100% = $811.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,811.80,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $811.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81175 * Qty 1 = $811.80 at 100% = $811.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,676.50,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,811.80,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $811.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81175 * Qty 1 = $811.80 at 100% = $811.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,UNITY HEALTH PLAN,UNITY HOSPICE,676.50,,,,,,,565.6100,2232.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1607.04,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,607.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1383.84,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,383.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1607.04,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,607.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1607.04,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,607.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASXL1 FULL GENE SEQUENCE,81175,CPT,310,RC,31000363,CDM,,,,both,,,2232.0000,1473.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1339.20,,,,,,,565.6100,2232.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,232.00 in Billed Charges for Rev 310 Proc 81175 = $1,339.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,AETNA,AETNA HSHS,1125.33,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,125.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,AETNA,AETNA MEDICARE,527.87,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,AETNA,ALL COMMERCIAL AETNA,1742.00,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,ANTHEM,ANTEHM MEDICAID,281.65,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81302 at $281.65 (Fee Schedule) = $281.65 (Total Line Payment) at 100% = $281.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,527.87,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,ANTHEM,ANTHEM POS/HMO,1742.00,,,,,,,281.6500,1742.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,847.55 from Fee Schedule WII28_25 for Rev 310 Proc 81302 Mod TC * Qty 1 = $1,847.55 at 100% = $1,847.55 (Limited to $1,742.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,ANTHEM,ANTHEM PPO,1742.00,,,,,,,281.6500,1742.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,847.55 from Fee Schedule WII28_25 for Rev 310 Proc 81302 Mod TC * Qty 1 = $1,847.55 at 100% = $1,847.55 (Limited to $1,742.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1742.00,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,CENPATICO,ALL MEDICAID CENPATICO,1742.00,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1480.70,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,480.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,CIGNA,ALL COMMERCIAL CIGNA,1219.40,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,219.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,COFINITY,COFINITY,1742.00,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,281.65,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81302 at $281.65 (Fee Schedule) = $281.65 (Total Line Payment) at 100% = $281.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,281.65,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81302 at $281.65 (Fee Schedule) = $281.65 (Total Line Payment) at 100% = $281.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1654.90,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,654.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,1463.28,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,463.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1236.82,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,236.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1271.66,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,271.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,846.61,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $846.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1480.70,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,480.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HUMANA,HUMANA CHOICE CARE HMO,897.38,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $897.38 from Fee Schedule 005543_170 for Rev 310 Proc 81302 * Qty 1 = $897.38 at 100% = $897.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HUMANA,HUMANA CHOICE CARE PPO,1480.70,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,480.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,527.87,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,HUMANA,HUMANA NATIIONAL POS HMO,897.38,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $897.38 from Fee Schedule 005543_170 for Rev 310 Proc 81302 * Qty 1 = $897.38 at 100% = $897.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1271.66,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,271.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1742.00,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,281.65,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81302 at $281.65 (Fee Schedule) = $281.65 (Total Line Payment) at 100% = $281.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,527.87,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,281.65,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81302 at $281.65 (Fee Schedule) = $281.65 (Total Line Payment) at 100% = $281.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,298.55,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81302 at $281.65 (Fee Schedule) = $281.65 (Total Line Payment) at 100% = $281.65... $281.65 at 106% = $298.55 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,527.87,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,871.00,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $871.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1463.28,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,463.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,1187.71,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1306.50,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,306.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1602.64,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,686.23,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,686.23,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,PREVEA HEALTH NETWORK,PREVEA360,686.23,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,686.23,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1111.92,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,111.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,533.15,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1254.24,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,254.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,TRIOLOGY,TRILOGY MEDICAID,298.55,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81302 at $281.65 (Fee Schedule) = $281.65 (Total Line Payment) at 106% = $298.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,633.44,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $633.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81302 * Qty 1 = $633.44 at 100% = $633.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,633.44,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $633.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81302 * Qty 1 = $633.44 at 100% = $633.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,527.87,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,633.44,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $633.44 from Fee Schedule UHC_98227C for Rev 310 Proc 81302 * Qty 1 = $633.44 at 100% = $633.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,UNITY HEALTH PLAN,UNITY HOSPICE,527.87,,,,,,,281.6500,1742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1254.24,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,254.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1080.04,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,080.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1254.24,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,254.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1254.24,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,254.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MECP2 GENE ANALYSIS FULL SEQ,81302,CPT,310,RC,31000364,CDM,,,,both,,,1742.0000,1149.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1045.20,,,,,,,281.6500,1742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,742.00 in Billed Charges for Rev 310 Proc 81302 = $1,045.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,AETNA,AETNA HSHS,271.32,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $271.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,AETNA,AETNA MEDICARE,127.43,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,AETNA,ALL COMMERCIAL AETNA,420.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,ANTHEM,ANTEHM MEDICAID,121.54,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81373 at $121.54 (Fee Schedule) = $121.54 (Total Line Payment) at 100% = $121.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,127.43,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,ANTHEM,ANTHEM POS/HMO,420.00,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $446.01 from Fee Schedule WII28_25 for Rev 310 Proc 81373 Mod TC * Qty 1 = $446.01 at 100% = $446.01 (Limited to $420.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,ANTHEM,ANTHEM PPO,420.00,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $446.01 from Fee Schedule WII28_25 for Rev 310 Proc 81373 Mod TC * Qty 1 = $446.01 at 100% = $446.01 (Limited to $420.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,420.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,CENPATICO,ALL MEDICAID CENPATICO,420.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,357.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $357.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,CIGNA,ALL COMMERCIAL CIGNA,294.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $294.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,COFINITY,COFINITY,420.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,121.54,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81373 at $121.54 (Fee Schedule) = $121.54 (Total Line Payment) at 100% = $121.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,121.54,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81373 at $121.54 (Fee Schedule) = $121.54 (Total Line Payment) at 100% = $121.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,399.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $399.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,352.80,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $352.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,298.20,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $298.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,306.60,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $306.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,204.12,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $204.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,357.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $357.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HUMANA,HUMANA CHOICE CARE HMO,216.63,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $216.63 from Fee Schedule 005543_170 for Rev 310 Proc 81373 * Qty 1 = $216.63 at 100% = $216.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HUMANA,HUMANA CHOICE CARE PPO,357.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $357.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,127.43,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,HUMANA,HUMANA NATIIONAL POS HMO,216.63,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $216.63 from Fee Schedule 005543_170 for Rev 310 Proc 81373 * Qty 1 = $216.63 at 100% = $216.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,306.60,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $306.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,420.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,121.54,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81373 at $121.54 (Fee Schedule) = $121.54 (Total Line Payment) at 100% = $121.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,127.43,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,121.54,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81373 at $121.54 (Fee Schedule) = $121.54 (Total Line Payment) at 100% = $121.54. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,128.83,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81373 at $121.54 (Fee Schedule) = $121.54 (Total Line Payment) at 100% = $121.54... $121.54 at 106% = $128.83 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,127.43,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,210.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $210.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,352.80,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $352.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,286.72,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,315.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,386.40,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $386.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,165.66,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,165.66,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,PREVEA HEALTH NETWORK,PREVEA360,165.66,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,165.66,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,268.09,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $268.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,128.70,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,302.40,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,TRIOLOGY,TRILOGY MEDICAID,128.83,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 81373 at $121.54 (Fee Schedule) = $121.54 (Total Line Payment) at 106% = $128.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,152.92,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $152.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81373 * Qty 1 = $152.92 at 100% = $152.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,152.92,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $152.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81373 * Qty 1 = $152.92 at 100% = $152.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,127.43,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,152.92,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $152.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81373 * Qty 1 = $152.92 at 100% = $152.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,UNITY HEALTH PLAN,UNITY HOSPICE,127.43,,,,,,,121.5400,420.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,302.40,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,260.40,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,302.40,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,302.40,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $302.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HLA B LOW RESOLUTION,81373,CPT,310,RC,31000366,CDM,,,,both,,,420.0000,277.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,252.00,,,,,,,121.5400,420.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $420.00 in Billed Charges for Rev 310 Proc 81373 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,AETNA,AETNA HSHS,2576.25,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,576.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,AETNA,AETNA MEDICARE,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,AETNA,ALL COMMERCIAL AETNA,3988.00,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,988.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,ANTHEM,ANTEHM MEDICAID,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0218U at $2,279.00 (Fee Schedule) = $2,279.00 (Total Line Payment) at 100% = $2,279.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,ANTHEM,ANTHEM POS/HMO,3988.00,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $7,976.50 from Fee Schedule WII28_25 for Rev 310 Proc 0218U Mod TC * Qty 1 = $7,976.50 at 100% = $7,976.50 (Limited to $3,988.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,ANTHEM,ANTHEM PPO,3988.00,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $7,976.50 from Fee Schedule WII28_25 for Rev 310 Proc 0218U Mod TC * Qty 1 = $7,976.50 at 100% = $7,976.50 (Limited to $3,988.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3988.00,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,988.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,CENPATICO,ALL MEDICAID CENPATICO,3988.00,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,988.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3389.80,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,389.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,CIGNA,ALL COMMERCIAL CIGNA,2791.60,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,791.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,COFINITY,COFINITY,3988.00,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,988.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0218U at $2,279.00 (Fee Schedule) = $2,279.00 (Total Line Payment) at 100% = $2,279.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0218U at $2,279.00 (Fee Schedule) = $2,279.00 (Total Line Payment) at 100% = $2,279.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3788.60,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,788.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,3349.92,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,349.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2831.48,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,831.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2911.24,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,911.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,1938.17,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $1,938.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3389.80,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,389.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HUMANA,HUMANA CHOICE CARE HMO,3874.30,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,874.30 from Fee Schedule 005543_170 for Rev 310 Proc 0218U * Qty 1 = $3,874.30 at 100% = $3,874.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HUMANA,HUMANA CHOICE CARE PPO,3389.80,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,389.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HUMANA,HUMANA MEDICARE ADVANTAGE,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,HUMANA,HUMANA NATIIONAL POS HMO,3874.30,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $3,874.30 from Fee Schedule 005543_170 for Rev 310 Proc 0218U * Qty 1 = $3,874.30 at 100% = $3,874.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2911.24,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,911.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3988.00,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,988.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0218U at $2,279.00 (Fee Schedule) = $2,279.00 (Total Line Payment) at 100% = $2,279.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0218U at $2,279.00 (Fee Schedule) = $2,279.00 (Total Line Payment) at 100% = $2,279.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,2415.74,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0218U at $2,279.00 (Fee Schedule) = $2,279.00 (Total Line Payment) at 100% = $2,279.00... $2,279.00 at 106% = $2,415.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,MOLINA HEALTHCARE,MOLINA MEDICARE,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1994.00,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $1,994.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3349.92,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,349.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,NAPHCARE,ALL COMMERICAL NAPHCARE,5127.75,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2991.00,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,991.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3668.96,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $3,668.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2962.70,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2962.70,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,PREVEA HEALTH NETWORK,PREVEA360,2962.70,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2962.70,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2545.54,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,545.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2301.79,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2871.36,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,871.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,TRIOLOGY,TRILOGY MEDICAID,2415.74,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0218U at $2,279.00 (Fee Schedule) = $2,279.00 (Total Line Payment) at 106% = $2,415.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2734.80,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,734.80 from Fee Schedule UHC_98227C for Rev 310 Proc 0218U * Qty 1 = $2,734.80 at 100% = $2,734.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,2734.80,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,734.80 from Fee Schedule UHC_98227C for Rev 310 Proc 0218U * Qty 1 = $2,734.80 at 100% = $2,734.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,2734.80,,,,,,,1938.1700,5127.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,734.80 from Fee Schedule UHC_98227C for Rev 310 Proc 0218U * Qty 1 = $2,734.80 at 100% = $2,734.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,UNITY HEALTH PLAN,UNITY HOSPICE,2279.00,,,,,,,1938.1700,5127.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2871.36,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,871.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2472.56,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,472.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2871.36,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,871.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2871.36,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,871.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VWD PROPEPTIDE AG LVL,0218U,CPT,310,RC,31000369,CDM,,,,both,,,3988.0000,2632.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2392.80,,,,,,,1938.1700,5127.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,988.00 in Billed Charges for Rev 310 Proc 0218U = $2,392.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,AETNA,AETNA HSHS,987.73,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $987.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,AETNA,AETNA MEDICARE,556.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,AETNA,ALL COMMERCIAL AETNA,1529.00,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,529.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,ANTHEM,ANTEHM MEDICAID,210.00,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,556.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,ANTHEM,ANTHEM POS/HMO,1529.00,,,,,,,210.0000,1529.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,948.10 from Fee Schedule WII28_25 for Rev 310 Proc 81220 Mod TC * Qty 1 = $1,948.10 at 100% = $1,948.10 (Limited to $1,529.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,ANTHEM,ANTHEM PPO,1529.00,,,,,,,210.0000,1529.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,948.10 from Fee Schedule WII28_25 for Rev 310 Proc 81220 Mod TC * Qty 1 = $1,948.10 at 100% = $1,948.10 (Limited to $1,529.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1529.00,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,529.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,CENPATICO,ALL MEDICAID CENPATICO,1529.00,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,529.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1299.65,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,299.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,CIGNA,ALL COMMERCIAL CIGNA,1070.30,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,070.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,COFINITY,COFINITY,1529.00,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,529.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,210.00,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,210.00,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1452.55,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,452.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,1284.36,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,284.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1085.59,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,085.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1116.17,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,116.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,743.09,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $743.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1299.65,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,299.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HUMANA,HUMANA CHOICE CARE HMO,946.22,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $946.22 from Fee Schedule 005543_170 for Rev 310 Proc 81220 * Qty 1 = $946.22 at 100% = $946.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HUMANA,HUMANA CHOICE CARE PPO,1299.65,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,299.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,556.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,HUMANA,HUMANA NATIIONAL POS HMO,946.22,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $946.22 from Fee Schedule 005543_170 for Rev 310 Proc 81220 * Qty 1 = $946.22 at 100% = $946.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1116.17,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,116.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1529.00,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,529.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,210.00,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,556.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,210.00,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,222.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 100% = $210.00... $210.00 at 106% = $222.60 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,556.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,764.50,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $764.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1284.36,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,284.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,1252.35,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1146.75,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,146.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1406.68,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,406.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,723.58,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,723.58,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,PREVEA HEALTH NETWORK,PREVEA360,723.58,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,723.58,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,975.96,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $975.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,562.17,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1100.88,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,100.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,TRIOLOGY,TRILOGY MEDICAID,222.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00387 Proc 81220 at $210.00 (Fee Schedule) = $210.00 (Total Line Payment) at 106% = $222.60. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,667.92,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $667.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81220 * Qty 1 = $667.92 at 100% = $667.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,667.92,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $667.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81220 * Qty 1 = $667.92 at 100% = $667.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,556.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,667.92,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $667.92 from Fee Schedule UHC_98227C for Rev 310 Proc 81220 * Qty 1 = $667.92 at 100% = $667.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,UNITY HEALTH PLAN,UNITY HOSPICE,556.60,,,,,,,210.0000,1529.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1100.88,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,100.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,947.98,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $947.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1100.88,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,100.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1100.88,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $1,100.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CFTR GENE COM VARIANTS,81220,CPT,310,RC,31000389,CDM,,,,both,,,1529.0000,1009.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,917.40,,,,,,,210.0000,1529.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,529.00 in Billed Charges for Rev 310 Proc 81220 = $917.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,AETNA,AETNA HSHS,3956.75,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $3,956.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,AETNA,AETNA MEDICARE,3500.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,AETNA,ALL COMMERCIAL AETNA,6125.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $6,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,ANTHEM,ANTEHM MEDICAID,866.06,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0037U at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3500.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,ANTHEM,ANTHEM POS/HMO,6125.00,,,,,,,866.0600,7875.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $12,250.00 from Fee Schedule WII28_25 for Rev 310 Proc 0037U Mod TC * Qty 1 = $12,250.00 at 100% = $12,250.00 (Limited to $6,125.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,ANTHEM,ANTHEM PPO,6125.00,,,,,,,866.0600,7875.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $12,250.00 from Fee Schedule WII28_25 for Rev 310 Proc 0037U Mod TC * Qty 1 = $12,250.00 at 100% = $12,250.00 (Limited to $6,125.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6125.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $6,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,CENPATICO,ALL MEDICAID CENPATICO,6125.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $6,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5206.25,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $5,206.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,CIGNA,ALL COMMERCIAL CIGNA,4287.50,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,287.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,COFINITY,COFINITY,6125.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $6,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,866.06,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0037U at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,866.06,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0037U at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5818.75,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $5,818.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,5145.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $5,145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4348.75,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,348.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4471.25,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,471.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,2976.75,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $2,976.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5206.25,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $5,206.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HUMANA,HUMANA CHOICE CARE HMO,5950.00,,,,,,,866.0600,7875.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,950.00 from Fee Schedule 005543_170 for Rev 310 Proc 0037U * Qty 1 = $5,950.00 at 100% = $5,950.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HUMANA,HUMANA CHOICE CARE PPO,5206.25,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $5,206.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,3500.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,HUMANA,HUMANA NATIIONAL POS HMO,5950.00,,,,,,,866.0600,7875.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,950.00 from Fee Schedule 005543_170 for Rev 310 Proc 0037U * Qty 1 = $5,950.00 at 100% = $5,950.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4471.25,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,471.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,6125.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $6,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,866.06,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0037U at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3500.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,866.06,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0037U at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,918.02,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0037U at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 100% = $866.06... $866.06 at 106% = $918.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,3500.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3062.50,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $3,062.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5145.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $5,145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,7875.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4593.75,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,593.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5635.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $5,635.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4550.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4550.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,PREVEA HEALTH NETWORK,PREVEA360,4550.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4550.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3909.59,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $3,909.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3535.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4410.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,TRIOLOGY,TRILOGY MEDICAID,918.03,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0037U at $125.60 (Base Rate) * 6.8954 (Relative Weight) = $866.06 (Total Line Payment) at 106% = $918.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4200.00,,,,,,,866.0600,7875.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,200.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0037U * Qty 1 = $4,200.00 at 100% = $4,200.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,4200.00,,,,,,,866.0600,7875.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,200.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0037U * Qty 1 = $4,200.00 at 100% = $4,200.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3500.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,4200.00,,,,,,,866.0600,7875.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,200.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0037U * Qty 1 = $4,200.00 at 100% = $4,200.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,UNITY HEALTH PLAN,UNITY HOSPICE,3500.00,,,,,,,866.0600,7875.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4410.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3797.50,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $3,797.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4410.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4410.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $4,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRGT GEN SEQ DNA 324 GENES,0037U,CPT,310,RC,31000391,CDM,,,,both,,,6125.0000,4042.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3675.00,,,,,,,866.0600,7875.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,125.00 in Billed Charges for Rev 310 Proc 0037U = $3,675.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,AETNA,AETNA HSHS,5461.93,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $5,461.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,AETNA,AETNA MEDICARE,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,AETNA,ALL COMMERCIAL AETNA,8455.00,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $8,455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,ANTHEM,ANTEHM MEDICAID,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,ANTHEM,ANTHEM POS/HMO,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $29,592.50 from Fee Schedule WII28_25 for Rev 310 Proc 0211U Mod TC * Qty 1 = $29,592.50 at 100% = $29,592.50 (Limited to $8,455.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,ANTHEM,ANTHEM PPO,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $29,592.50 from Fee Schedule WII28_25 for Rev 310 Proc 0211U Mod TC * Qty 1 = $29,592.50 at 100% = $29,592.50 (Limited to $8,455.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8455.00,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $8,455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,CENPATICO,ALL MEDICAID CENPATICO,8455.00,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $8,455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7186.75,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $7,186.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,CIGNA,ALL COMMERCIAL CIGNA,5918.50,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $5,918.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,COFINITY,COFINITY,8455.00,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $8,455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8032.25,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $8,032.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,7102.20,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $7,102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6003.05,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $6,003.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6172.15,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $6,172.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,4109.13,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $4,109.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7186.75,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $7,186.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HUMANA,HUMANA CHOICE CARE HMO,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $14,373.50 from Fee Schedule 005543_170 for Rev 310 Proc 0211U * Qty 1 = $14,373.50 at 100% = $14,373.50 (Limited to $8,455.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HUMANA,HUMANA CHOICE CARE PPO,7186.75,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $7,186.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,HUMANA,HUMANA NATIIONAL POS HMO,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $14,373.50 from Fee Schedule 005543_170 for Rev 310 Proc 0211U * Qty 1 = $14,373.50 at 100% = $14,373.50 (Limited to $8,455.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6172.15,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $6,172.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,8455.00,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $8,455.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,8962.30,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00... $8,455.00 at 106% = $8,962.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4227.50,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $4,227.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7102.20,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $7,102.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,19023.75,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6341.25,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $6,341.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7778.60,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $7,778.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,PREVEA HEALTH NETWORK,PREVEA360,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5396.83,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $5,396.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8539.55,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6087.60,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $6,087.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,TRIOLOGY,TRILOGY MEDICAID,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 106% = $8,962.30 (Service Line reduced to $8,455.00, claim capped at $8,455.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,146.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0211U * Qty 1 = $10,146.00 at 100% = $10,146.00 (Service Line reduced to $8,455.00, claim capped at $8,455.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,146.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0211U * Qty 1 = $10,146.00 at 100% = $10,146.00 (Service Line reduced to $8,455.00, claim capped at $8,455.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,146.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0211U * Qty 1 = $10,146.00 at 100% = $10,146.00 (Service Line reduced to $8,455.00, claim capped at $8,455.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,UNITY HEALTH PLAN,UNITY HOSPICE,8455.00,,,,,,,4109.1300,19023.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6087.60,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $6,087.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5242.10,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $5,242.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6087.60,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $6,087.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6087.60,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $6,087.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING,0211U,CPT,310,RC,31000397,CDM,,,,both,,,8455.0000,5580.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5073.00,,,,,,,4109.1300,19023.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,455.00 in Billed Charges for Rev 310 Proc 0211U = $5,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA HSHS,96.90,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $96.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,AETNA,AETNA MEDICARE,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,AETNA,ALL COMMERCIAL AETNA,150.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTEHM MEDICAID,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM POS/HMO,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $29,592.50 from Fee Schedule WII28_25 for Rev 310 Proc 0211U Mod TC * Qty 1 = $29,592.50 at 100% = $29,592.50 (Limited to $150.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,ANTHEM,ANTHEM PPO,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $29,592.50 from Fee Schedule WII28_25 for Rev 310 Proc 0211U Mod TC * Qty 1 = $29,592.50 at 100% = $29,592.50 (Limited to $150.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,150.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,CENPATICO,ALL MEDICAID CENPATICO,150.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.50,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,CIGNA,ALL COMMERCIAL CIGNA,105.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,COFINITY,COFINITY,150.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.50,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $142.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,126.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.50,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.50,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,72.90,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $72.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.50,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE HMO,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $14,373.50 from Fee Schedule 005543_170 for Rev 310 Proc 0211U * Qty 1 = $14,373.50 at 100% = $14,373.50 (Limited to $150.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA CHOICE CARE PPO,127.50,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,HUMANA,HUMANA NATIIONAL POS HMO,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $14,373.50 from Fee Schedule 005543_170 for Rev 310 Proc 0211U * Qty 1 = $14,373.50 at 100% = $14,373.50 (Limited to $150.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.50,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,150.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $150.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,159.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 100% = $8,455.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges)... $150.00 at 106% = $159.00 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,337.50,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.50,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $138.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.75,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,151.50,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,TRIOLOGY,TRILOGY MEDICAID,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 02045 Proc 0211U at $8,455.00 (Fee Schedule) = $8,455.00 (Total Line Payment) at 106% = $8,962.30 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,146.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0211U * Qty 1 = $10,146.00 at 100% = $10,146.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,146.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0211U * Qty 1 = $10,146.00 at 100% = $10,146.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,150.00,,,,,,,72.9000,337.5000,fee schedule,"ST VINCENT HOSPITAL (ACU). $10,146.00 from Fee Schedule UHC_98227C for Rev 310 Proc 0211U * Qty 1 = $10,146.00 at 100% = $10,146.00 (Service Line reduced to $150.00, claim capped at $150.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,UNITY HEALTH PLAN,UNITY HOSPICE,150.00,,,,,,,72.9000,337.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ONC PAN-TUM DNA&RNA GNRJ SEQ,0211U,CPT,310,RC,31000398,CDM,,,,both,,,150.0000,99.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.00,,,,,,,72.9000,337.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $150.00 in Billed Charges for Rev 310 Proc 0211U = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,AETNA,AETNA HSHS,360.47,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $360.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,AETNA,AETNA MEDICARE,279.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,AETNA,ALL COMMERCIAL AETNA,558.00,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,ANTHEM,ANTEHM MEDICAID,140.01,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81161 at $140.01 (Fee Schedule) = $140.01 (Total Line Payment) at 100% = $140.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,279.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,ANTHEM,ANTHEM POS/HMO,558.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $976.50 from Fee Schedule WII28_25 for Rev 310 Proc 81161 Mod TC * Qty 1 = $976.50 at 100% = $976.50 (Limited to $558.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,ANTHEM,ANTHEM PPO,558.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $976.50 from Fee Schedule WII28_25 for Rev 310 Proc 81161 Mod TC * Qty 1 = $976.50 at 100% = $976.50 (Limited to $558.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,558.00,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,CENPATICO,ALL MEDICAID CENPATICO,558.00,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,474.30,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $474.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,CIGNA,ALL COMMERCIAL CIGNA,390.60,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $390.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,COFINITY,COFINITY,558.00,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,140.01,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81161 at $140.01 (Fee Schedule) = $140.01 (Total Line Payment) at 100% = $140.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,140.01,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81161 at $140.01 (Fee Schedule) = $140.01 (Total Line Payment) at 100% = $140.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,530.10,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $530.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,468.72,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $468.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,396.18,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $396.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,407.34,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $407.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,271.19,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $271.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,474.30,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $474.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HUMANA,HUMANA CHOICE CARE HMO,474.30,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $474.30 from Fee Schedule 005543_170 for Rev 310 Proc 81161 * Qty 1 = $474.30 at 100% = $474.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HUMANA,HUMANA CHOICE CARE PPO,474.30,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $474.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,279.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,HUMANA,HUMANA NATIIONAL POS HMO,474.30,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $474.30 from Fee Schedule 005543_170 for Rev 310 Proc 81161 * Qty 1 = $474.30 at 100% = $474.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,407.34,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $407.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,558.00,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,140.01,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81161 at $140.01 (Fee Schedule) = $140.01 (Total Line Payment) at 100% = $140.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,279.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,140.01,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81161 at $140.01 (Fee Schedule) = $140.01 (Total Line Payment) at 100% = $140.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,148.41,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81161 at $140.01 (Fee Schedule) = $140.01 (Total Line Payment) at 100% = $140.01... $140.01 at 106% = $148.41 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,279.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,279.00,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $279.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,468.72,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $468.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,627.75,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,418.50,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $418.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,513.36,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $513.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,362.70,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,362.70,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,PREVEA HEALTH NETWORK,PREVEA360,362.70,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,362.70,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,356.17,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $356.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,281.79,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,401.76,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $401.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,TRIOLOGY,TRILOGY MEDICAID,148.41,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81161 at $140.01 (Fee Schedule) = $140.01 (Total Line Payment) at 106% = $148.41. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,334.80,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $334.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81161 * Qty 1 = $334.80 at 100% = $334.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,334.80,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $334.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81161 * Qty 1 = $334.80 at 100% = $334.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,279.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,334.80,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $334.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81161 * Qty 1 = $334.80 at 100% = $334.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,UNITY HEALTH PLAN,UNITY HOSPICE,279.00,,,,,,,140.0100,627.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,401.76,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $401.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,345.96,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $345.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,401.76,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $401.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,401.76,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $401.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DMD DUPLICATION/DELETION ANALYSIS,81161,CPT,310,RC,31000399,CDM,,,,both,,,558.0000,368.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,334.80,,,,,,,140.0100,627.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $558.00 in Billed Charges for Rev 310 Proc 81161 = $334.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,AETNA,AETNA HSHS,873.39,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $873.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,AETNA,AETNA MEDICARE,676.50,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,AETNA,ALL COMMERCIAL AETNA,1352.00,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,ANTHEM,ANTEHM MEDICAID,226.30,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81307 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,676.50,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,ANTHEM,ANTHEM POS/HMO,1352.00,,,,,,,226.3000,1522.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,367.75 from Fee Schedule WII28_25 for Rev 310 Proc 81307 Mod TC * Qty 1 = $2,367.75 at 100% = $2,367.75 (Limited to $1,352.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,ANTHEM,ANTHEM PPO,1352.00,,,,,,,226.3000,1522.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,367.75 from Fee Schedule WII28_25 for Rev 310 Proc 81307 Mod TC * Qty 1 = $2,367.75 at 100% = $2,367.75 (Limited to $1,352.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1352.00,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,CENPATICO,ALL MEDICAID CENPATICO,1352.00,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1149.20,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,149.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,CIGNA,ALL COMMERCIAL CIGNA,946.40,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $946.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,COFINITY,COFINITY,1352.00,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,226.30,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81307 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,226.30,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81307 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1284.40,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,284.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,1135.68,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,135.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,959.92,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $959.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,986.96,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $986.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,657.07,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $657.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1149.20,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,149.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HUMANA,HUMANA CHOICE CARE HMO,1150.05,,,,,,,226.3000,1522.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,150.05 from Fee Schedule 005543_170 for Rev 310 Proc 81307 * Qty 1 = $1,150.05 at 100% = $1,150.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HUMANA,HUMANA CHOICE CARE PPO,1149.20,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,149.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,676.50,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,HUMANA,HUMANA NATIIONAL POS HMO,1150.05,,,,,,,226.3000,1522.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,150.05 from Fee Schedule 005543_170 for Rev 310 Proc 81307 * Qty 1 = $1,150.05 at 100% = $1,150.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,986.96,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $986.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1352.00,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,226.30,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81307 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,676.50,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,226.30,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81307 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,239.88,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81307 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 100% = $226.30... $226.30 at 106% = $239.88 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,676.50,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,676.00,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $676.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1135.68,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,135.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,1522.13,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1014.00,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,014.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1243.84,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $1,243.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,879.45,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,879.45,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,PREVEA HEALTH NETWORK,PREVEA360,879.45,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,879.45,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,862.98,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $862.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,683.27,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,973.44,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $973.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,TRIOLOGY,TRILOGY MEDICAID,239.88,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02044 Proc 81307 at $226.30 (Fee Schedule) = $226.30 (Total Line Payment) at 106% = $239.88. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,811.80,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $811.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81307 * Qty 1 = $811.80 at 100% = $811.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,811.80,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $811.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81307 * Qty 1 = $811.80 at 100% = $811.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,676.50,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,811.80,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $811.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81307 * Qty 1 = $811.80 at 100% = $811.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,UNITY HEALTH PLAN,UNITY HOSPICE,676.50,,,,,,,226.3000,1522.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,973.44,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $973.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,838.24,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $838.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,973.44,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $973.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,973.44,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $973.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,81307,CPT,310,RC,31000400,CDM,,,,both,,,1352.0000,892.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,811.20,,,,,,,226.3000,1522.1300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,352.00 in Billed Charges for Rev 310 Proc 81307 = $811.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,AETNA,AETNA HSHS,257.11,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $257.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,AETNA,AETNA MEDICARE,40.70,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,AETNA,ALL COMMERCIAL AETNA,398.00,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $398.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,ANTHEM,ANTEHM MEDICAID,35.62,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88272 at $35.62 (Fee Schedule) = $35.62 (Total Line Payment) at 100% = $35.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,40.70,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,ANTHEM,ANTHEM POS/HMO,142.45,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $142.45 from Fee Schedule WII28_25 for Rev 310 Proc 88272 Mod TC * Qty 1 = $142.45 at 100% = $142.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,ANTHEM,ANTHEM PPO,142.45,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $142.45 from Fee Schedule WII28_25 for Rev 310 Proc 88272 Mod TC * Qty 1 = $142.45 at 100% = $142.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,398.00,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $398.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,CENPATICO,ALL MEDICAID CENPATICO,398.00,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $398.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,338.30,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $338.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,CIGNA,ALL COMMERCIAL CIGNA,278.60,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $278.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,COFINITY,COFINITY,398.00,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $398.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,35.62,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88272 at $35.62 (Fee Schedule) = $35.62 (Total Line Payment) at 100% = $35.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,35.62,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88272 at $35.62 (Fee Schedule) = $35.62 (Total Line Payment) at 100% = $35.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,378.10,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $378.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,334.32,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $334.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,282.58,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $282.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,290.54,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $290.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,193.43,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $193.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,338.30,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $338.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HUMANA,HUMANA CHOICE CARE HMO,69.19,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $69.19 from Fee Schedule 005543_170 for Rev 310 Proc 88272 * Qty 1 = $69.19 at 100% = $69.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HUMANA,HUMANA CHOICE CARE PPO,338.30,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $338.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,40.70,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,HUMANA,HUMANA NATIIONAL POS HMO,69.19,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $69.19 from Fee Schedule 005543_170 for Rev 310 Proc 88272 * Qty 1 = $69.19 at 100% = $69.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,290.54,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $290.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,398.00,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $398.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,35.62,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88272 at $35.62 (Fee Schedule) = $35.62 (Total Line Payment) at 100% = $35.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,40.70,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,35.62,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88272 at $35.62 (Fee Schedule) = $35.62 (Total Line Payment) at 100% = $35.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,37.76,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88272 at $35.62 (Fee Schedule) = $35.62 (Total Line Payment) at 100% = $35.62... $35.62 at 106% = $37.76 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,40.70,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,199.00,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $199.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,334.32,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $334.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,91.58,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,298.50,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $298.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,366.16,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $366.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,52.91,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,52.91,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,PREVEA HEALTH NETWORK,PREVEA360,52.91,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,52.91,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,254.04,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $254.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,41.11,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,286.56,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $286.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,TRIOLOGY,TRILOGY MEDICAID,37.76,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00385 Proc 88272 at $35.62 (Fee Schedule) = $35.62 (Total Line Payment) at 106% = $37.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,48.84,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.84 from Fee Schedule UHC_98227C for Rev 310 Proc 88272 * Qty 1 = $48.84 at 100% = $48.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,48.84,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.84 from Fee Schedule UHC_98227C for Rev 310 Proc 88272 * Qty 1 = $48.84 at 100% = $48.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,40.70,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,48.84,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.84 from Fee Schedule UHC_98227C for Rev 310 Proc 88272 * Qty 1 = $48.84 at 100% = $48.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,UNITY HEALTH PLAN,UNITY HOSPICE,40.70,,,,,,,35.6200,398.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,286.56,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $286.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,246.76,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $246.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,286.56,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $286.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,286.56,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $286.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS,88272,CPT,310,RC,31000401,CDM,,,,both,,,398.0000,262.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,238.80,,,,,,,35.6200,398.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $398.00 in Billed Charges for Rev 310 Proc 88272 = $238.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,AETNA,AETNA HSHS,659.57,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $659.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,AETNA,AETNA MEDICARE,295.79,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,AETNA,ALL COMMERCIAL AETNA,1021.00,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $1,021.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,ANTHEM,ANTEHM MEDICAID,175.10,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81311 at $175.10 (Fee Schedule) = $175.10 (Total Line Payment) at 100% = $175.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,295.79,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,ANTHEM,ANTHEM POS/HMO,1021.00,,,,,,,175.1000,1021.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,035.27 from Fee Schedule WII28_25 for Rev 310 Proc 81311 Mod TC * Qty 1 = $1,035.27 at 100% = $1,035.27 (Limited to $1,021.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,ANTHEM,ANTHEM PPO,1021.00,,,,,,,175.1000,1021.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,035.27 from Fee Schedule WII28_25 for Rev 310 Proc 81311 Mod TC * Qty 1 = $1,035.27 at 100% = $1,035.27 (Limited to $1,021.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1021.00,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $1,021.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,CENPATICO,ALL MEDICAID CENPATICO,1021.00,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $1,021.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,867.85,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $867.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,CIGNA,ALL COMMERCIAL CIGNA,714.70,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $714.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,COFINITY,COFINITY,1021.00,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $1,021.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,175.10,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81311 at $175.10 (Fee Schedule) = $175.10 (Total Line Payment) at 100% = $175.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,175.10,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81311 at $175.10 (Fee Schedule) = $175.10 (Total Line Payment) at 100% = $175.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,969.95,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $969.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,857.64,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $857.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,724.91,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $724.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,745.33,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $745.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,496.21,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $496.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,867.85,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $867.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HUMANA,HUMANA CHOICE CARE HMO,502.84,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $502.84 from Fee Schedule 005543_170 for Rev 310 Proc 81311 * Qty 1 = $502.84 at 100% = $502.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HUMANA,HUMANA CHOICE CARE PPO,867.85,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $867.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,295.79,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,HUMANA,HUMANA NATIIONAL POS HMO,502.84,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $502.84 from Fee Schedule 005543_170 for Rev 310 Proc 81311 * Qty 1 = $502.84 at 100% = $502.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,745.33,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $745.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1021.00,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $1,021.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,175.10,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81311 at $175.10 (Fee Schedule) = $175.10 (Total Line Payment) at 100% = $175.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,295.79,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,175.10,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81311 at $175.10 (Fee Schedule) = $175.10 (Total Line Payment) at 100% = $175.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,185.61,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81311 at $175.10 (Fee Schedule) = $175.10 (Total Line Payment) at 100% = $175.10... $175.10 at 106% = $185.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,295.79,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,510.50,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $510.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,857.64,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $857.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,665.53,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,765.75,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $765.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,939.32,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $939.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,384.53,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,384.53,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,PREVEA HEALTH NETWORK,PREVEA360,384.53,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,384.53,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,651.70,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $651.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,298.75,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,735.12,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $735.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,TRIOLOGY,TRILOGY MEDICAID,185.61,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81311 at $175.10 (Fee Schedule) = $175.10 (Total Line Payment) at 106% = $185.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,354.95,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $354.95 from Fee Schedule UHC_98227C for Rev 310 Proc 81311 * Qty 1 = $354.95 at 100% = $354.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,354.95,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $354.95 from Fee Schedule UHC_98227C for Rev 310 Proc 81311 * Qty 1 = $354.95 at 100% = $354.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,295.79,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,354.95,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $354.95 from Fee Schedule UHC_98227C for Rev 310 Proc 81311 * Qty 1 = $354.95 at 100% = $354.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,UNITY HEALTH PLAN,UNITY HOSPICE,295.79,,,,,,,175.1000,1021.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,735.12,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $735.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,633.02,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $633.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,735.12,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $735.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,735.12,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $735.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NRAS GENE VARIANTS EXON 2&3,81311,CPT,310,RC,31040107,CDM,,,,both,,,1021.0000,673.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,612.60,,,,,,,175.1000,1021.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,021.00 in Billed Charges for Rev 310 Proc 81311 = $612.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,AETNA,AETNA HSHS,952.20,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $952.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,AETNA,AETNA MEDICARE,274.83,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,AETNA,ALL COMMERCIAL AETNA,1474.00,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,ANTHEM,ANTEHM MEDICAID,219.86,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81404 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,274.83,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,ANTHEM,ANTHEM POS/HMO,961.91,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $961.91 from Fee Schedule WII28_25 for Rev 310 Proc 81404 Mod TC * Qty 1 = $961.91 at 100% = $961.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,ANTHEM,ANTHEM PPO,961.91,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $961.91 from Fee Schedule WII28_25 for Rev 310 Proc 81404 Mod TC * Qty 1 = $961.91 at 100% = $961.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1474.00,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,CENPATICO,ALL MEDICAID CENPATICO,1474.00,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1252.90,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,252.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,CIGNA,ALL COMMERCIAL CIGNA,1031.80,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,031.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,COFINITY,COFINITY,1474.00,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,219.86,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81404 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,219.86,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81404 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1400.30,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,400.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,1238.16,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,238.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1046.54,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,046.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1076.02,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,076.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,716.36,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $716.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1252.90,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,252.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HUMANA,HUMANA CHOICE CARE HMO,467.21,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $467.21 from Fee Schedule 005543_170 for Rev 310 Proc 81404 * Qty 1 = $467.21 at 100% = $467.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HUMANA,HUMANA CHOICE CARE PPO,1252.90,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,252.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,274.83,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,HUMANA,HUMANA NATIIONAL POS HMO,467.21,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $467.21 from Fee Schedule 005543_170 for Rev 310 Proc 81404 * Qty 1 = $467.21 at 100% = $467.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1076.02,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,076.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1474.00,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,219.86,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81404 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,274.83,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,219.86,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81404 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,233.05,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81404 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 100% = $219.86... $219.86 at 106% = $233.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,274.83,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,737.00,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $737.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1238.16,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,238.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,618.37,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1105.50,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,105.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1356.08,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,356.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,357.28,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,357.28,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,PREVEA HEALTH NETWORK,PREVEA360,357.28,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,357.28,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,940.85,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $940.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,277.58,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1061.28,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,061.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,TRIOLOGY,TRILOGY MEDICAID,233.05,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00386 Proc 81404 at $219.86 (Fee Schedule) = $219.86 (Total Line Payment) at 106% = $233.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,329.80,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81404 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,329.80,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81404 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,274.83,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,329.80,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $329.80 from Fee Schedule UHC_98227C for Rev 310 Proc 81404 * Qty 1 = $329.80 at 100% = $329.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,UNITY HEALTH PLAN,UNITY HOSPICE,274.83,,,,,,,219.8600,1474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1061.28,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,061.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,913.88,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $913.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1061.28,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,061.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1061.28,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $1,061.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MOLECULAR PATH PROC LEVEL 5,81404,CPT,310,RC,31040108,CDM,,,,both,,,1474.0000,972.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,884.40,,,,,,,219.8600,1474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,474.00 in Billed Charges for Rev 310 Proc 81404 = $884.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,AETNA,AETNA HSHS,213.18,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $213.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,AETNA,AETNA MEDICARE,36.28,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,AETNA,ALL COMMERCIAL AETNA,330.00,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88108 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,36.28,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,ANTHEM,ANTHEM POS/HMO,140.70,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $140.70 from Fee Schedule WII28_25 for Rev 311 Proc 88108 Mod TC * Qty 1 = $140.70 at 100% = $140.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,ANTHEM,ANTHEM PPO,140.70,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $140.70 from Fee Schedule WII28_25 for Rev 311 Proc 88108 Mod TC * Qty 1 = $140.70 at 100% = $140.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,330.00,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,CENPATICO,ALL MEDICAID CENPATICO,330.00,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,280.50,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $280.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,CIGNA,ALL COMMERCIAL CIGNA,231.00,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,COFINITY,COFINITY,330.00,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88108 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88108 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,313.50,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $313.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,277.20,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $277.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,234.30,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $234.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,240.90,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $240.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,160.38,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $160.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,280.50,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $280.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HUMANA,HUMANA CHOICE CARE HMO,111.93,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.93 from Fee Schedule 005543_170 for Rev 311 Proc 88108 * Qty 1 = $111.93 at 100% = $111.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HUMANA,HUMANA CHOICE CARE PPO,280.50,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $280.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,36.28,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,HUMANA,HUMANA NATIIONAL POS HMO,111.93,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.93 from Fee Schedule 005543_170 for Rev 311 Proc 88108 * Qty 1 = $111.93 at 100% = $111.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,240.90,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $240.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,330.00,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88108 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,36.28,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88108 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88108 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,36.28,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,165.00,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $165.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,277.20,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $277.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,81.63,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,247.50,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,303.60,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $303.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,198.00,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,198.00,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,PREVEA HEALTH NETWORK,PREVEA360,198.00,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,198.00,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,210.64,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $210.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,36.64,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,237.60,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $237.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88108 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,40.75,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.75 from Fee Schedule UHC_98227C for Rev 311 Proc 88108 * Qty 1 = $40.75 at 100% = $40.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,40.75,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.75 from Fee Schedule UHC_98227C for Rev 311 Proc 88108 * Qty 1 = $40.75 at 100% = $40.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,36.28,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,40.75,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $40.75 from Fee Schedule UHC_98227C for Rev 311 Proc 88108 * Qty 1 = $40.75 at 100% = $40.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,UNITY HEALTH PLAN,UNITY HOSPICE,36.28,,,,,,,12.2000,330.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,237.60,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $237.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,204.60,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $204.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,237.60,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $237.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,237.60,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $237.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH CONCENTRATE TECH,88108,CPT,311,RC,31100102,CDM,,,,both,,,330.0000,217.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,198.00,,,,,,,12.2000,330.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $330.00 in Billed Charges for Rev 311 Proc 88108 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,AETNA,AETNA HSHS,39.41,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $39.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,AETNA,AETNA MEDICARE,14.65,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,AETNA,ALL COMMERCIAL AETNA,61.00,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,ANTHEM,ANTEHM MEDICAID,8.42,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88155 at $8.42 (Fee Schedule) = $8.42 (Total Line Payment) at 100% = $8.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.65,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,ANTHEM,ANTHEM POS/HMO,51.28,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.28 from Fee Schedule WII28_25 for Rev 311 Proc 88155 Mod TC * Qty 1 = $51.28 at 100% = $51.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,ANTHEM,ANTHEM PPO,51.28,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.28 from Fee Schedule WII28_25 for Rev 311 Proc 88155 Mod TC * Qty 1 = $51.28 at 100% = $51.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,61.00,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,CENPATICO,ALL MEDICAID CENPATICO,61.00,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,51.85,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $51.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,CIGNA,ALL COMMERCIAL CIGNA,42.70,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $42.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,COFINITY,COFINITY,61.00,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,8.42,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88155 at $8.42 (Fee Schedule) = $8.42 (Total Line Payment) at 100% = $8.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,8.42,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88155 at $8.42 (Fee Schedule) = $8.42 (Total Line Payment) at 100% = $8.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,57.95,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $57.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,51.24,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $51.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,43.31,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $43.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,44.53,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $44.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,29.65,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $29.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,51.85,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $51.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HUMANA,HUMANA CHOICE CARE HMO,24.91,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.91 from Fee Schedule 005543_170 for Rev 311 Proc 88155 * Qty 1 = $24.91 at 100% = $24.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HUMANA,HUMANA CHOICE CARE PPO,51.85,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $51.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,14.65,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,HUMANA,HUMANA NATIIONAL POS HMO,24.91,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.91 from Fee Schedule 005543_170 for Rev 311 Proc 88155 * Qty 1 = $24.91 at 100% = $24.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,44.53,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $44.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,61.00,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,8.42,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88155 at $8.42 (Fee Schedule) = $8.42 (Total Line Payment) at 100% = $8.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.65,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,8.42,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88155 at $8.42 (Fee Schedule) = $8.42 (Total Line Payment) at 100% = $8.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,8.93,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88155 at $8.42 (Fee Schedule) = $8.42 (Total Line Payment) at 100% = $8.42... $8.42 at 106% = $8.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,14.65,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,30.50,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $30.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,51.24,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $51.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,32.96,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,45.75,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $45.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,56.12,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $56.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,19.05,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,19.05,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,PREVEA HEALTH NETWORK,PREVEA360,19.05,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,19.05,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38.94,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $38.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.80,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,43.92,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $43.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,TRIOLOGY,TRILOGY MEDICAID,8.93,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88155 at $8.42 (Fee Schedule) = $8.42 (Total Line Payment) at 106% = $8.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.58,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.58 from Fee Schedule UHC_98227C for Rev 311 Proc 88155 * Qty 1 = $17.58 at 100% = $17.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,17.58,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.58 from Fee Schedule UHC_98227C for Rev 311 Proc 88155 * Qty 1 = $17.58 at 100% = $17.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.65,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,17.58,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.58 from Fee Schedule UHC_98227C for Rev 311 Proc 88155 * Qty 1 = $17.58 at 100% = $17.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,UNITY HEALTH PLAN,UNITY HOSPICE,14.65,,,,,,,8.4200,61.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,43.92,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $43.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37.82,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $37.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,43.92,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $43.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,43.92,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $43.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH MATURATION INDEX,88155,CPT,311,RC,31100109,CDM,,,,both,,,61.0000,40.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,36.60,,,,,,,8.4200,61.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $61.00 in Billed Charges for Rev 311 Proc 88155 = $36.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,AETNA,AETNA HSHS,164.73,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $164.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,AETNA,AETNA MEDICARE,28.09,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,AETNA,ALL COMMERCIAL AETNA,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88160 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.09,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,ANTHEM,ANTHEM POS/HMO,154.39,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $154.39 from Fee Schedule WII28_25 for Rev 311 Proc 88160 Mod TC * Qty 1 = $154.39 at 100% = $154.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,ANTHEM,ANTHEM PPO,154.39,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $154.39 from Fee Schedule WII28_25 for Rev 311 Proc 88160 Mod TC * Qty 1 = $154.39 at 100% = $154.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,CENPATICO,ALL MEDICAID CENPATICO,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,216.75,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $216.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,CIGNA,ALL COMMERCIAL CIGNA,178.50,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $178.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,COFINITY,COFINITY,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88160 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88160 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,242.25,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $242.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,214.20,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,181.05,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $181.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,186.15,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $186.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,123.93,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $123.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,216.75,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $216.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HUMANA,HUMANA CHOICE CARE HMO,129.59,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $129.59 from Fee Schedule 005543_170 for Rev 311 Proc 88160 * Qty 1 = $129.59 at 100% = $129.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HUMANA,HUMANA CHOICE CARE PPO,216.75,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $216.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,28.09,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,HUMANA,HUMANA NATIIONAL POS HMO,129.59,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $129.59 from Fee Schedule 005543_170 for Rev 311 Proc 88160 * Qty 1 = $129.59 at 100% = $129.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,186.15,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $186.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,255.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $255.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88160 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.09,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88160 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88160 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,28.09,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,127.50,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $127.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,214.20,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $214.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,63.21,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,191.25,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,234.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $234.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,153.00,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,153.00,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,PREVEA HEALTH NETWORK,PREVEA360,153.00,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,153.00,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,162.77,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $162.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,28.37,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,183.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88160 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,29.95,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.95 from Fee Schedule UHC_98227C for Rev 311 Proc 88160 * Qty 1 = $29.95 at 100% = $29.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,29.95,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.95 from Fee Schedule UHC_98227C for Rev 311 Proc 88160 * Qty 1 = $29.95 at 100% = $29.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.09,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,29.95,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.95 from Fee Schedule UHC_98227C for Rev 311 Proc 88160 * Qty 1 = $29.95 at 100% = $29.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,UNITY HEALTH PLAN,UNITY HOSPICE,28.09,,,,,,,12.2000,255.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,183.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,158.10,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $158.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,183.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,183.60,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,311,RC,31100110,CDM,,,,both,,,255.0000,168.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,153.00,,,,,,,12.2000,255.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $255.00 in Billed Charges for Rev 311 Proc 88160 = $153.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,AETNA,AETNA HSHS,242.90,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $242.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,AETNA,AETNA MEDICARE,50.62,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,AETNA,ALL COMMERCIAL AETNA,376.00,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $376.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88162 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,50.62,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,ANTHEM,ANTHEM POS/HMO,249.45,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $249.45 from Fee Schedule WII28_25 for Rev 311 Proc 88162 Mod TC * Qty 1 = $249.45 at 100% = $249.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,ANTHEM,ANTHEM PPO,249.45,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $249.45 from Fee Schedule WII28_25 for Rev 311 Proc 88162 Mod TC * Qty 1 = $249.45 at 100% = $249.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,376.00,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $376.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,CENPATICO,ALL MEDICAID CENPATICO,376.00,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $376.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,319.60,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $319.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,CIGNA,ALL COMMERCIAL CIGNA,263.20,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $263.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,COFINITY,COFINITY,376.00,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $376.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88162 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88162 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,357.20,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $357.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,315.84,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $315.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,266.96,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $266.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,274.48,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $274.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,182.74,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $182.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,319.60,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $319.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HUMANA,HUMANA CHOICE CARE HMO,209.47,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $209.47 from Fee Schedule 005543_170 for Rev 311 Proc 88162 * Qty 1 = $209.47 at 100% = $209.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HUMANA,HUMANA CHOICE CARE PPO,319.60,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $319.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,50.62,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,HUMANA,HUMANA NATIIONAL POS HMO,209.47,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $209.47 from Fee Schedule 005543_170 for Rev 311 Proc 88162 * Qty 1 = $209.47 at 100% = $209.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,274.48,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $274.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,376.00,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $376.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88162 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,50.62,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88162 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88162 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,50.62,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,188.00,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,315.84,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $315.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,113.89,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,282.00,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,345.92,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $345.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,225.60,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,225.60,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,PREVEA HEALTH NETWORK,PREVEA360,225.60,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,225.60,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,240.00,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $240.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.13,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,270.72,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $270.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88162 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.17,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88162 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,60.17,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88162 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,50.62,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,60.17,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88162 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,UNITY HEALTH PLAN,UNITY HOSPICE,50.62,,,,,,,12.2000,376.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,270.72,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $270.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,233.12,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $233.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,270.72,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $270.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,270.72,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $270.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SMEAR OVER 5 SLIDES,88162,CPT,311,RC,31100112,CDM,,,,both,,,376.0000,248.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,225.60,,,,,,,12.2000,376.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $376.00 in Billed Charges for Rev 311 Proc 88162 = $225.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,AETNA,AETNA HSHS,60.08,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $60.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,AETNA,AETNA MEDICARE,18.54,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,AETNA,ALL COMMERCIAL AETNA,93.00,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,ANTHEM,ANTEHM MEDICAID,14.86,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88164 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,18.54,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,ANTHEM,ANTHEM POS/HMO,55.72,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.72 from Fee Schedule WII28_25 for Rev 311 Proc 88164 Mod TC * Qty 1 = $55.72 at 100% = $55.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,ANTHEM,ANTHEM PPO,55.72,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.72 from Fee Schedule WII28_25 for Rev 311 Proc 88164 Mod TC * Qty 1 = $55.72 at 100% = $55.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,93.00,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,CENPATICO,ALL MEDICAID CENPATICO,93.00,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.05,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,CIGNA,ALL COMMERCIAL CIGNA,65.10,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $65.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,COFINITY,COFINITY,93.00,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,14.86,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88164 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,14.86,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88164 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,88.35,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $88.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,78.12,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $78.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.03,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $66.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,67.89,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $67.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,45.20,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $45.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.05,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HUMANA,HUMANA CHOICE CARE HMO,30.19,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.19 from Fee Schedule 005543_170 for Rev 311 Proc 88164 * Qty 1 = $30.19 at 100% = $30.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HUMANA,HUMANA CHOICE CARE PPO,79.05,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HUMANA,HUMANA MEDICARE ADVANTAGE,18.54,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,HUMANA,HUMANA NATIIONAL POS HMO,30.19,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.19 from Fee Schedule 005543_170 for Rev 311 Proc 88164 * Qty 1 = $30.19 at 100% = $30.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,67.89,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $67.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,93.00,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $93.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,14.86,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88164 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,18.54,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,14.86,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88164 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,MOLINA HEALTHCARE,MOLINA MEDICAID,15.75,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88164 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 100% = $14.86... $14.86 at 106% = $15.75 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,MOLINA HEALTHCARE,MOLINA MEDICARE,18.54,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.50,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $46.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.12,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $78.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,NAPHCARE,ALL COMMERICAL NAPHCARE,41.72,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,69.75,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $69.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,85.56,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $85.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,24.10,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,24.10,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,PREVEA HEALTH NETWORK,PREVEA360,24.10,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,24.10,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,59.36,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $59.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,18.73,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,66.96,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,TRIOLOGY,TRILOGY MEDICAID,15.75,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00392 Proc 88164 at $14.86 (Fee Schedule) = $14.86 (Total Line Payment) at 106% = $15.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.77,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.77 from Fee Schedule UHC_98227C for Rev 311 Proc 88164 * Qty 1 = $20.77 at 100% = $20.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,UNITED HEALTHCARE,UHC ONEIDA NATION,20.77,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.77 from Fee Schedule UHC_98227C for Rev 311 Proc 88164 * Qty 1 = $20.77 at 100% = $20.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,18.54,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,UNITED HEALTHCARE,UNITED HEALTHCARE,20.77,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.77 from Fee Schedule UHC_98227C for Rev 311 Proc 88164 * Qty 1 = $20.77 at 100% = $20.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,UNITY HEALTH PLAN,UNITY HOSPICE,18.54,,,,,,,14.8600,93.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,66.96,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,57.66,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $57.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,66.96,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,66.96,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $66.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CYTOPATH SCR BETHESDA,88164,CPT,311,RC,31100113,CDM,,,,both,,,93.0000,61.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.80,,,,,,,14.8600,93.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.00 in Billed Charges for Rev 311 Proc 88164 = $55.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,AETNA,AETNA HSHS,350.13,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $350.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,AETNA,AETNA MEDICARE,50.62,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,AETNA,ALL COMMERCIAL AETNA,542.00,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,ANTHEM,ANTEHM MEDICAID,38.30,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 88173 at $125.60 (Base Rate) * 0.3049 (Relative Weight) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,50.62,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,ANTHEM,ANTHEM POS/HMO,291.24,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $291.24 from Fee Schedule WII28_25 for Rev 311 Proc 88173 Mod TC * Qty 1 = $291.24 at 100% = $291.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,ANTHEM,ANTHEM PPO,291.24,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $291.24 from Fee Schedule WII28_25 for Rev 311 Proc 88173 Mod TC * Qty 1 = $291.24 at 100% = $291.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,542.00,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,CENPATICO,ALL MEDICAID CENPATICO,542.00,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,460.70,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $460.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,CIGNA,ALL COMMERCIAL CIGNA,379.40,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $379.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,COFINITY,COFINITY,542.00,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,38.30,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 88173 at $125.60 (Base Rate) * 0.3049 (Relative Weight) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,38.30,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 88173 at $125.60 (Base Rate) * 0.3049 (Relative Weight) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,514.90,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $514.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,455.28,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $455.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,384.82,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $384.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,395.66,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $395.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,263.41,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $263.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,460.70,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $460.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HUMANA,HUMANA CHOICE CARE HMO,273.48,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $273.48 from Fee Schedule 005543_170 for Rev 311 Proc 88173 * Qty 1 = $273.48 at 100% = $273.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HUMANA,HUMANA CHOICE CARE PPO,460.70,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $460.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,50.62,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,HUMANA,HUMANA NATIIONAL POS HMO,273.48,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $273.48 from Fee Schedule 005543_170 for Rev 311 Proc 88173 * Qty 1 = $273.48 at 100% = $273.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,395.66,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $395.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,542.00,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,38.30,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 88173 at $125.60 (Base Rate) * 0.3049 (Relative Weight) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,50.62,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,38.30,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 88173 at $125.60 (Base Rate) * 0.3049 (Relative Weight) = $38.30 (Total Line Payment) at 100% = $38.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,40.60,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 88173 at $125.60 (Base Rate) * 0.3049 (Relative Weight) = $38.30 (Total Line Payment) at 100% = $38.30... $38.30 at 106% = $40.60 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,50.62,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,271.00,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,455.28,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $455.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,113.89,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,406.50,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $406.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,498.64,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $498.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,325.20,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,325.20,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,PREVEA HEALTH NETWORK,PREVEA360,325.20,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,325.20,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,345.96,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $345.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.13,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,390.24,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $390.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,TRIOLOGY,TRILOGY MEDICAID,40.59,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00158 Proc 88173 at $125.60 (Base Rate) * 0.3049 (Relative Weight) = $38.30 (Total Line Payment) at 106% = $40.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.17,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88173 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,60.17,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88173 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,50.62,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,60.17,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88173 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,UNITY HEALTH PLAN,UNITY HOSPICE,50.62,,,,,,,38.3000,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,390.24,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $390.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,336.04,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $336.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,390.24,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $390.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,390.24,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $390.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE INTERP,88173,CPT,311,RC,31100115,CDM,,,,both,,,542.0000,357.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,325.20,,,,,,,38.3000,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $542.00 in Billed Charges for Rev 311 Proc 88173 = $325.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,AETNA,AETNA HSHS,87.86,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $87.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,AETNA,ALL COMMERCIAL AETNA,136.00,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88177 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTHEM POS/HMO,23.96,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.96 from Fee Schedule WII28_25 for Rev 311 Proc 88177 Mod TC * Qty 1 = $23.96 at 100% = $23.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,ANTHEM,ANTHEM PPO,23.96,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.96 from Fee Schedule WII28_25 for Rev 311 Proc 88177 Mod TC * Qty 1 = $23.96 at 100% = $23.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,136.00,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,CENPATICO,ALL MEDICAID CENPATICO,136.00,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,115.60,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,CIGNA,ALL COMMERCIAL CIGNA,95.20,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $95.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,COFINITY,COFINITY,136.00,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88177 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88177 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,129.20,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $129.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,114.24,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $114.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,96.56,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $96.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,99.28,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $99.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,66.10,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $66.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,115.60,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA CHOICE CARE HMO,48.33,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.33 from Fee Schedule 005543_170 for Rev 311 Proc 88177 * Qty 1 = $48.33 at 100% = $48.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA CHOICE CARE PPO,115.60,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $115.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,HUMANA,HUMANA NATIIONAL POS HMO,48.33,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.33 from Fee Schedule 005543_170 for Rev 311 Proc 88177 * Qty 1 = $48.33 at 100% = $48.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,99.28,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $99.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,136.00,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $136.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88177 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88177 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88177 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,68.00,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $68.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,114.24,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $114.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,102.00,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,125.12,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $125.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,81.60,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,81.60,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA360,81.60,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,81.60,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,86.81,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $86.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,97.92,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88177 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.76,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.76 from Fee Schedule UHC_98227C for Rev 311 Proc 88177 * Qty 1 = $9.76 at 100% = $9.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,9.76,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.76 from Fee Schedule UHC_98227C for Rev 311 Proc 88177 * Qty 1 = $9.76 at 100% = $9.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,9.76,,,,,,,9.7600,136.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.76 from Fee Schedule UHC_98227C for Rev 311 Proc 88177 * Qty 1 = $9.76 at 100% = $9.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,97.92,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,84.32,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $84.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,97.92,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,97.92,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $97.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FINE NEEDLE EVAL ADDL,88177,CPT,311,RC,31100116,CDM,,,,both,,,136.0000,89.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,81.60,,,,,,,9.7600,136.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $136.00 in Billed Charges for Rev 311 Proc 88177 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,AETNA,AETNA HSHS,534.89,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $534.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,AETNA,AETNA MEDICARE,50.62,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,AETNA,ALL COMMERCIAL AETNA,828.00,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,ANTHEM,ANTEHM MEDICAID,12.20,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,50.62,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,ANTHEM,ANTHEM POS/HMO,361.98,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $361.98 from Fee Schedule WII28_25 for Rev 311 Proc 88182 Mod TC * Qty 1 = $361.98 at 100% = $361.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,ANTHEM,ANTHEM PPO,361.98,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $361.98 from Fee Schedule WII28_25 for Rev 311 Proc 88182 Mod TC * Qty 1 = $361.98 at 100% = $361.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,828.00,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,CENPATICO,ALL MEDICAID CENPATICO,828.00,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,703.80,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $703.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,CIGNA,ALL COMMERCIAL CIGNA,579.60,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,COFINITY,COFINITY,828.00,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.20,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.20,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,786.60,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $786.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,695.52,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $695.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,587.88,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $587.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,604.44,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $604.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,402.41,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $402.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,703.80,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $703.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HUMANA,HUMANA CHOICE CARE HMO,271.07,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $271.07 from Fee Schedule 005543_170 for Rev 311 Proc 88182 * Qty 1 = $271.07 at 100% = $271.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HUMANA,HUMANA CHOICE CARE PPO,703.80,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $703.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HUMANA,HUMANA MEDICARE ADVANTAGE,50.62,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,HUMANA,HUMANA NATIIONAL POS HMO,271.07,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $271.07 from Fee Schedule 005543_170 for Rev 311 Proc 88182 * Qty 1 = $271.07 at 100% = $271.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,604.44,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $604.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,828.00,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.20,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,50.62,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.20,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,MOLINA HEALTHCARE,MOLINA MEDICAID,12.93,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 100% = $12.20... $12.20 at 106% = $12.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,MOLINA HEALTHCARE,MOLINA MEDICARE,50.62,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,414.00,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,695.52,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $695.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,NAPHCARE,ALL COMMERICAL NAPHCARE,113.89,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,621.00,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,761.76,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $761.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,496.80,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,496.80,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,PREVEA HEALTH NETWORK,PREVEA360,496.80,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,496.80,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,528.51,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $528.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,51.13,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,596.16,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $596.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,TRIOLOGY,TRILOGY MEDICAID,12.93,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00391 Proc 88182 at $125.60 (Base Rate) * 0.0971 (Relative Weight) = $12.20 (Total Line Payment) at 106% = $12.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.17,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88182 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,60.17,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88182 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,50.62,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,60.17,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.17 from Fee Schedule UHC_98227C for Rev 311 Proc 88182 * Qty 1 = $60.17 at 100% = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,UNITY HEALTH PLAN,UNITY HOSPICE,50.62,,,,,,,12.2000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,596.16,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $596.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,513.36,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $513.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,596.16,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $596.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,596.16,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $596.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC T&B CELL QN FLOWCYT (DNA CELL CYCLE),88182,CPT,311,RC,31100118,CDM,,,,both,,,828.0000,546.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,496.80,,,,,,,12.2000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $828.00 in Billed Charges for Rev 311 Proc 88182 = $496.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,AETNA,AETNA HSHS,407.63,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $407.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,AETNA,AETNA MEDICARE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,AETNA,ALL COMMERCIAL AETNA,631.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $631.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,ANTHEM,ANTEHM MEDICAID,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,ANTHEM,ANTHEM POS/HMO,226.63,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $226.63 from Fee Schedule WII28_25 for Rev 311 Proc 88184 Mod TC * Qty 1 = $226.63 at 100% = $226.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,ANTHEM,ANTHEM PPO,226.63,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $226.63 from Fee Schedule WII28_25 for Rev 311 Proc 88184 Mod TC * Qty 1 = $226.63 at 100% = $226.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,631.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $631.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,CENPATICO,ALL MEDICAID CENPATICO,631.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $631.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,536.35,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $536.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,CIGNA,ALL COMMERCIAL CIGNA,441.70,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $441.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,COFINITY,COFINITY,631.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $631.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,599.45,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $599.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,530.04,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $530.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,448.01,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $448.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,460.63,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $460.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,306.67,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $306.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,536.35,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $536.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HUMANA,HUMANA CHOICE CARE HMO,126.02,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $126.02 from Fee Schedule 005543_170 for Rev 311 Proc 88184 * Qty 1 = $126.02 at 100% = $126.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HUMANA,HUMANA CHOICE CARE PPO,536.35,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $536.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,HUMANA,HUMANA NATIIONAL POS HMO,126.02,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $126.02 from Fee Schedule 005543_170 for Rev 311 Proc 88184 * Qty 1 = $126.02 at 100% = $126.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,460.63,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $460.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,631.00,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $631.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,67.75,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,71.82,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 100% = $67.75... $67.75 at 106% = $71.82 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,315.50,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $315.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,530.04,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $530.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,783.38,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,473.25,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $473.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,580.52,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $580.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,378.60,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,378.60,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,PREVEA HEALTH NETWORK,PREVEA360,378.60,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,378.60,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,402.77,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $402.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,351.65,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,454.32,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,TRIOLOGY,TRILOGY MEDICAID,71.81,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88184 at $125.60 (Base Rate) * 0.5394 (Relative Weight) = $67.75 (Total Line Payment) at 106% = $71.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,388.93,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 311 Proc 88184 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,388.93,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 311 Proc 88184 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,388.93,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $388.93 from Fee Schedule UHC_98227C for Rev 311 Proc 88184 * Qty 1 = $388.93 at 100% = $388.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,UNITY HEALTH PLAN,UNITY HOSPICE,348.17,,,,,,,67.7500,783.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,454.32,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,391.22,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $391.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,454.32,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,454.32,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,311,RC,31100121,CDM,,,,both,,,631.0000,416.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,378.60,,,,,,,67.7500,783.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $631.00 in Billed Charges for Rev 311 Proc 88184 = $378.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,AETNA,AETNA HSHS,441.22,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $441.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,AETNA,AETNA MEDICARE,116.49,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,AETNA,ALL COMMERCIAL AETNA,683.00,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $683.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,ANTHEM,ANTEHM MEDICAID,70.04,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88230 at $70.04 (Fee Schedule) = $70.04 (Total Line Payment) at 100% = $70.04. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,116.49,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,ANTHEM,ANTHEM POS/HMO,407.72,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $407.72 from Fee Schedule WII28_25 for Rev 311 Proc 88230 Mod TC * Qty 1 = $407.72 at 100% = $407.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,ANTHEM,ANTHEM PPO,407.72,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $407.72 from Fee Schedule WII28_25 for Rev 311 Proc 88230 Mod TC * Qty 1 = $407.72 at 100% = $407.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,683.00,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $683.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,CENPATICO,ALL MEDICAID CENPATICO,683.00,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $683.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,580.55,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $580.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,CIGNA,ALL COMMERCIAL CIGNA,478.10,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $478.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,COFINITY,COFINITY,683.00,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $683.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,70.04,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88230 at $70.04 (Fee Schedule) = $70.04 (Total Line Payment) at 100% = $70.04. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,70.04,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88230 at $70.04 (Fee Schedule) = $70.04 (Total Line Payment) at 100% = $70.04. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,648.85,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $648.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,573.72,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $573.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,484.93,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $484.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,498.59,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $498.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,331.94,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $331.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,580.55,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $580.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HUMANA,HUMANA CHOICE CARE HMO,198.03,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $198.03 from Fee Schedule 005543_170 for Rev 311 Proc 88230 * Qty 1 = $198.03 at 100% = $198.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HUMANA,HUMANA CHOICE CARE PPO,580.55,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $580.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,116.49,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,HUMANA,HUMANA NATIIONAL POS HMO,198.03,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $198.03 from Fee Schedule 005543_170 for Rev 311 Proc 88230 * Qty 1 = $198.03 at 100% = $198.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,498.59,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $498.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,683.00,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $683.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,70.04,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88230 at $70.04 (Fee Schedule) = $70.04 (Total Line Payment) at 100% = $70.04. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,116.49,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,70.04,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88230 at $70.04 (Fee Schedule) = $70.04 (Total Line Payment) at 100% = $70.04. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,74.24,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88230 at $70.04 (Fee Schedule) = $70.04 (Total Line Payment) at 100% = $70.04... $70.04 at 106% = $74.24 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,116.49,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,341.50,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $341.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,573.72,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $573.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,262.10,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,512.25,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $512.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,628.36,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $628.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,151.44,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,151.44,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,PREVEA HEALTH NETWORK,PREVEA360,151.44,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,151.44,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,435.96,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $435.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,117.65,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,491.76,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $491.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,TRIOLOGY,TRILOGY MEDICAID,74.24,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00308 Proc 88230 at $70.04 (Fee Schedule) = $70.04 (Total Line Payment) at 106% = $74.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,139.79,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $139.79 from Fee Schedule UHC_98227C for Rev 311 Proc 88230 * Qty 1 = $139.79 at 100% = $139.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,139.79,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $139.79 from Fee Schedule UHC_98227C for Rev 311 Proc 88230 * Qty 1 = $139.79 at 100% = $139.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,116.49,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,139.79,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $139.79 from Fee Schedule UHC_98227C for Rev 311 Proc 88230 * Qty 1 = $139.79 at 100% = $139.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,UNITY HEALTH PLAN,UNITY HOSPICE,116.49,,,,,,,70.0400,683.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,491.76,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $491.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,423.46,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $423.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,491.76,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $491.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,491.76,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $491.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TISSUE CLT NONNEO (CHROMO),88230,CPT,311,RC,31100131,CDM,,,,both,,,683.0000,450.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,409.80,,,,,,,70.0400,683.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $683.00 in Billed Charges for Rev 311 Proc 88230 = $409.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,AETNA,AETNA HSHS,2153.76,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,153.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,AETNA,ALL COMMERCIAL AETNA,3334.00,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $3,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,ANTHEM,ANTEHM MEDICAID,821.51,,,,,,,821.5100,3334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31633 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,ANTHEM,ANTHEM POS/HMO,3334.00,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $3,334.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,334.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,ANTHEM,ANTHEM PPO,3334.00,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $3,334.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,334.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3334.00,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $3,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,CENPATICO,ALL MEDICAID CENPATICO,3334.00,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $3,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2833.90,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,833.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,CIGNA,ALL COMMERCIAL CIGNA,2333.80,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,333.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,COFINITY,COFINITY,3334.00,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $3,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,821.51,,,,,,,821.5100,3334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31633 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,821.51,,,,,,,821.5100,3334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31633 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3167.30,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $3,167.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,2800.56,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,800.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2367.14,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,367.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2433.82,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,433.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,1620.32,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $1,620.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2833.90,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,833.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,HUMANA,HUMANA CHOICE CARE HMO,3334.00,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $3,334.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,334.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,HUMANA,HUMANA CHOICE CARE PPO,2833.90,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,833.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,HUMANA,HUMANA NATIIONAL POS HMO,3334.00,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $3,334.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,334.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2433.82,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,433.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3334.00,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $3,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,821.51,,,,,,,821.5100,3334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31633 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,821.51,,,,,,,821.5100,3334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31633 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,870.80,,,,,,,821.5100,3334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31633 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51... $821.51 at 106% = $870.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1667.00,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $1,667.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2800.56,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,800.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2500.50,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,500.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3067.28,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $3,067.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2048.23,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2048.23,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,PREVEA HEALTH NETWORK,PREVEA360,2048.23,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2048.23,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2128.09,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,128.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2400.48,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,400.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,TRIOLOGY,TRILOGY MEDICAID,870.80,,,,,,,821.5100,3334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31633 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 106% = $870.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2153.10,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,2153.10,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,2153.10,,,,,,,821.5100,3334.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31633 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2400.48,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,400.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2067.08,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,067.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2400.48,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,400.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2400.48,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,400.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE ADD W ION,31633,CPT,360,RC,36000804,CDM,,,,both,,,3334.0000,2200.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2000.40,,,,,,,821.5100,3334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,334.00 in Billed Charges for Rev 360 Proc 31633 = $2,000.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,AETNA,AETNA HSHS,3384.39,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,384.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,AETNA,AETNA MEDICARE,3621.46,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,AETNA,ALL COMMERCIAL AETNA,5239.00,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $5,239.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,ANTHEM,ANTEHM MEDICAID,1673.77,,,,,,,1673.7700,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31653 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3621.46,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,ANTHEM,ANTHEM POS/HMO,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total (Limited to $5,239.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,239.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,ANTHEM,ANTHEM PPO,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total (Limited to $5,239.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,239.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5239.00,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $5,239.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,CENPATICO,ALL MEDICAID CENPATICO,5239.00,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $5,239.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4453.15,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $4,453.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,CIGNA,ALL COMMERCIAL CIGNA,3667.30,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,667.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,COFINITY,COFINITY,5239.00,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $5,239.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1673.77,,,,,,,1673.7700,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31653 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1673.77,,,,,,,1673.7700,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31653 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4977.05,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $4,977.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,4400.76,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $4,400.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3719.69,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,719.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3824.47,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,824.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,2546.15,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $2,546.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4453.15,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $4,453.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HUMANA,HUMANA CHOICE CARE HMO,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $5,239.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,239.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HUMANA,HUMANA CHOICE CARE PPO,4453.15,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $4,453.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,3621.46,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,HUMANA,HUMANA NATIIONAL POS HMO,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $5,239.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,239.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3824.47,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,824.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,5239.00,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $5,239.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1673.77,,,,,,,1673.7700,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31653 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3621.46,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1673.77,,,,,,,1673.7700,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31653 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,1774.20,,,,,,,1673.7700,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31653 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 100% = $1,673.77... $1,673.77 at 106% = $1,774.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,3621.46,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2619.50,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $2,619.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4400.76,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $4,400.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,8148.29,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3929.25,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,929.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4819.88,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $4,819.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total (Service Line reduced to $5,239.00, claim capped at $5,239.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total (Service Line reduced to $5,239.00, claim capped at $5,239.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,PREVEA HEALTH NETWORK,PREVEA360,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total (Service Line reduced to $5,239.00, claim capped at $5,239.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total (Service Line reduced to $5,239.00, claim capped at $5,239.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3344.05,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,344.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3657.67,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3772.08,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,772.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,TRIOLOGY,TRILOGY MEDICAID,1774.20,,,,,,,1673.7700,8148.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00071 Proc 31653 at $125.60 (Base Rate) * 13.3262 (Relative Weight) = $1,673.77 (Total Line Payment) at 106% = $1,774.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $5,239.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,239.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $5,239.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,239.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3621.46,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,5239.00,,,,,,,1673.7700,8148.2900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 31653 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $5,239.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,239.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,UNITY HEALTH PLAN,UNITY HOSPICE,3621.46,,,,,,,1673.7700,8148.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3772.08,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,772.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3248.18,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,248.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3772.08,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,772.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3772.08,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,772.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCH RIGID/FLEX EBUS 3 OR MORE NODES W ION,31653,CPT,360,RC,36000805,CDM,,,,both,,,5239.0000,3457.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3143.40,,,,,,,1673.7700,8148.2900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,239.00 in Billed Charges for Rev 360 Proc 31653 = $3,143.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,AETNA,AETNA HSHS,4328.85,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,328.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,AETNA,AETNA MEDICARE,3803.19,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,AETNA,ALL COMMERCIAL AETNA,6701.00,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $6,701.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,ANTHEM,ANTEHM MEDICAID,1491.15,,,,,,,1491.1500,8557.1700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00021 Proc 19328 at $125.60 (Base Rate) * 11.8722 (Relative Weight) = $1,491.15 (Total Line Payment) at 100% = $1,491.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3803.19,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,ANTHEM,ANTHEM POS/HMO,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total (Limited to $6,701.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,701.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,ANTHEM,ANTHEM PPO,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total (Limited to $6,701.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,701.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6701.00,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $6,701.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,CENPATICO,ALL MEDICAID CENPATICO,6701.00,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $6,701.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5695.85,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $5,695.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,CIGNA,ALL COMMERCIAL CIGNA,4690.70,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,690.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,COFINITY,COFINITY,6701.00,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $6,701.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1491.15,,,,,,,1491.1500,8557.1700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00021 Proc 19328 at $125.60 (Base Rate) * 11.8722 (Relative Weight) = $1,491.15 (Total Line Payment) at 100% = $1,491.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1491.15,,,,,,,1491.1500,8557.1700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00021 Proc 19328 at $125.60 (Base Rate) * 11.8722 (Relative Weight) = $1,491.15 (Total Line Payment) at 100% = $1,491.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6365.95,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $6,365.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,5628.84,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $5,628.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4757.71,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,757.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4891.73,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,891.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,3256.69,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $3,256.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5695.85,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $5,695.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HUMANA,HUMANA CHOICE CARE HMO,3061.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HUMANA,HUMANA CHOICE CARE PPO,5695.85,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $5,695.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,3803.19,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,HUMANA,HUMANA NATIIONAL POS HMO,3061.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4891.73,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,891.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,6701.00,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $6,701.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1491.15,,,,,,,1491.1500,8557.1700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00021 Proc 19328 at $125.60 (Base Rate) * 11.8722 (Relative Weight) = $1,491.15 (Total Line Payment) at 100% = $1,491.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3803.19,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1491.15,,,,,,,1491.1500,8557.1700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00021 Proc 19328 at $125.60 (Base Rate) * 11.8722 (Relative Weight) = $1,491.15 (Total Line Payment) at 100% = $1,491.15. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,1580.62,,,,,,,1491.1500,8557.1700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00021 Proc 19328 at $125.60 (Base Rate) * 11.8722 (Relative Weight) = $1,491.15 (Total Line Payment) at 100% = $1,491.15... $1,491.15 at 106% = $1,580.62 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,3803.19,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3350.50,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $3,350.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5628.84,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $5,628.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,8557.17,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5025.75,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $5,025.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6164.92,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $6,164.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $6,701.00, claim capped at $6,701.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $6,701.00, claim capped at $6,701.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,PREVEA HEALTH NETWORK,PREVEA360,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $6,701.00, claim capped at $6,701.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total (Service Line reduced to $6,701.00, claim capped at $6,701.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4277.25,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,277.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3841.22,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4824.72,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,824.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,TRIOLOGY,TRILOGY MEDICAID,1580.62,,,,,,,1491.1500,8557.1700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00021 Proc 19328 at $125.60 (Base Rate) * 11.8722 (Relative Weight) = $1,491.15 (Total Line Payment) at 106% = $1,580.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $6,701.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,701.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $6,701.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,701.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3803.19,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,6701.00,,,,,,,1491.1500,8557.1700,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 19328 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total (Limited to $6,701.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,701.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,UNITY HEALTH PLAN,UNITY HOSPICE,3803.19,,,,,,,1491.1500,8557.1700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4824.72,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,824.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4154.62,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,154.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4824.72,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,824.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4824.72,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,824.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BREAST IMPLANT REMOVAL,19328,CPT,360,RC,36030059,CDM,,,,both,,,6701.0000,4422.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4020.60,,,,,,,1491.1500,8557.1700,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,701.00 in Billed Charges for Rev 360 Proc 19328 = $4,020.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,AETNA,AETNA HSHS,678.30,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,050.00 in Billed Charges for Rev 360 = $678.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,AETNA,ALL COMMERCIAL AETNA,1050.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,050.00 in Billed Charges for Rev 360 = $1,050.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1050.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,050.00 in Billed Charges for Rev 360 = $1,050.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,CENPATICO,ALL MEDICAID CENPATICO,1050.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,050.00 in Billed Charges for Rev 360 = $1,050.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,892.50,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,050.00 in Billed Charges for Rev 360 = $892.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,CIGNA,ALL COMMERCIAL CIGNA,735.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,050.00 in Billed Charges for Rev 360 = $735.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,COFINITY,COFINITY,1050.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,050.00 in Billed Charges for Rev 360 = $1,050.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,997.50,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,050.00 in Billed Charges for Rev 360 = $997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,882.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,050.00 in Billed Charges for Rev 360 = $882.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,745.50,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,050.00 in Billed Charges for Rev 360 = $745.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,766.50,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,050.00 in Billed Charges for Rev 360 = $766.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,510.30,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,050.00 in Billed Charges for Rev 360 = $510.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,892.50,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,050.00 in Billed Charges for Rev 360 = $892.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,HUMANA,HUMANA CHOICE CARE PPO,892.50,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,050.00 in Billed Charges for Rev 360 = $892.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,766.50,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,050.00 in Billed Charges for Rev 360 = $766.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1050.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,050.00 in Billed Charges for Rev 360 = $1,050.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,525.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,050.00 in Billed Charges for Rev 360 = $525.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,882.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,050.00 in Billed Charges for Rev 360 = $882.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,787.50,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,050.00 in Billed Charges for Rev 360 = $787.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,966.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,050.00 in Billed Charges for Rev 360 = $966.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,630.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,050.00 in Billed Charges for Rev 360 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,630.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,050.00 in Billed Charges for Rev 360 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,PREVEA HEALTH NETWORK,PREVEA360,630.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,050.00 in Billed Charges for Rev 360 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,630.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,050.00 in Billed Charges for Rev 360 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,670.22,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,050.00 in Billed Charges for Rev 360 = $670.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,756.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,050.00 in Billed Charges for Rev 360 = $756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,756.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,050.00 in Billed Charges for Rev 360 = $756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,651.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,050.00 in Billed Charges for Rev 360 = $651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,756.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,050.00 in Billed Charges for Rev 360 = $756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,756.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,050.00 in Billed Charges for Rev 360 = $756.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RADIATION ONC TRMT PKG HOSPICE ASC,360,RC,36030078,CDM,,,,,,both,,,1050.0000,693.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,630.00,,,,,,,510.3000,1050.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,050.00 in Billed Charges for Rev 360 = $630.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,AETNA,AETNA HSHS,1453.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,250.00 in Billed Charges for Rev 360 = $1,453.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,AETNA,ALL COMMERCIAL AETNA,2250.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,250.00 in Billed Charges for Rev 360 = $2,250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2250.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,250.00 in Billed Charges for Rev 360 = $2,250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,CENPATICO,ALL MEDICAID CENPATICO,2250.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,250.00 in Billed Charges for Rev 360 = $2,250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1912.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,250.00 in Billed Charges for Rev 360 = $1,912.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,CIGNA,ALL COMMERCIAL CIGNA,1575.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,250.00 in Billed Charges for Rev 360 = $1,575.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,COFINITY,COFINITY,2250.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,250.00 in Billed Charges for Rev 360 = $2,250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2137.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,250.00 in Billed Charges for Rev 360 = $2,137.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,1890.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,250.00 in Billed Charges for Rev 360 = $1,890.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1597.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,250.00 in Billed Charges for Rev 360 = $1,597.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1642.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,250.00 in Billed Charges for Rev 360 = $1,642.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,1093.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,250.00 in Billed Charges for Rev 360 = $1,093.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1912.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,250.00 in Billed Charges for Rev 360 = $1,912.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,HUMANA,HUMANA CHOICE CARE PPO,1912.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,250.00 in Billed Charges for Rev 360 = $1,912.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1642.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,250.00 in Billed Charges for Rev 360 = $1,642.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2250.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,250.00 in Billed Charges for Rev 360 = $2,250.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1125.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,250.00 in Billed Charges for Rev 360 = $1,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1890.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,250.00 in Billed Charges for Rev 360 = $1,890.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1687.50,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,250.00 in Billed Charges for Rev 360 = $1,687.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2070.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,250.00 in Billed Charges for Rev 360 = $2,070.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1350.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,250.00 in Billed Charges for Rev 360 = $1,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1350.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,250.00 in Billed Charges for Rev 360 = $1,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,PREVEA HEALTH NETWORK,PREVEA360,1350.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,250.00 in Billed Charges for Rev 360 = $1,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1350.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,250.00 in Billed Charges for Rev 360 = $1,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1436.18,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,250.00 in Billed Charges for Rev 360 = $1,436.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1620.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,250.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1620.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,250.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1395.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,250.00 in Billed Charges for Rev 360 = $1,395.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1620.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,250.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1620.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,250.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DENTAL 151 AND GREATER ASC,360,RC,36030114,CDM,,,,,,both,,,2250.0000,1485.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1350.00,,,,,,,1093.5000,2250.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,250.00 in Billed Charges for Rev 360 = $1,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,AETNA,AETNA HSHS,1046.52,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,620.00 in Billed Charges for Rev 360 = $1,046.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,AETNA,ALL COMMERCIAL AETNA,1620.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,620.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1620.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,620.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,CENPATICO,ALL MEDICAID CENPATICO,1620.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,620.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1377.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,620.00 in Billed Charges for Rev 360 = $1,377.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,CIGNA,ALL COMMERCIAL CIGNA,1134.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,620.00 in Billed Charges for Rev 360 = $1,134.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,COFINITY,COFINITY,1620.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,620.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1539.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,620.00 in Billed Charges for Rev 360 = $1,539.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,1360.80,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,620.00 in Billed Charges for Rev 360 = $1,360.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1150.20,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,620.00 in Billed Charges for Rev 360 = $1,150.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1182.60,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,620.00 in Billed Charges for Rev 360 = $1,182.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,787.32,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,620.00 in Billed Charges for Rev 360 = $787.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1377.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,620.00 in Billed Charges for Rev 360 = $1,377.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,HUMANA,HUMANA CHOICE CARE PPO,1377.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,620.00 in Billed Charges for Rev 360 = $1,377.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1182.60,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,620.00 in Billed Charges for Rev 360 = $1,182.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1620.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,620.00 in Billed Charges for Rev 360 = $1,620.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,810.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,620.00 in Billed Charges for Rev 360 = $810.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1360.80,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,620.00 in Billed Charges for Rev 360 = $1,360.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1215.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,620.00 in Billed Charges for Rev 360 = $1,215.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1490.40,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,620.00 in Billed Charges for Rev 360 = $1,490.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,972.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,620.00 in Billed Charges for Rev 360 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,972.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,620.00 in Billed Charges for Rev 360 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,PREVEA HEALTH NETWORK,PREVEA360,972.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,620.00 in Billed Charges for Rev 360 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,972.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,620.00 in Billed Charges for Rev 360 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1034.05,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,620.00 in Billed Charges for Rev 360 = $1,034.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1166.40,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,620.00 in Billed Charges for Rev 360 = $1,166.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1166.40,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,620.00 in Billed Charges for Rev 360 = $1,166.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1004.40,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,620.00 in Billed Charges for Rev 360 = $1,004.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1166.40,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,620.00 in Billed Charges for Rev 360 = $1,166.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1166.40,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,620.00 in Billed Charges for Rev 360 = $1,166.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION MINI,360,RC,36030120,CDM,,,,,,both,,,1620.0000,1069.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,972.00,,,,,,,787.3200,1620.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,620.00 in Billed Charges for Rev 360 = $972.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,AETNA,AETNA HSHS,2089.81,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,235.00 in Billed Charges for Rev 360 = $2,089.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,AETNA,ALL COMMERCIAL AETNA,3235.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,235.00 in Billed Charges for Rev 360 = $3,235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3235.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,235.00 in Billed Charges for Rev 360 = $3,235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,CENPATICO,ALL MEDICAID CENPATICO,3235.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,235.00 in Billed Charges for Rev 360 = $3,235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2749.75,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,235.00 in Billed Charges for Rev 360 = $2,749.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,CIGNA,ALL COMMERCIAL CIGNA,2264.50,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,235.00 in Billed Charges for Rev 360 = $2,264.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,COFINITY,COFINITY,3235.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,235.00 in Billed Charges for Rev 360 = $3,235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3073.25,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,235.00 in Billed Charges for Rev 360 = $3,073.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,2717.40,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,235.00 in Billed Charges for Rev 360 = $2,717.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2296.85,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,235.00 in Billed Charges for Rev 360 = $2,296.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2361.55,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,235.00 in Billed Charges for Rev 360 = $2,361.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,1572.21,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,235.00 in Billed Charges for Rev 360 = $1,572.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2749.75,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,235.00 in Billed Charges for Rev 360 = $2,749.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,HUMANA,HUMANA CHOICE CARE PPO,2749.75,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,235.00 in Billed Charges for Rev 360 = $2,749.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2361.55,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,235.00 in Billed Charges for Rev 360 = $2,361.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3235.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,235.00 in Billed Charges for Rev 360 = $3,235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1617.50,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,235.00 in Billed Charges for Rev 360 = $1,617.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2717.40,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,235.00 in Billed Charges for Rev 360 = $2,717.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2426.25,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,235.00 in Billed Charges for Rev 360 = $2,426.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2976.20,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,235.00 in Billed Charges for Rev 360 = $2,976.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1941.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,235.00 in Billed Charges for Rev 360 = $1,941.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1941.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,235.00 in Billed Charges for Rev 360 = $1,941.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,PREVEA HEALTH NETWORK,PREVEA360,1941.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,235.00 in Billed Charges for Rev 360 = $1,941.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1941.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,235.00 in Billed Charges for Rev 360 = $1,941.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2064.90,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,235.00 in Billed Charges for Rev 360 = $2,064.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2329.20,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,235.00 in Billed Charges for Rev 360 = $2,329.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2329.20,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,235.00 in Billed Charges for Rev 360 = $2,329.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2005.70,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,235.00 in Billed Charges for Rev 360 = $2,005.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2329.20,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,235.00 in Billed Charges for Rev 360 = $2,329.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2329.20,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,235.00 in Billed Charges for Rev 360 = $2,329.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LIPOSUCTION FULL,360,RC,36030122,CDM,,,,,,both,,,3235.0000,2135.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1941.00,,,,,,,1572.2100,3235.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,235.00 in Billed Charges for Rev 360 = $1,941.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,AETNA,AETNA HSHS,1281.02,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,983.00 in Billed Charges for Rev 360 = $1,281.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,AETNA,ALL COMMERCIAL AETNA,1983.00,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,983.00 in Billed Charges for Rev 360 = $1,983.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1983.00,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,983.00 in Billed Charges for Rev 360 = $1,983.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,CENPATICO,ALL MEDICAID CENPATICO,1983.00,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,983.00 in Billed Charges for Rev 360 = $1,983.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1685.55,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,983.00 in Billed Charges for Rev 360 = $1,685.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,CIGNA,ALL COMMERCIAL CIGNA,1388.10,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,983.00 in Billed Charges for Rev 360 = $1,388.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,COFINITY,COFINITY,1983.00,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,983.00 in Billed Charges for Rev 360 = $1,983.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1883.85,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,983.00 in Billed Charges for Rev 360 = $1,883.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,1665.72,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,983.00 in Billed Charges for Rev 360 = $1,665.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1407.93,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,983.00 in Billed Charges for Rev 360 = $1,407.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1447.59,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,983.00 in Billed Charges for Rev 360 = $1,447.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,963.74,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,983.00 in Billed Charges for Rev 360 = $963.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1685.55,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,983.00 in Billed Charges for Rev 360 = $1,685.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,HUMANA,HUMANA CHOICE CARE PPO,1685.55,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,983.00 in Billed Charges for Rev 360 = $1,685.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1447.59,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,983.00 in Billed Charges for Rev 360 = $1,447.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1983.00,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,983.00 in Billed Charges for Rev 360 = $1,983.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,991.50,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,983.00 in Billed Charges for Rev 360 = $991.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1665.72,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,983.00 in Billed Charges for Rev 360 = $1,665.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1487.25,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,983.00 in Billed Charges for Rev 360 = $1,487.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1824.36,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,983.00 in Billed Charges for Rev 360 = $1,824.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1189.80,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,983.00 in Billed Charges for Rev 360 = $1,189.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1189.80,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,983.00 in Billed Charges for Rev 360 = $1,189.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,PREVEA HEALTH NETWORK,PREVEA360,1189.80,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,983.00 in Billed Charges for Rev 360 = $1,189.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1189.80,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,983.00 in Billed Charges for Rev 360 = $1,189.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1265.75,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,983.00 in Billed Charges for Rev 360 = $1,265.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1427.76,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,983.00 in Billed Charges for Rev 360 = $1,427.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1427.76,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,983.00 in Billed Charges for Rev 360 = $1,427.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1229.46,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,983.00 in Billed Charges for Rev 360 = $1,229.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1427.76,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,983.00 in Billed Charges for Rev 360 = $1,427.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1427.76,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,983.00 in Billed Charges for Rev 360 = $1,427.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO MINI,360,RC,36030123,CDM,,,,,,both,,,1983.0000,1308.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1189.80,,,,,,,963.7400,1983.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,983.00 in Billed Charges for Rev 360 = $1,189.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,AETNA,AETNA HSHS,2326.25,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,601.00 in Billed Charges for Rev 360 = $2,326.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,AETNA,ALL COMMERCIAL AETNA,3601.00,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,601.00 in Billed Charges for Rev 360 = $3,601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3601.00,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,601.00 in Billed Charges for Rev 360 = $3,601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,CENPATICO,ALL MEDICAID CENPATICO,3601.00,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,601.00 in Billed Charges for Rev 360 = $3,601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3060.85,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,601.00 in Billed Charges for Rev 360 = $3,060.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,CIGNA,ALL COMMERCIAL CIGNA,2520.70,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,601.00 in Billed Charges for Rev 360 = $2,520.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,COFINITY,COFINITY,3601.00,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,601.00 in Billed Charges for Rev 360 = $3,601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3420.95,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,601.00 in Billed Charges for Rev 360 = $3,420.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,3024.84,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,601.00 in Billed Charges for Rev 360 = $3,024.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2556.71,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,601.00 in Billed Charges for Rev 360 = $2,556.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2628.73,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,601.00 in Billed Charges for Rev 360 = $2,628.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,1750.09,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,601.00 in Billed Charges for Rev 360 = $1,750.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3060.85,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,601.00 in Billed Charges for Rev 360 = $3,060.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,HUMANA,HUMANA CHOICE CARE PPO,3060.85,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,601.00 in Billed Charges for Rev 360 = $3,060.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2628.73,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,601.00 in Billed Charges for Rev 360 = $2,628.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,3601.00,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,601.00 in Billed Charges for Rev 360 = $3,601.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1800.50,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,601.00 in Billed Charges for Rev 360 = $1,800.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3024.84,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,601.00 in Billed Charges for Rev 360 = $3,024.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2700.75,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,601.00 in Billed Charges for Rev 360 = $2,700.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3312.92,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,601.00 in Billed Charges for Rev 360 = $3,312.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2160.60,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,601.00 in Billed Charges for Rev 360 = $2,160.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2160.60,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,601.00 in Billed Charges for Rev 360 = $2,160.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,PREVEA HEALTH NETWORK,PREVEA360,2160.60,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,601.00 in Billed Charges for Rev 360 = $2,160.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2160.60,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,601.00 in Billed Charges for Rev 360 = $2,160.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2298.52,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,601.00 in Billed Charges for Rev 360 = $2,298.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2592.72,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,601.00 in Billed Charges for Rev 360 = $2,592.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2592.72,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,601.00 in Billed Charges for Rev 360 = $2,592.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2232.62,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,601.00 in Billed Charges for Rev 360 = $2,232.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2592.72,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,601.00 in Billed Charges for Rev 360 = $2,592.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2592.72,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,601.00 in Billed Charges for Rev 360 = $2,592.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SLIM LIPO PRO FULL,360,RC,36030125,CDM,,,,,,both,,,3601.0000,2376.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2160.60,,,,,,,1750.0900,3601.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,601.00 in Billed Charges for Rev 360 = $2,160.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,AETNA,AETNA HSHS,4200.29,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,502.00 in Billed Charges for Rev 360 = $4,200.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,AETNA,ALL COMMERCIAL AETNA,6502.00,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,502.00 in Billed Charges for Rev 360 = $6,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6502.00,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,502.00 in Billed Charges for Rev 360 = $6,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,CENPATICO,ALL MEDICAID CENPATICO,6502.00,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,502.00 in Billed Charges for Rev 360 = $6,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5526.70,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,502.00 in Billed Charges for Rev 360 = $5,526.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,CIGNA,ALL COMMERCIAL CIGNA,4551.40,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,502.00 in Billed Charges for Rev 360 = $4,551.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,COFINITY,COFINITY,6502.00,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,502.00 in Billed Charges for Rev 360 = $6,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6176.90,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,502.00 in Billed Charges for Rev 360 = $6,176.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,5461.68,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,502.00 in Billed Charges for Rev 360 = $5,461.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4616.42,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,502.00 in Billed Charges for Rev 360 = $4,616.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4746.46,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,502.00 in Billed Charges for Rev 360 = $4,746.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,3159.97,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,502.00 in Billed Charges for Rev 360 = $3,159.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5526.70,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,502.00 in Billed Charges for Rev 360 = $5,526.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,HUMANA,HUMANA CHOICE CARE PPO,5526.70,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,502.00 in Billed Charges for Rev 360 = $5,526.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4746.46,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,502.00 in Billed Charges for Rev 360 = $4,746.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,6502.00,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,502.00 in Billed Charges for Rev 360 = $6,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3251.00,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,502.00 in Billed Charges for Rev 360 = $3,251.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5461.68,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,502.00 in Billed Charges for Rev 360 = $5,461.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4876.50,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,502.00 in Billed Charges for Rev 360 = $4,876.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5981.84,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,502.00 in Billed Charges for Rev 360 = $5,981.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3901.20,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,502.00 in Billed Charges for Rev 360 = $3,901.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3901.20,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,502.00 in Billed Charges for Rev 360 = $3,901.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,PREVEA HEALTH NETWORK,PREVEA360,3901.20,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,502.00 in Billed Charges for Rev 360 = $3,901.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3901.20,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,502.00 in Billed Charges for Rev 360 = $3,901.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4150.23,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,502.00 in Billed Charges for Rev 360 = $4,150.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4681.44,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,502.00 in Billed Charges for Rev 360 = $4,681.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4681.44,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,502.00 in Billed Charges for Rev 360 = $4,681.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4031.24,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,502.00 in Billed Charges for Rev 360 = $4,031.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4681.44,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,502.00 in Billed Charges for Rev 360 = $4,681.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4681.44,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,502.00 in Billed Charges for Rev 360 = $4,681.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INSERT GASTRIC BALLOON,360,RC,36030126,CDM,,,,,,both,,,6502.0000,4291.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3901.20,,,,,,,3159.9700,6502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,502.00 in Billed Charges for Rev 360 = $3,901.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,AETNA,AETNA HSHS,4038.79,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,252.00 in Billed Charges for Rev 360 = $4,038.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,AETNA,ALL COMMERCIAL AETNA,6252.00,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,252.00 in Billed Charges for Rev 360 = $6,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6252.00,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,252.00 in Billed Charges for Rev 360 = $6,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,CENPATICO,ALL MEDICAID CENPATICO,6252.00,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,252.00 in Billed Charges for Rev 360 = $6,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5314.20,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,252.00 in Billed Charges for Rev 360 = $5,314.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,CIGNA,ALL COMMERCIAL CIGNA,4376.40,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,252.00 in Billed Charges for Rev 360 = $4,376.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,COFINITY,COFINITY,6252.00,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,252.00 in Billed Charges for Rev 360 = $6,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5939.40,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,252.00 in Billed Charges for Rev 360 = $5,939.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,5251.68,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,252.00 in Billed Charges for Rev 360 = $5,251.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4438.92,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,252.00 in Billed Charges for Rev 360 = $4,438.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4563.96,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,252.00 in Billed Charges for Rev 360 = $4,563.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,3038.47,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,252.00 in Billed Charges for Rev 360 = $3,038.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5314.20,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,252.00 in Billed Charges for Rev 360 = $5,314.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,HUMANA,HUMANA CHOICE CARE PPO,5314.20,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,252.00 in Billed Charges for Rev 360 = $5,314.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4563.96,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,252.00 in Billed Charges for Rev 360 = $4,563.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,6252.00,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,252.00 in Billed Charges for Rev 360 = $6,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3126.00,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,252.00 in Billed Charges for Rev 360 = $3,126.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5251.68,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,252.00 in Billed Charges for Rev 360 = $5,251.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4689.00,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,252.00 in Billed Charges for Rev 360 = $4,689.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5751.84,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,252.00 in Billed Charges for Rev 360 = $5,751.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3751.20,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,252.00 in Billed Charges for Rev 360 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3751.20,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,252.00 in Billed Charges for Rev 360 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,PREVEA HEALTH NETWORK,PREVEA360,3751.20,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,252.00 in Billed Charges for Rev 360 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3751.20,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,252.00 in Billed Charges for Rev 360 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3990.65,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,252.00 in Billed Charges for Rev 360 = $3,990.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4501.44,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,252.00 in Billed Charges for Rev 360 = $4,501.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4501.44,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,252.00 in Billed Charges for Rev 360 = $4,501.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3876.24,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,252.00 in Billed Charges for Rev 360 = $3,876.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4501.44,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,252.00 in Billed Charges for Rev 360 = $4,501.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4501.44,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,252.00 in Billed Charges for Rev 360 = $4,501.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC VASOVASOSTOMY,360,RC,36030127,CDM,,,,,,both,,,6252.0000,4126.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3751.20,,,,,,,3038.4700,6252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,252.00 in Billed Charges for Rev 360 = $3,751.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,AETNA,AETNA HSHS,1180.89,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,180.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,AETNA,AETNA MEDICARE,511.59,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,AETNA,ALL COMMERCIAL AETNA,1828.00,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9035 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,511.59,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,ANTHEM,ANTHEM POS/HMO,1243.04,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,243.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,ANTHEM,ANTHEM PPO,1243.04,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,243.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1828.00,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,CENPATICO,ALL MEDICAID CENPATICO,1828.00,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1553.80,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,553.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,CIGNA,ALL COMMERCIAL CIGNA,1279.60,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,279.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,COFINITY,COFINITY,1828.00,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9035 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9035 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1736.60,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,736.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,1535.52,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,535.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1297.88,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,297.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1334.44,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,334.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,888.41,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $888.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1553.80,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,553.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HUMANA,HUMANA CHOICE CARE HMO,1160.78,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,160.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HUMANA,HUMANA CHOICE CARE PPO,1553.80,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,553.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HUMANA,HUMANA MEDICARE ADVANTAGE,511.59,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,HUMANA,HUMANA NATIIONAL POS HMO,1160.78,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,160.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1334.44,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,334.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1828.00,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9035 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,511.59,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9035 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9035 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,MOLINA HEALTHCARE,MOLINA MEDICARE,511.59,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,914.00,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $914.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1535.52,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,535.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,NAPHCARE,ALL COMMERICAL NAPHCARE,1151.08,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1371.00,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1681.76,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,681.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1096.80,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,096.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1096.80,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,096.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,PREVEA HEALTH NETWORK,PREVEA360,1096.80,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,096.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1096.80,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,096.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1166.81,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,166.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,516.71,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1316.16,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,316.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9035 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,1828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9035 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,1828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9035 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,511.59,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,1828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9035 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,UNITY HEALTH PLAN,UNITY HOSPICE,511.59,,,,,,,126.6200,1828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1316.16,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,316.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1133.36,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,133.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1316.16,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,316.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1316.16,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,316.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PLATELET PHERES LEUKOREDUCED,P9035,HCPCS,390,RC,39000120,CDM,,,,both,,,1828.0000,1206.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1096.80,,,,,,,126.6200,1828.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,828.00 in Billed Charges for Rev 390 Proc P9035 = $1,096.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,AETNA,AETNA HSHS,1349.49,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,349.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,AETNA,AETNA MEDICARE,680.61,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,AETNA,ALL COMMERCIAL AETNA,2089.00,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $2,089.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,680.61,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,ANTHEM,ANTHEM POS/HMO,1420.52,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,420.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,ANTHEM,ANTHEM PPO,1420.52,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,420.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2089.00,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $2,089.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,CENPATICO,ALL MEDICAID CENPATICO,2089.00,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $2,089.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1775.65,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,775.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,CIGNA,ALL COMMERCIAL CIGNA,1462.30,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,462.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,COFINITY,COFINITY,2089.00,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $2,089.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1984.55,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,984.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,1754.76,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,754.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1483.19,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,483.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1524.97,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,524.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,1015.25,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,015.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1775.65,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,775.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HUMANA,HUMANA CHOICE CARE HMO,1326.52,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,326.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HUMANA,HUMANA CHOICE CARE PPO,1775.65,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,775.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,680.61,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,HUMANA,HUMANA NATIIONAL POS HMO,1326.52,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,326.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1524.97,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,524.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2089.00,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $2,089.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,680.61,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,680.61,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1044.50,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,044.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1754.76,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,754.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,1531.37,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1566.75,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,566.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1921.88,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,921.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1253.40,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,253.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1253.40,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,253.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,PREVEA HEALTH NETWORK,PREVEA360,1253.40,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,253.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1253.40,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,253.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1333.41,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,333.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,687.42,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1504.08,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,504.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,2089.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9037 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,2089.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9037 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,680.61,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,2089.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9037 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,UNITY HEALTH PLAN,UNITY HOSPICE,680.61,,,,,,,126.6200,2089.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1504.08,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,504.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1295.18,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,295.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1504.08,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,504.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1504.08,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,504.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA (WASHED),P9037,HCPCS,390,RC,39000123,CDM,,,,both,,,2089.0000,1378.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1253.40,,,,,,,126.6200,2089.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,089.00 in Billed Charges for Rev 390 Proc P9037 = $1,253.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,AETNA,AETNA HSHS,65.25,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $65.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,AETNA,AETNA MEDICARE,53.08,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,AETNA,ALL COMMERCIAL AETNA,101.00,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9047 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,53.08,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,ANTHEM,ANTHEM POS/HMO,68.68,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $68.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,ANTHEM,ANTHEM PPO,68.68,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $68.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,101.00,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,CENPATICO,ALL MEDICAID CENPATICO,101.00,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,85.85,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,CIGNA,ALL COMMERCIAL CIGNA,70.70,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $70.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,COFINITY,COFINITY,101.00,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9047 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9047 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,95.95,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $95.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,84.84,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $84.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,71.71,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $71.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,73.73,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $73.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,49.09,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $49.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,85.85,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HUMANA,HUMANA CHOICE CARE HMO,64.14,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $64.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HUMANA,HUMANA CHOICE CARE PPO,85.85,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,53.08,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,HUMANA,HUMANA NATIIONAL POS HMO,64.14,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $64.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,73.73,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $73.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,101.00,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9047 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,53.08,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9047 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9047 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,53.08,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,50.50,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $50.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,84.84,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $84.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,119.42,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,75.75,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $75.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,92.92,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $92.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,60.60,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $60.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,60.60,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $60.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,PREVEA HEALTH NETWORK,PREVEA360,60.60,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $60.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,60.60,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $60.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,64.47,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $64.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,53.61,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,72.72,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9047 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,101.00,,,,,,,49.0900,119.4200,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9047 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $101.00, claim capped at $101.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,101.00,,,,,,,49.0900,119.4200,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9047 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $101.00, claim capped at $101.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,53.08,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,101.00,,,,,,,49.0900,119.4200,other,"ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9047 1 Visit at $505.20 per Visit = $505.20 (Service Line reduced to $101.00, claim capped at $101.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,UNITY HEALTH PLAN,UNITY HOSPICE,53.08,,,,,,,49.0900,119.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,72.72,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,62.62,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $62.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,72.72,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,72.72,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALBUMIN VL 25% 100 ML,P9047,HCPCS,390,RC,39000128,CDM,,,,both,,,101.0000,66.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,60.60,,,,,,,49.0900,119.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.00 in Billed Charges for Rev 390 Proc P9047 = $60.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,AETNA,AETNA HSHS,1725.47,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,725.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,AETNA,ALL COMMERCIAL AETNA,2671.00,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,2671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9050 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,ANTHEM,ANTHEM POS/HMO,1816.28,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,816.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,ANTHEM,ANTHEM PPO,1816.28,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,816.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2671.00,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,CENPATICO,ALL MEDICAID CENPATICO,2671.00,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2270.35,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,270.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,CIGNA,ALL COMMERCIAL CIGNA,1869.70,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,869.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,COFINITY,COFINITY,2671.00,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,2671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9050 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,2671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9050 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2537.45,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,537.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,2243.64,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,243.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1896.41,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,896.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1949.83,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,949.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,1298.11,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,298.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2270.35,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,270.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,HUMANA,HUMANA CHOICE CARE HMO,1696.09,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,696.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,HUMANA,HUMANA CHOICE CARE PPO,2270.35,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,270.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,HUMANA,HUMANA NATIIONAL POS HMO,1696.09,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,696.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1949.83,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,949.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2671.00,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,671.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,2671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9050 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,2671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9050 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,2671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9050 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1335.50,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,335.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2243.64,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,243.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2003.25,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,003.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2457.32,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $2,457.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1602.60,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,602.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1602.60,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,602.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,PREVEA HEALTH NETWORK,PREVEA360,1602.60,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,602.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1602.60,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,602.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1704.90,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,704.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1923.12,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,923.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,2671.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9050 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,2671.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9050 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,2671.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9050 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,2671.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9050 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1923.12,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,923.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1656.02,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,656.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1923.12,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,923.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1923.12,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,923.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"GRANULOCYTES, PHERESIS UNIT",P9050,HCPCS,390,RC,39000129,CDM,,,,both,,,2671.0000,1762.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1602.60,,,,,,,126.6200,2671.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,671.00 in Billed Charges for Rev 390 Proc P9050 = $1,602.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,AETNA,AETNA HSHS,480.62,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $480.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,AETNA,AETNA MEDICARE,151.58,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,AETNA,ALL COMMERCIAL AETNA,744.00,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $744.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9051 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,151.58,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,ANTHEM,ANTHEM POS/HMO,505.92,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $505.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,ANTHEM,ANTHEM PPO,505.92,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $505.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,744.00,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $744.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,CENPATICO,ALL MEDICAID CENPATICO,744.00,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $744.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,632.40,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $632.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,CIGNA,ALL COMMERCIAL CIGNA,520.80,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $520.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,COFINITY,COFINITY,744.00,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $744.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9051 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9051 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,706.80,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $706.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,624.96,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $624.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,528.24,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $528.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,543.12,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $543.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,361.58,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $361.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,632.40,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $632.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HUMANA,HUMANA CHOICE CARE HMO,472.44,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $472.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HUMANA,HUMANA CHOICE CARE PPO,632.40,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $632.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HUMANA,HUMANA MEDICARE ADVANTAGE,151.58,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,HUMANA,HUMANA NATIIONAL POS HMO,472.44,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $472.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,543.12,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $543.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,744.00,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $744.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9051 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,151.58,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9051 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9051 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,MOLINA HEALTHCARE,MOLINA MEDICARE,151.58,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,372.00,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,624.96,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $624.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,NAPHCARE,ALL COMMERICAL NAPHCARE,341.06,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,558.00,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,684.48,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $684.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,446.40,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $446.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,446.40,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $446.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,PREVEA HEALTH NETWORK,PREVEA360,446.40,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $446.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,446.40,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $446.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,474.90,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $474.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,153.10,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,535.68,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $535.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9051 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,57.4200,744.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9051 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,57.4200,744.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9051 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,151.58,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,57.4200,744.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9051 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,UNITY HEALTH PLAN,UNITY HOSPICE,151.58,,,,,,,57.4200,744.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,535.68,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $535.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,461.28,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $461.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,535.68,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $535.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,535.68,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $535.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R CMV NEG EA,P9051,HCPCS,390,RC,39000131,CDM,,,,both,,,744.0000,491.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,446.40,,,,,,,57.4200,744.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $744.00 in Billed Charges for Rev 390 Proc P9051 = $446.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,AETNA,AETNA HSHS,711.89,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $711.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,AETNA,AETNA MEDICARE,265.19,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,AETNA,ALL COMMERCIAL AETNA,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9054 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,265.19,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM POS/HMO,749.36,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $749.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM PPO,749.36,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $749.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,CENPATICO,ALL MEDICAID CENPATICO,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,936.70,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,CIGNA,ALL COMMERCIAL CIGNA,771.40,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $771.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,COFINITY,COFINITY,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9054 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9054 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1046.90,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $1,046.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,925.68,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $925.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,782.42,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $782.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,804.46,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $804.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,535.57,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $535.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,936.70,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA CHOICE CARE HMO,699.77,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $699.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA CHOICE CARE PPO,936.70,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,265.19,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA NATIIONAL POS HMO,699.77,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $699.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,804.46,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $804.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9054 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,265.19,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9054 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9054 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,265.19,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,551.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,925.68,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $925.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,596.68,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,826.50,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $826.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1013.84,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $1,013.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA360,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,703.41,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $703.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,267.84,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,793.44,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9054 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,57.4200,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9054 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,57.4200,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9054 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,265.19,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,57.4200,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9054 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,UNITY HEALTH PLAN,UNITY HOSPICE,265.19,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,793.44,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,683.24,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $683.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,793.44,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,793.44,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED DEGLYC (RC),P9054,HCPCS,390,RC,39000136,CDM,,,,both,,,1102.0000,727.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9054 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,AETNA,AETNA HSHS,711.89,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $711.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,AETNA,AETNA MEDICARE,184.91,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,AETNA,ALL COMMERCIAL AETNA,1102.00,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTEHM MEDICAID,449.49,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,184.91,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM POS/HMO,749.36,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $749.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM PPO,749.36,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $749.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1102.00,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,CENPATICO,ALL MEDICAID CENPATICO,1102.00,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,936.70,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,CIGNA,ALL COMMERCIAL CIGNA,771.40,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $771.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,COFINITY,COFINITY,1102.00,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,449.49,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,449.49,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1046.90,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $1,046.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,925.68,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $925.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,782.42,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $782.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,804.46,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $804.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,535.57,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $535.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,936.70,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA CHOICE CARE HMO,699.77,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $699.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA CHOICE CARE PPO,936.70,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,184.91,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA NATIIONAL POS HMO,699.77,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $699.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,804.46,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $804.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1102.00,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,449.49,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,184.91,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,449.49,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,476.46,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49... $449.49 at 106% = $476.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,184.91,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,551.00,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,925.68,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $925.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,416.05,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,826.50,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $826.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1013.84,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $1,013.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,661.20,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,661.20,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA360,661.20,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,661.20,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,703.41,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $703.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,186.76,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,793.44,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,TRIOLOGY,TRILOGY MEDICAID,476.46,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 106% = $476.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,184.9100,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,184.9100,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,184.91,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,184.9100,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,UNITY HEALTH PLAN,UNITY HOSPICE,184.91,,,,,,,184.9100,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,793.44,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,683.24,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $683.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,793.44,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,793.44,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RBC L/R WASHED SALINE (RC),P9016,HCPCS,390,RC,39000137,CDM,,,,both,,,1102.0000,727.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,661.20,,,,,,,184.9100,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9016 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,AETNA,AETNA HSHS,606.59,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $606.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,AETNA,AETNA MEDICARE,249.40,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,AETNA,ALL COMMERCIAL AETNA,939.00,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $939.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9058 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,249.40,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,ANTHEM,ANTHEM POS/HMO,638.52,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $638.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,ANTHEM,ANTHEM PPO,638.52,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $638.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,939.00,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $939.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,CENPATICO,ALL MEDICAID CENPATICO,939.00,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $939.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,798.15,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $798.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,CIGNA,ALL COMMERCIAL CIGNA,657.30,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $657.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,COFINITY,COFINITY,939.00,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $939.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9058 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9058 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,892.05,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $892.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,788.76,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $788.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,666.69,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $666.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,685.47,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $685.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,456.35,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $456.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,798.15,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $798.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HUMANA,HUMANA CHOICE CARE HMO,596.27,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $596.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HUMANA,HUMANA CHOICE CARE PPO,798.15,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $798.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,249.40,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,HUMANA,HUMANA NATIIONAL POS HMO,596.27,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $596.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,685.47,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $685.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,939.00,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $939.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9058 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,249.40,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9058 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9058 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,249.40,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,469.50,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $469.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,788.76,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $788.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,561.15,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,704.25,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $704.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,863.88,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $863.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,563.40,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $563.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,563.40,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $563.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,PREVEA HEALTH NETWORK,PREVEA360,563.40,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $563.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,563.40,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $563.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,599.36,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $599.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,251.89,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,676.08,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $676.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9058 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,57.4200,939.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9058 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,57.4200,939.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9058 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,249.40,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,57.4200,939.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9058 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,UNITY HEALTH PLAN,UNITY HOSPICE,249.40,,,,,,,57.4200,939.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,676.08,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $676.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,582.18,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $582.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,676.08,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $676.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,676.08,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $676.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"RBC, L/R, CMV-NEG, IRRAD",P9058,HCPCS,390,RC,39000140,CDM,,,,both,,,939.0000,619.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,563.40,,,,,,,57.4200,939.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $939.00 in Billed Charges for Rev 390 Proc P9058 = $563.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,AETNA,AETNA HSHS,361.76,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,AETNA,AETNA MEDICARE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,AETNA,ALL COMMERCIAL AETNA,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,ANTHEM,ANTEHM MEDICAID,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,ANTHEM,ANTHEM POS/HMO,350.00,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 1 Visit at $350.00 per Visit = $350.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,ANTHEM,ANTHEM PPO,350.00,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 1 Visit at $350.00 per Visit = $350.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,CENPATICO,ALL MEDICAID CENPATICO,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,476.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,CIGNA,ALL COMMERCIAL CIGNA,392.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,COFINITY,COFINITY,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,532.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,470.40,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $470.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,397.60,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $397.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,408.80,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $408.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,272.16,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $272.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,476.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HUMANA,HUMANA CHOICE CARE HMO,218.57,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.57 from Fee Schedule 005543_205 for Rev 401 Proc 77066 Mod TC * Qty 1 = $218.57 at 100% = $218.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HUMANA,HUMANA CHOICE CARE PPO,476.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,HUMANA,HUMANA NATIIONAL POS HMO,218.57,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.57 from Fee Schedule 005543_205 for Rev 401 Proc 77066 Mod TC * Qty 1 = $218.57 at 100% = $218.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,408.80,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $408.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,23.18,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87... $21.87 at 106% = $23.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,280.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $280.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,470.40,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $470.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,237.33,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,420.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,515.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $515.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA360,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,357.45,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $357.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,106.53,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,403.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,TRIOLOGY,TRILOGY MEDICAID,23.18,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 106% = $23.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,193.80,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,193.80,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,193.80,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,UNITY HEALTH PLAN,UNITY HOSPICE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,403.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,347.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $347.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,403.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,403.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD BI,77066,CPT,401,RC,40100003,CDM,,,,both,,,560.0000,369.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,AETNA,AETNA HSHS,3000.02,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,000.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,AETNA,AETNA MEDICARE,1604.25,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,AETNA,ALL COMMERCIAL AETNA,4644.00,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $4,644.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,ANTHEM,ANTEHM MEDICAID,1061.18,,,,,,,279.7600,4644.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00054 Proc 20670 at $125.60 (Base Rate) * 8.4489 (Relative Weight) = $1,061.18 (Total Line Payment) at 100% = $1,061.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1604.25,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,ANTHEM,ANTHEM PPO,500.00,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4644.00,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $4,644.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,CENPATICO,ALL MEDICAID CENPATICO,4644.00,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $4,644.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3947.40,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,947.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,CIGNA,ALL COMMERCIAL CIGNA,3250.80,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,250.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,COFINITY,COFINITY,4644.00,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $4,644.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1061.18,,,,,,,279.7600,4644.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00054 Proc 20670 at $125.60 (Base Rate) * 8.4489 (Relative Weight) = $1,061.18 (Total Line Payment) at 100% = $1,061.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1061.18,,,,,,,279.7600,4644.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00054 Proc 20670 at $125.60 (Base Rate) * 8.4489 (Relative Weight) = $1,061.18 (Total Line Payment) at 100% = $1,061.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4411.80,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $4,411.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,3900.96,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,900.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3297.24,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,297.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3390.12,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,390.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,2256.98,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $2,256.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3947.40,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,947.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HUMANA,HUMANA CHOICE CARE HMO,279.76,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $279.76 from Fee Schedule 005543_205 for Rev 402 Proc 20670 Mod TC * Qty 1 = $279.76 at 100% = $279.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HUMANA,HUMANA CHOICE CARE PPO,3947.40,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,947.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HUMANA,HUMANA MEDICARE ADVANTAGE,1604.25,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,HUMANA,HUMANA NATIIONAL POS HMO,279.76,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $279.76 from Fee Schedule 005543_205 for Rev 402 Proc 20670 Mod TC * Qty 1 = $279.76 at 100% = $279.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3390.12,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,390.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,4644.00,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $4,644.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1061.18,,,,,,,279.7600,4644.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00054 Proc 20670 at $125.60 (Base Rate) * 8.4489 (Relative Weight) = $1,061.18 (Total Line Payment) at 100% = $1,061.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1604.25,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1061.18,,,,,,,279.7600,4644.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00054 Proc 20670 at $125.60 (Base Rate) * 8.4489 (Relative Weight) = $1,061.18 (Total Line Payment) at 100% = $1,061.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,MOLINA HEALTHCARE,MOLINA MEDICAID,1124.85,,,,,,,279.7600,4644.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00054 Proc 20670 at $125.60 (Base Rate) * 8.4489 (Relative Weight) = $1,061.18 (Total Line Payment) at 100% = $1,061.18... $1,061.18 at 106% = $1,124.85 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,MOLINA HEALTHCARE,MOLINA MEDICARE,1604.25,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2322.00,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $2,322.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3900.96,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,900.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,NAPHCARE,ALL COMMERICAL NAPHCARE,3609.56,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3483.00,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,483.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4272.48,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $4,272.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2964.27,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $2,964.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1620.29,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3343.68,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,343.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,TRIOLOGY,TRILOGY MEDICAID,1124.85,,,,,,,279.7600,4644.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00054 Proc 20670 at $125.60 (Base Rate) * 8.4489 (Relative Weight) = $1,061.18 (Total Line Payment) at 106% = $1,124.85. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1604.25,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,279.7600,4644.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 20670 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,UNITY HEALTH PLAN,UNITY HOSPICE,1604.25,,,,,,,279.7600,4644.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3343.68,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,343.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2879.28,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $2,879.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3343.68,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,343.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3343.68,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $3,343.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC REM IMPL WIRE SUPERFIC,20670,CPT,402,RC,40200002,CDM,,,,both,,,4644.0000,3065.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2786.40,,,,,,,279.7600,4644.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,644.00 in Billed Charges for Rev 402 Proc 20670 = $2,786.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,AETNA,AETNA HSHS,420.55,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $420.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,AETNA,AETNA MEDICARE,230.06,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,AETNA,ALL COMMERCIAL AETNA,651.00,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,ANTHEM,ANTEHM MEDICAID,651.00,,,,,,,230.0600,690.0600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00069 Proc 21899 at $125.60 (Base Rate) * 8.4503 (Relative Weight) = $1,061.36 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,061.36 at 100% = $1,061.36 (Service Line reduced to $651.00, claim capped at $651.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,230.06,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,ANTHEM,ANTHEM PPO,500.00,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,651.00,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,CENPATICO,ALL MEDICAID CENPATICO,651.00,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,553.35,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $553.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,CIGNA,ALL COMMERCIAL CIGNA,455.70,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $455.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,COFINITY,COFINITY,651.00,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,651.00,,,,,,,230.0600,690.0600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00069 Proc 21899 at $125.60 (Base Rate) * 8.4503 (Relative Weight) = $1,061.36 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,061.36 at 100% = $1,061.36 (Service Line reduced to $651.00, claim capped at $651.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,651.00,,,,,,,230.0600,690.0600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00069 Proc 21899 at $125.60 (Base Rate) * 8.4503 (Relative Weight) = $1,061.36 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,061.36 at 100% = $1,061.36 (Service Line reduced to $651.00, claim capped at $651.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,618.45,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $618.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,546.84,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $546.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,462.21,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $462.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,475.23,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $475.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,316.39,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $316.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,553.35,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $553.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,HUMANA,HUMANA CHOICE CARE PPO,553.35,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $553.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,230.06,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,475.23,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $475.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,651.00,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,651.00,,,,,,,230.0600,690.0600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00069 Proc 21899 at $125.60 (Base Rate) * 8.4503 (Relative Weight) = $1,061.36 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,061.36 at 100% = $1,061.36 (Service Line reduced to $651.00, claim capped at $651.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,230.06,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,651.00,,,,,,,230.0600,690.0600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00069 Proc 21899 at $125.60 (Base Rate) * 8.4503 (Relative Weight) = $1,061.36 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,061.36 at 100% = $1,061.36 (Service Line reduced to $651.00, claim capped at $651.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,690.06,,,,,,,230.0600,690.0600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00069 Proc 21899 at $125.60 (Base Rate) * 8.4503 (Relative Weight) = $1,061.36 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,061.36 at 100% = $1,061.36 (Service Line reduced to $651.00, claim capped at $651.00 in billed charges)... $651.00 at 106% = $690.06 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,230.06,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,325.50,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $325.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,546.84,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $546.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,517.64,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,488.25,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $488.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,598.92,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $598.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,415.53,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $415.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,232.36,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,468.72,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $468.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,TRIOLOGY,TRILOGY MEDICAID,651.00,,,,,,,230.0600,690.0600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00069 Proc 21899 at $125.60 (Base Rate) * 8.4503 (Relative Weight) = $1,061.36 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $1,061.36 at 106% = $1,125.04 (Service Line reduced to $651.00, claim capped at $651.00 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,230.06,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,230.0600,690.0600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21899 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,UNITY HEALTH PLAN,UNITY HOSPICE,230.06,,,,,,,230.0600,690.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,468.72,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $468.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,403.62,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $403.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,468.72,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $468.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,468.72,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $468.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE NECK/THORAX,21899,CPT,402,RC,40200003,CDM,,,,both,,,651.0000,429.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,390.60,,,,,,,230.0600,690.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $651.00 in Billed Charges for Rev 402 Proc 21899 = $390.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,AETNA,AETNA HSHS,3594.34,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $3,594.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,AETNA,AETNA MEDICARE,3144.33,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,AETNA,ALL COMMERCIAL AETNA,5564.00,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,ANTHEM,ANTEHM MEDICAID,1065.36,,,,,,,500.0000,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58805 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3144.33,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,ANTHEM,ANTHEM PPO,500.00,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5564.00,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,CENPATICO,ALL MEDICAID CENPATICO,5564.00,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4729.40,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,729.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,CIGNA,ALL COMMERCIAL CIGNA,3894.80,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $3,894.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,COFINITY,COFINITY,5564.00,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1065.36,,,,,,,500.0000,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58805 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1065.36,,,,,,,500.0000,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58805 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5285.80,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $5,285.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,4673.76,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,673.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3950.44,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $3,950.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4061.72,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,061.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,2704.10,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $2,704.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4729.40,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,729.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,HUMANA CHOICE CARE HMO,819.51,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). $819.51 from Fee Schedule 005543_205 for Rev 402 Proc 58805 Mod TC * Qty 1 = $819.51 at 100% = $819.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,HUMANA CHOICE CARE PPO,4729.40,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,729.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,3144.33,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,HUMANA NATIIONAL POS HMO,819.51,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). $819.51 from Fee Schedule 005543_205 for Rev 402 Proc 58805 Mod TC * Qty 1 = $819.51 at 100% = $819.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4061.72,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,061.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,5564.00,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1065.36,,,,,,,500.0000,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58805 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3144.33,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1065.36,,,,,,,500.0000,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58805 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,1129.28,,,,,,,500.0000,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58805 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36... $1,065.36 at 106% = $1,129.28 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,3144.33,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2782.00,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $2,782.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4673.76,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,673.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,7074.73,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4173.00,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5118.88,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $5,118.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3551.50,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $3,551.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3175.77,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4006.08,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,006.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,TRIOLOGY,TRILOGY MEDICAID,1129.29,,,,,,,500.0000,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58805 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 106% = $1,129.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3144.33,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,500.0000,7074.7300,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 58805 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,UNITY HEALTH PLAN,UNITY HOSPICE,3144.33,,,,,,,500.0000,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4006.08,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,006.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3449.68,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $3,449.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4006.08,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,006.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4006.08,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $4,006.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OVARIAN CYST DRAIN ABDM,58805,CPT,402,RC,40200008,CDM,,,,both,,,5564.0000,3672.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3338.40,,,,,,,500.0000,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,564.00 in Billed Charges for Rev 402 Proc 58805 = $3,338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,AETNA,AETNA HSHS,396.64,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $396.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,AETNA,ALL COMMERCIAL AETNA,614.00,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $614.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76604 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,614.00,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $614.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,CENPATICO,ALL MEDICAID CENPATICO,614.00,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $614.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,521.90,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $521.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,CIGNA,ALL COMMERCIAL CIGNA,429.80,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $429.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,COFINITY,COFINITY,614.00,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $614.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76604 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76604 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,583.30,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $583.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,515.76,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $515.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,435.94,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $435.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,448.22,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $448.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,298.40,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $298.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,521.90,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $521.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HUMANA,HUMANA CHOICE CARE HMO,59.00,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.00 from Fee Schedule 005543_205 for Rev 402 Proc 76604 Mod TC * Qty 1 = $59.00 at 100% = $59.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HUMANA,HUMANA CHOICE CARE PPO,521.90,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $521.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,HUMANA,HUMANA NATIIONAL POS HMO,59.00,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $59.00 from Fee Schedule 005543_205 for Rev 402 Proc 76604 Mod TC * Qty 1 = $59.00 at 100% = $59.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,448.22,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $448.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,614.00,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $614.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76604 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76604 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76604 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,307.00,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $307.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,515.76,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $515.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,460.50,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $460.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,564.88,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $564.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,391.92,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $391.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,442.08,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $442.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76604 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,614.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76604 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,614.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,442.08,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $442.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,380.68,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $380.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,442.08,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $442.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,442.08,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $442.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US CHEST,76604,CPT,402,RC,40200014,CDM,,,,both,,,614.0000,405.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,368.40,,,,,,,50.1000,614.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $614.00 in Billed Charges for Rev 402 Proc 76604 = $368.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,AETNA,AETNA HSHS,384.37,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $384.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,AETNA,AETNA MEDICARE,84.53,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,AETNA,ALL COMMERCIAL AETNA,595.00,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $595.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76642 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,84.53,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,595.00,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $595.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,CENPATICO,ALL MEDICAID CENPATICO,595.00,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $595.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,505.75,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $505.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,CIGNA,ALL COMMERCIAL CIGNA,416.50,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $416.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,COFINITY,COFINITY,595.00,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $595.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76642 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76642 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,565.25,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $565.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,499.80,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $499.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,422.45,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $422.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,434.35,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $434.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,289.17,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $289.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,505.75,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $505.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HUMANA,HUMANA CHOICE CARE HMO,103.40,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $103.40 from Fee Schedule 005543_205 for Rev 402 Proc 76642 Mod TC * Qty 1 = $103.40 at 100% = $103.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HUMANA,HUMANA CHOICE CARE PPO,505.75,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $505.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,84.53,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,HUMANA,HUMANA NATIIONAL POS HMO,103.40,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $103.40 from Fee Schedule 005543_205 for Rev 402 Proc 76642 Mod TC * Qty 1 = $103.40 at 100% = $103.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,434.35,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $434.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,595.00,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $595.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76642 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,84.53,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76642 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76642 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,84.53,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,297.50,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $297.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,499.80,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $499.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,190.19,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,446.25,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $446.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,547.40,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $547.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,379.79,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $379.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,85.38,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,428.40,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $428.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76642 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,84.53,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,595.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76642 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,UNITY HEALTH PLAN,UNITY HOSPICE,84.53,,,,,,,50.1000,595.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,428.40,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $428.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,368.90,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $368.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,428.40,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $428.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,428.40,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $428.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST LIMITED,76642,CPT,402,RC,40200016,CDM,,,,both,,,595.0000,392.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,357.00,,,,,,,50.1000,595.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $595.00 in Billed Charges for Rev 402 Proc 76642 = $357.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,AETNA,AETNA HSHS,554.27,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $554.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,AETNA,AETNA MEDICARE,101.55,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,AETNA,ALL COMMERCIAL AETNA,858.00,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,ANTHEM,ANTEHM MEDICAID,77.18,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76770 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,ANTHEM,ANTHEM PPO,500.00,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,858.00,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,CENPATICO,ALL MEDICAID CENPATICO,858.00,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,729.30,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $729.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,CIGNA,ALL COMMERCIAL CIGNA,600.60,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $600.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,COFINITY,COFINITY,858.00,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.18,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76770 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.18,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76770 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,815.10,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $815.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,720.72,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $720.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,609.18,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $609.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,626.34,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $626.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,416.99,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $416.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,729.30,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $729.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HUMANA,HUMANA CHOICE CARE HMO,143.89,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $143.89 from Fee Schedule 005543_205 for Rev 402 Proc 76770 Mod TC * Qty 1 = $143.89 at 100% = $143.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HUMANA,HUMANA CHOICE CARE PPO,729.30,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $729.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,HUMANA,HUMANA NATIIONAL POS HMO,143.89,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $143.89 from Fee Schedule 005543_205 for Rev 402 Proc 76770 Mod TC * Qty 1 = $143.89 at 100% = $143.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,626.34,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $626.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,858.00,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.18,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76770 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.18,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76770 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,81.81,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76770 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18... $77.18 at 106% = $81.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,429.00,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $429.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,720.72,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $720.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,643.50,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $643.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,789.36,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $789.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,547.66,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $547.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,617.76,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $617.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,TRIOLOGY,TRILOGY MEDICAID,81.81,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76770 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 106% = $81.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,77.1800,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76770 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,77.1800,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,617.76,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $617.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,531.96,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $531.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,617.76,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $617.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,617.76,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $617.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITIONEAL,76770,CPT,402,RC,40200019,CDM,,,,both,,,858.0000,566.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,514.80,,,,,,,77.1800,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $858.00 in Billed Charges for Rev 402 Proc 76770 = $514.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,AETNA,AETNA HSHS,445.09,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $445.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,AETNA,AETNA MEDICARE,101.55,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,AETNA,ALL COMMERCIAL AETNA,689.00,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $689.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76801 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,ANTHEM,ANTHEM PPO,500.00,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,689.00,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $689.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,CENPATICO,ALL MEDICAID CENPATICO,689.00,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $689.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,585.65,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $585.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,CIGNA,ALL COMMERCIAL CIGNA,482.30,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $482.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,COFINITY,COFINITY,689.00,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $689.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76801 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76801 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,654.55,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $654.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,578.76,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $578.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,489.19,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $489.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,502.97,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $502.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,334.85,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $334.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,585.65,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $585.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HUMANA,HUMANA CHOICE CARE HMO,138.68,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $138.68 from Fee Schedule 005543_205 for Rev 402 Proc 76801 Mod TC * Qty 1 = $138.68 at 100% = $138.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HUMANA,HUMANA CHOICE CARE PPO,585.65,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $585.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,HUMANA,HUMANA NATIIONAL POS HMO,138.68,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $138.68 from Fee Schedule 005543_205 for Rev 402 Proc 76801 Mod TC * Qty 1 = $138.68 at 100% = $138.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,502.97,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $502.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,689.00,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $689.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76801 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76801 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76801 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,344.50,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $344.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,578.76,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $578.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,516.75,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $516.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,633.88,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $633.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,439.79,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $439.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,496.08,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $496.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76801 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,46.1600,689.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76801 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,46.1600,689.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,496.08,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $496.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,427.18,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $427.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,496.08,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $496.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,496.08,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $496.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS SGL,76801,CPT,402,RC,40200023,CDM,,,,both,,,689.0000,454.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,413.40,,,,,,,46.1600,689.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $689.00 in Billed Charges for Rev 402 Proc 76801 = $413.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,AETNA,AETNA HSHS,301.04,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $301.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,AETNA,ALL COMMERCIAL AETNA,466.00,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $466.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76810 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,ANTHEM,ANTHEM POS/HMO,466.00,,,,,,,46.1600,466.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 Qty 1 * $500.00 = $500.00 (Limited to $466.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,ANTHEM,ANTHEM PPO,466.00,,,,,,,46.1600,466.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 Qty 1 * $500.00 = $500.00 (Limited to $466.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,466.00,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $466.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,CENPATICO,ALL MEDICAID CENPATICO,466.00,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $466.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,396.10,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $396.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,CIGNA,ALL COMMERCIAL CIGNA,326.20,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $326.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,COFINITY,COFINITY,466.00,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $466.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76810 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76810 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,442.70,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $442.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,391.44,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $391.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,330.86,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $330.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,340.18,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $340.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,226.48,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $226.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,396.10,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $396.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,HUMANA,HUMANA CHOICE CARE HMO,80.54,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.54 from Fee Schedule 005543_205 for Rev 402 Proc 76810 Mod TC * Qty 1 = $80.54 at 100% = $80.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,HUMANA,HUMANA CHOICE CARE PPO,396.10,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $396.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,HUMANA,HUMANA NATIIONAL POS HMO,80.54,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.54 from Fee Schedule 005543_205 for Rev 402 Proc 76810 Mod TC * Qty 1 = $80.54 at 100% = $80.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,340.18,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $340.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,466.00,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $466.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76810 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76810 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76810 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,233.00,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $233.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,391.44,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $391.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,349.50,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $349.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,428.72,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $428.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,466.00,,,,,,,46.1600,466.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $466.00, claim capped at $466.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,466.00,,,,,,,46.1600,466.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $466.00, claim capped at $466.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,PREVEA HEALTH NETWORK,PREVEA360,466.00,,,,,,,46.1600,466.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $466.00, claim capped at $466.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,466.00,,,,,,,46.1600,466.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $466.00, claim capped at $466.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,297.45,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $297.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,335.52,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $335.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,466.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76810 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,466.00,,,,,,,46.1600,466.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $466.00, claim capped at $466.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,466.00,,,,,,,46.1600,466.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $466.00, claim capped at $466.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,466.00,,,,,,,46.1600,466.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76810 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $466.00, claim capped at $466.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,335.52,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $335.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,288.92,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $288.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,335.52,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $335.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,335.52,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $335.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS ADDL,76810,CPT,402,RC,40200027,CDM,,,,both,,,466.0000,307.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,279.60,,,,,,,46.1600,466.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $466.00 in Billed Charges for Rev 402 Proc 76810 = $279.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,AETNA,AETNA HSHS,636.31,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $636.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,AETNA,AETNA MEDICARE,231.76,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,AETNA,ALL COMMERCIAL AETNA,985.00,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $985.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76811 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,231.76,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,ANTHEM,ANTHEM PPO,500.00,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,985.00,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $985.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,CENPATICO,ALL MEDICAID CENPATICO,985.00,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $985.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,837.25,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $837.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,CIGNA,ALL COMMERCIAL CIGNA,689.50,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $689.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,COFINITY,COFINITY,985.00,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $985.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76811 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76811 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,935.75,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $935.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,827.40,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $827.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,699.35,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $699.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,719.05,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $719.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,478.71,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $478.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,837.25,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $837.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HUMANA,HUMANA CHOICE CARE HMO,171.79,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.79 from Fee Schedule 005543_205 for Rev 402 Proc 76811 Mod TC * Qty 1 = $171.79 at 100% = $171.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HUMANA,HUMANA CHOICE CARE PPO,837.25,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $837.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,231.76,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,HUMANA,HUMANA NATIIONAL POS HMO,171.79,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.79 from Fee Schedule 005543_205 for Rev 402 Proc 76811 Mod TC * Qty 1 = $171.79 at 100% = $171.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,719.05,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $719.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,985.00,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $985.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76811 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,231.76,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76811 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76811 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,231.76,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,492.50,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $492.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,827.40,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $827.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,521.46,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,738.75,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $738.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,906.20,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $906.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,628.73,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $628.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,234.08,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,709.20,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $709.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76811 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,231.76,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,46.1600,985.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76811 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,UNITY HEALTH PLAN,UNITY HOSPICE,231.76,,,,,,,46.1600,985.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,709.20,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $709.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,610.70,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $610.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,709.20,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $709.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,709.20,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $709.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED SGL,76811,CPT,402,RC,40200028,CDM,,,,both,,,985.0000,650.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,591.00,,,,,,,46.1600,985.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $985.00 in Billed Charges for Rev 402 Proc 76811 = $591.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,AETNA,AETNA HSHS,290.70,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $290.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,AETNA,ALL COMMERCIAL AETNA,450.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76812 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,ANTHEM,ANTHEM POS/HMO,450.00,,,,,,,46.1600,450.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 Qty 1 * $500.00 = $500.00 (Limited to $450.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,ANTHEM,ANTHEM PPO,450.00,,,,,,,46.1600,450.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 Qty 1 * $500.00 = $500.00 (Limited to $450.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,450.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,CENPATICO,ALL MEDICAID CENPATICO,450.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,382.50,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $382.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,CIGNA,ALL COMMERCIAL CIGNA,315.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $315.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,COFINITY,COFINITY,450.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76812 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76812 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,427.50,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $427.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,378.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $378.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,319.50,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $319.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,328.50,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $328.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,218.70,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $218.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,382.50,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $382.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,HUMANA,HUMANA CHOICE CARE HMO,210.74,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.74 from Fee Schedule 005543_205 for Rev 402 Proc 76812 Mod TC * Qty 1 = $210.74 at 100% = $210.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,HUMANA,HUMANA CHOICE CARE PPO,382.50,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $382.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,HUMANA,HUMANA NATIIONAL POS HMO,210.74,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $210.74 from Fee Schedule 005543_205 for Rev 402 Proc 76812 Mod TC * Qty 1 = $210.74 at 100% = $210.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,328.50,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $328.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,450.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $450.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76812 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76812 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76812 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,225.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,378.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $378.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,337.50,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $337.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,414.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,450.00,,,,,,,46.1600,450.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $450.00, claim capped at $450.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,450.00,,,,,,,46.1600,450.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $450.00, claim capped at $450.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,PREVEA HEALTH NETWORK,PREVEA360,450.00,,,,,,,46.1600,450.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $450.00, claim capped at $450.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,450.00,,,,,,,46.1600,450.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $450.00, claim capped at $450.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,287.24,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $287.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,324.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,450.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76812 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,450.00,,,,,,,46.1600,450.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $450.00, claim capped at $450.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,450.00,,,,,,,46.1600,450.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $450.00, claim capped at $450.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,450.00,,,,,,,46.1600,450.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76812 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $450.00, claim capped at $450.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,324.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,279.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $279.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,324.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,324.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $324.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY DETAILED ADDL,76812,CPT,402,RC,40200029,CDM,,,,both,,,450.0000,297.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,270.00,,,,,,,46.1600,450.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $450.00 in Billed Charges for Rev 402 Proc 76812 = $270.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,AETNA,AETNA HSHS,314.60,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $314.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,AETNA,AETNA MEDICARE,101.55,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,AETNA,ALL COMMERCIAL AETNA,487.00,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76816 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,ANTHEM,ANTHEM POS/HMO,487.00,,,,,,,46.1600,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 Qty 1 * $500.00 = $500.00 (Limited to $487.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,ANTHEM,ANTHEM PPO,487.00,,,,,,,46.1600,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 Qty 1 * $500.00 = $500.00 (Limited to $487.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,487.00,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,CENPATICO,ALL MEDICAID CENPATICO,487.00,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,413.95,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,CIGNA,ALL COMMERCIAL CIGNA,340.90,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $340.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,COFINITY,COFINITY,487.00,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76816 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76816 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,462.65,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $462.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,409.08,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $409.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,345.77,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $345.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,355.51,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $355.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,236.68,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $236.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,413.95,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HUMANA,HUMANA CHOICE CARE HMO,136.71,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $136.71 from Fee Schedule 005543_205 for Rev 402 Proc 76816 Mod TC * Qty 1 = $136.71 at 100% = $136.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HUMANA,HUMANA CHOICE CARE PPO,413.95,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,HUMANA,HUMANA NATIIONAL POS HMO,136.71,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $136.71 from Fee Schedule 005543_205 for Rev 402 Proc 76816 Mod TC * Qty 1 = $136.71 at 100% = $136.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,355.51,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $355.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,487.00,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76816 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76816 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76816 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,243.50,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $243.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,409.08,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $409.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,365.25,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $365.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,448.04,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $448.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,487.00,,,,,,,46.1600,487.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $487.00, claim capped at $487.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,487.00,,,,,,,46.1600,487.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $487.00, claim capped at $487.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,PREVEA HEALTH NETWORK,PREVEA360,487.00,,,,,,,46.1600,487.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $487.00, claim capped at $487.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,487.00,,,,,,,46.1600,487.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $487.00, claim capped at $487.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,310.85,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $310.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,350.64,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $350.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76816 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,487.00,,,,,,,46.1600,487.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $487.00, claim capped at $487.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,487.00,,,,,,,46.1600,487.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $487.00, claim capped at $487.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,487.00,,,,,,,46.1600,487.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76816 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $487.00, claim capped at $487.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,46.1600,487.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,350.64,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $350.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,301.94,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $301.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,350.64,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $350.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,350.64,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $350.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US OB GROWTH FOLLOWUP,76816,CPT,402,RC,40200030,CDM,,,,both,,,487.0000,321.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,292.20,,,,,,,46.1600,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $487.00 in Billed Charges for Rev 402 Proc 76816 = $292.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,AETNA,AETNA HSHS,390.18,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $390.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,AETNA,AETNA MEDICARE,101.55,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,AETNA,ALL COMMERCIAL AETNA,604.00,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76819 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,ANTHEM,ANTHEM PPO,500.00,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,604.00,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,CENPATICO,ALL MEDICAID CENPATICO,604.00,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,513.40,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $513.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,CIGNA,ALL COMMERCIAL CIGNA,422.80,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $422.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,COFINITY,COFINITY,604.00,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76819 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76819 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,573.80,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $573.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,507.36,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $507.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,428.84,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $428.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,440.92,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $440.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,293.54,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $293.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,513.40,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $513.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HUMANA,HUMANA CHOICE CARE HMO,96.45,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $96.45 from Fee Schedule 005543_205 for Rev 402 Proc 76819 Mod TC * Qty 1 = $96.45 at 100% = $96.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HUMANA,HUMANA CHOICE CARE PPO,513.40,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $513.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,HUMANA,HUMANA NATIIONAL POS HMO,96.45,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $96.45 from Fee Schedule 005543_205 for Rev 402 Proc 76819 Mod TC * Qty 1 = $96.45 at 100% = $96.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,440.92,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $440.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,604.00,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76819 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76819 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76819 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,302.00,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,507.36,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $507.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,453.00,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $453.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,555.68,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $555.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,385.53,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $385.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,434.88,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $434.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76819 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,46.1600,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76819 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,46.1600,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,434.88,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $434.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,374.48,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $374.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,434.88,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $434.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,434.88,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $434.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/O NST,76819,CPT,402,RC,40200034,CDM,,,,both,,,604.0000,398.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,362.40,,,,,,,46.1600,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $604.00 in Billed Charges for Rev 402 Proc 76819 = $362.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,AETNA,AETNA HSHS,286.18,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $286.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,AETNA,AETNA MEDICARE,101.55,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,AETNA,ALL COMMERCIAL AETNA,443.00,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76820 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,ANTHEM,ANTHEM POS/HMO,443.00,,,,,,,41.3700,443.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 Qty 1 * $500.00 = $500.00 (Limited to $443.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,ANTHEM,ANTHEM PPO,443.00,,,,,,,41.3700,443.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 Qty 1 * $500.00 = $500.00 (Limited to $443.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,443.00,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,CENPATICO,ALL MEDICAID CENPATICO,443.00,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,376.55,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $376.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,CIGNA,ALL COMMERCIAL CIGNA,310.10,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $310.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,COFINITY,COFINITY,443.00,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76820 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76820 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,420.85,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $420.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,372.12,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $372.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,314.53,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $314.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,323.39,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $323.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,215.30,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $215.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,376.55,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $376.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HUMANA,HUMANA CHOICE CARE HMO,41.37,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.37 from Fee Schedule 005543_205 for Rev 402 Proc 76820 Mod TC * Qty 1 = $41.37 at 100% = $41.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HUMANA,HUMANA CHOICE CARE PPO,376.55,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $376.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,HUMANA,HUMANA NATIIONAL POS HMO,41.37,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.37 from Fee Schedule 005543_205 for Rev 402 Proc 76820 Mod TC * Qty 1 = $41.37 at 100% = $41.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,323.39,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $323.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,443.00,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $443.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76820 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76820 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76820 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,221.50,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $221.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,372.12,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $372.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,332.25,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $332.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,407.56,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $407.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,443.00,,,,,,,41.3700,443.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $443.00, claim capped at $443.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,443.00,,,,,,,41.3700,443.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $443.00, claim capped at $443.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,PREVEA HEALTH NETWORK,PREVEA360,443.00,,,,,,,41.3700,443.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $443.00, claim capped at $443.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,443.00,,,,,,,41.3700,443.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $443.00, claim capped at $443.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,282.77,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $282.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,318.96,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $318.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76820 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,443.00,,,,,,,41.3700,443.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $443.00, claim capped at $443.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,UNITED HEALTHCARE,UHC ONEIDA NATION,443.00,,,,,,,41.3700,443.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $443.00, claim capped at $443.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,UNITED HEALTHCARE,UNITED HEALTHCARE,443.00,,,,,,,41.3700,443.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76820 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $443.00, claim capped at $443.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,41.3700,443.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,318.96,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $318.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,274.66,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $274.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,318.96,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $318.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,318.96,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $318.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL DOPLR VELO UMB,76820,CPT,402,RC,40200036,CDM,,,,both,,,443.0000,292.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,265.80,,,,,,,41.3700,443.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $443.00 in Billed Charges for Rev 402 Proc 76820 = $265.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,AETNA,AETNA HSHS,520.03,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $520.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,AETNA,ALL COMMERCIAL AETNA,805.00,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76830 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,805.00,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,CENPATICO,ALL MEDICAID CENPATICO,805.00,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,684.25,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $684.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,CIGNA,ALL COMMERCIAL CIGNA,563.50,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $563.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,COFINITY,COFINITY,805.00,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76830 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76830 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,764.75,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $764.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,676.20,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $676.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,571.55,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $571.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,587.65,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $587.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,391.23,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $391.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,684.25,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $684.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HUMANA,HUMANA CHOICE CARE HMO,169.60,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $169.60 from Fee Schedule 005543_205 for Rev 402 Proc 76830 Mod TC * Qty 1 = $169.60 at 100% = $169.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HUMANA,HUMANA CHOICE CARE PPO,684.25,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $684.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,HUMANA,HUMANA NATIIONAL POS HMO,169.60,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $169.60 from Fee Schedule 005543_205 for Rev 402 Proc 76830 Mod TC * Qty 1 = $169.60 at 100% = $169.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,587.65,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $587.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,805.00,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $805.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76830 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76830 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76830 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,402.50,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $402.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,676.20,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $676.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,603.75,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $603.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,740.60,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $740.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,513.83,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $513.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,579.60,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76830 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,805.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76830 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,805.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,579.60,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,499.10,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $499.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,579.60,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,579.60,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSVAGINAL,76830,CPT,402,RC,40200038,CDM,,,,both,,,805.0000,531.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,483.00,,,,,,,50.1000,805.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $805.00 in Billed Charges for Rev 402 Proc 76830 = $483.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,AETNA,AETNA HSHS,479.33,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $479.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,AETNA,AETNA MEDICARE,231.76,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,AETNA,ALL COMMERCIAL AETNA,742.00,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,ANTHEM,ANTEHM MEDICAID,77.18,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76831 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,231.76,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,ANTHEM,ANTHEM PPO,500.00,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,742.00,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,CENPATICO,ALL MEDICAID CENPATICO,742.00,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,630.70,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $630.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,CIGNA,ALL COMMERCIAL CIGNA,519.40,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $519.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,COFINITY,COFINITY,742.00,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.18,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76831 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.18,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76831 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,704.90,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $704.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,623.28,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $623.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,526.82,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $526.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,541.66,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $541.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,360.61,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $360.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,630.70,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $630.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HUMANA,HUMANA CHOICE CARE HMO,160.86,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $160.86 from Fee Schedule 005543_205 for Rev 402 Proc 76831 Mod TC * Qty 1 = $160.86 at 100% = $160.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HUMANA,HUMANA CHOICE CARE PPO,630.70,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $630.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,231.76,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,HUMANA,HUMANA NATIIONAL POS HMO,160.86,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $160.86 from Fee Schedule 005543_205 for Rev 402 Proc 76831 Mod TC * Qty 1 = $160.86 at 100% = $160.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,541.66,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $541.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,742.00,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.18,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76831 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,231.76,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.18,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76831 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,81.81,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76831 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18... $77.18 at 106% = $81.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,231.76,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,371.00,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,623.28,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $623.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,521.46,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,556.50,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $556.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,682.64,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $682.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,473.62,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $473.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,234.08,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,534.24,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,TRIOLOGY,TRILOGY MEDICAID,81.81,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76831 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 106% = $81.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,231.76,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,77.1800,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76831 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,UNITY HEALTH PLAN,UNITY HOSPICE,231.76,,,,,,,77.1800,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,534.24,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,460.04,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $460.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,534.24,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,534.24,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HYSTEROSONOGRAM,76831,CPT,402,RC,40200039,CDM,,,,both,,,742.0000,489.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,445.20,,,,,,,77.1800,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $742.00 in Billed Charges for Rev 402 Proc 76831 = $445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,AETNA,AETNA HSHS,602.07,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $602.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,AETNA,AETNA MEDICARE,101.55,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,AETNA,ALL COMMERCIAL AETNA,932.00,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $932.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,ANTHEM,ANTEHM MEDICAID,77.18,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76856 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,ANTHEM,ANTHEM PPO,500.00,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,932.00,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $932.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,CENPATICO,ALL MEDICAID CENPATICO,932.00,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $932.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,792.20,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $792.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,CIGNA,ALL COMMERCIAL CIGNA,652.40,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $652.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,COFINITY,COFINITY,932.00,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $932.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.18,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76856 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.18,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76856 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,885.40,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $885.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,782.88,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $782.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,661.72,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $661.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,680.36,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $680.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,452.95,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $452.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,792.20,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $792.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HUMANA,HUMANA CHOICE CARE HMO,143.25,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $143.25 from Fee Schedule 005543_205 for Rev 402 Proc 76856 Mod TC * Qty 1 = $143.25 at 100% = $143.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HUMANA,HUMANA CHOICE CARE PPO,792.20,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $792.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,HUMANA,HUMANA NATIIONAL POS HMO,143.25,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $143.25 from Fee Schedule 005543_205 for Rev 402 Proc 76856 Mod TC * Qty 1 = $143.25 at 100% = $143.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,680.36,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $680.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,932.00,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $932.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.18,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76856 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.18,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76856 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,81.81,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76856 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18... $77.18 at 106% = $81.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,466.00,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $466.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,782.88,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $782.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,699.00,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $699.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,857.44,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $857.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,594.90,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $594.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,671.04,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $671.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,TRIOLOGY,TRILOGY MEDICAID,81.81,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76856 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 106% = $81.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,77.1800,932.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76856 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,77.1800,932.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,671.04,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $671.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,577.84,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $577.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,671.04,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $671.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,671.04,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $671.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON OB,76856,CPT,402,RC,40200040,CDM,,,,both,,,932.0000,615.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,559.20,,,,,,,77.1800,932.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $932.00 in Billed Charges for Rev 402 Proc 76856 = $559.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,AETNA,AETNA HSHS,472.23,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $472.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,AETNA,ALL COMMERCIAL AETNA,731.00,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76857 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,731.00,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,CENPATICO,ALL MEDICAID CENPATICO,731.00,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,621.35,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,CIGNA,ALL COMMERCIAL CIGNA,511.70,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $511.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,COFINITY,COFINITY,731.00,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76857 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76857 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,694.45,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $694.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,614.04,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $614.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,519.01,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $519.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,533.63,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,355.27,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $355.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,621.35,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA CHOICE CARE HMO,51.17,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.17 from Fee Schedule 005543_205 for Rev 402 Proc 76857 Mod TC * Qty 1 = $51.17 at 100% = $51.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA CHOICE CARE PPO,621.35,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA NATIIONAL POS HMO,51.17,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.17 from Fee Schedule 005543_205 for Rev 402 Proc 76857 Mod TC * Qty 1 = $51.17 at 100% = $51.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,533.63,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,731.00,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76857 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76857 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76857 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,365.50,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $365.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,614.04,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $614.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,548.25,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $548.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,672.52,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $672.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,466.60,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $466.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,526.32,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76857 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76857 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,526.32,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,453.22,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $453.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,526.32,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,526.32,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PELVIS NON-OB LTD,76857,CPT,402,RC,40200041,CDM,,,,both,,,731.0000,482.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,438.60,,,,,,,50.1000,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $731.00 in Billed Charges for Rev 402 Proc 76857 = $438.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,AETNA,AETNA HSHS,223.52,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $223.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,AETNA,ALL COMMERCIAL AETNA,346.00,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $346.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76872 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,ANTHEM,ANTHEM POS/HMO,346.00,,,,,,,50.1000,346.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 Qty 1 * $500.00 = $500.00 (Limited to $346.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,ANTHEM,ANTHEM PPO,346.00,,,,,,,50.1000,346.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 Qty 1 * $500.00 = $500.00 (Limited to $346.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,346.00,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $346.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,CENPATICO,ALL MEDICAID CENPATICO,346.00,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $346.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,294.10,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $294.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,CIGNA,ALL COMMERCIAL CIGNA,242.20,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $242.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,COFINITY,COFINITY,346.00,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $346.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76872 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76872 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,328.70,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $328.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,290.64,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $290.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,245.66,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $245.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,252.58,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $252.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,168.16,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $168.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,294.10,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $294.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HUMANA,HUMANA CHOICE CARE HMO,330.91,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $330.91 from Fee Schedule 005543_205 for Rev 402 Proc 76872 Mod TC * Qty 1 = $330.91 at 100% = $330.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HUMANA,HUMANA CHOICE CARE PPO,294.10,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $294.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,HUMANA,HUMANA NATIIONAL POS HMO,330.91,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $330.91 from Fee Schedule 005543_205 for Rev 402 Proc 76872 Mod TC * Qty 1 = $330.91 at 100% = $330.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,252.58,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $252.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,346.00,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $346.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76872 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76872 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76872 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,173.00,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,290.64,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $290.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,259.50,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $259.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,318.32,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $318.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,346.00,,,,,,,50.1000,346.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $346.00, claim capped at $346.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,346.00,,,,,,,50.1000,346.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $346.00, claim capped at $346.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,PREVEA HEALTH NETWORK,PREVEA360,346.00,,,,,,,50.1000,346.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $346.00, claim capped at $346.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,346.00,,,,,,,50.1000,346.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $346.00, claim capped at $346.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,220.85,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $220.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,249.12,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $249.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76872 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,346.00,,,,,,,50.1000,346.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $346.00, claim capped at $346.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,346.00,,,,,,,50.1000,346.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $346.00, claim capped at $346.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,346.00,,,,,,,50.1000,346.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76872 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $346.00, claim capped at $346.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,346.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,249.12,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $249.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,214.52,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $214.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,249.12,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $249.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,249.12,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $249.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRA BX PROS,76872,CPT,402,RC,40200043,CDM,,,,both,,,346.0000,228.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,207.60,,,,,,,50.1000,346.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $346.00 in Billed Charges for Rev 402 Proc 76872 = $207.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,AETNA,AETNA HSHS,554.27,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $554.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,AETNA,AETNA MEDICARE,101.55,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,AETNA,ALL COMMERCIAL AETNA,858.00,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76881 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,ANTHEM,ANTHEM PPO,500.00,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,858.00,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,CENPATICO,ALL MEDICAID CENPATICO,858.00,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,729.30,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $729.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,CIGNA,ALL COMMERCIAL CIGNA,600.60,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $600.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,COFINITY,COFINITY,858.00,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76881 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76881 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,815.10,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $815.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,720.72,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $720.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,609.18,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $609.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,626.34,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $626.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,416.99,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $416.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,729.30,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $729.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HUMANA,HUMANA CHOICE CARE HMO,21.12,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.12 from Fee Schedule 005543_205 for Rev 402 Proc 76881 Mod TC * Qty 1 = $21.12 at 100% = $21.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HUMANA,HUMANA CHOICE CARE PPO,729.30,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $729.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,HUMANA,HUMANA NATIIONAL POS HMO,21.12,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.12 from Fee Schedule 005543_205 for Rev 402 Proc 76881 Mod TC * Qty 1 = $21.12 at 100% = $21.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,626.34,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $626.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,858.00,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76881 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76881 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76881 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,429.00,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $429.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,720.72,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $720.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,643.50,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $643.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,789.36,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $789.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,547.66,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $547.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,617.76,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $617.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76881 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,21.1200,858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76881 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,21.1200,858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,617.76,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $617.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,531.96,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $531.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,617.76,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $617.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,617.76,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $617.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR COMP,76881,CPT,402,RC,40200045,CDM,,,,both,,,858.0000,566.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,514.80,,,,,,,21.1200,858.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $858.00 in Billed Charges for Rev 402 Proc 76881 = $514.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,AETNA,AETNA HSHS,684.76,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $684.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,AETNA,ALL COMMERCIAL AETNA,1060.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,ANTHEM,ANTEHM MEDICAID,51.53,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76942 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,ANTHEM,ANTHEM PPO,500.00,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1060.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,CENPATICO,ALL MEDICAID CENPATICO,1060.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,901.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,CIGNA,ALL COMMERCIAL CIGNA,742.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,COFINITY,COFINITY,1060.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.53,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76942 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.53,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76942 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1007.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $1,007.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,890.40,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,752.60,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $752.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,773.80,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $773.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,515.16,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $515.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,901.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,HUMANA,HUMANA CHOICE CARE HMO,55.08,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.08 from Fee Schedule 005543_205 for Rev 402 Proc 76942 Mod TC * Qty 1 = $55.08 at 100% = $55.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,HUMANA,HUMANA CHOICE CARE PPO,901.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,HUMANA,HUMANA NATIIONAL POS HMO,55.08,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.08 from Fee Schedule 005543_205 for Rev 402 Proc 76942 Mod TC * Qty 1 = $55.08 at 100% = $55.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,773.80,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $773.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1060.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.53,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76942 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.53,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76942 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,54.62,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76942 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53... $51.53 at 106% = $54.62 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,530.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $530.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,890.40,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,795.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $795.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,975.20,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $975.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,676.60,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $676.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,763.20,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,TRIOLOGY,TRILOGY MEDICAID,54.63,,,,,,,51.5300,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76942 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 106% = $54.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,51.5300,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76942 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,763.20,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,657.20,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $657.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,763.20,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,763.20,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE PLCMT,76942,CPT,402,RC,40200053,CDM,,,,both,,,1060.0000,699.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,636.00,,,,,,,51.5300,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,060.00 in Billed Charges for Rev 402 Proc 76942 = $636.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,AETNA,AETNA HSHS,3699.00,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $3,699.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,AETNA,AETNA MEDICARE,1604.25,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,AETNA,ALL COMMERCIAL AETNA,5726.00,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $5,726.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,ANTHEM,ANTEHM MEDICAID,609.80,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00020 Proc 19083 at $125.60 (Base Rate) * 4.8551 (Relative Weight) = $609.80 (Total Line Payment) at 100% = $609.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1604.25,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,ANTHEM,ANTHEM PPO,500.00,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5726.00,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $5,726.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,CENPATICO,ALL MEDICAID CENPATICO,5726.00,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $5,726.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4867.10,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,867.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,CIGNA,ALL COMMERCIAL CIGNA,4008.20,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,008.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,COFINITY,COFINITY,5726.00,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $5,726.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,609.80,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00020 Proc 19083 at $125.60 (Base Rate) * 4.8551 (Relative Weight) = $609.80 (Total Line Payment) at 100% = $609.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,609.80,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00020 Proc 19083 at $125.60 (Base Rate) * 4.8551 (Relative Weight) = $609.80 (Total Line Payment) at 100% = $609.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5439.70,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $5,439.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,4809.84,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,809.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4065.46,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,065.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4179.98,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,179.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,2782.84,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $2,782.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4867.10,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,867.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HUMANA,HUMANA CHOICE CARE HMO,290.83,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $290.83 from Fee Schedule 005543_205 for Rev 402 Proc 19083 Mod TC * Qty 1 = $290.83 at 100% = $290.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HUMANA,HUMANA CHOICE CARE PPO,4867.10,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,867.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,1604.25,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,HUMANA,HUMANA NATIIONAL POS HMO,290.83,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $290.83 from Fee Schedule 005543_205 for Rev 402 Proc 19083 Mod TC * Qty 1 = $290.83 at 100% = $290.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4179.98,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,179.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,5726.00,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $5,726.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,609.80,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00020 Proc 19083 at $125.60 (Base Rate) * 4.8551 (Relative Weight) = $609.80 (Total Line Payment) at 100% = $609.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1604.25,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,609.80,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00020 Proc 19083 at $125.60 (Base Rate) * 4.8551 (Relative Weight) = $609.80 (Total Line Payment) at 100% = $609.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,MOLINA HEALTHCARE,MOLINA MEDICAID,646.39,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00020 Proc 19083 at $125.60 (Base Rate) * 4.8551 (Relative Weight) = $609.80 (Total Line Payment) at 100% = $609.80... $609.80 at 106% = $646.39 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,1604.25,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2863.00,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $2,863.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4809.84,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,809.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,3609.56,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4294.50,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,294.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5267.92,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $5,267.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3654.91,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $3,654.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1620.29,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4122.72,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,122.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,TRIOLOGY,TRILOGY MEDICAID,646.39,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00020 Proc 19083 at $125.60 (Base Rate) * 4.8551 (Relative Weight) = $609.80 (Total Line Payment) at 106% = $646.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1604.25,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,290.8300,5726.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 19083 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,UNITY HEALTH PLAN,UNITY HOSPICE,1604.25,,,,,,,290.8300,5726.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4122.72,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,122.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3550.12,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $3,550.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4122.72,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,122.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4122.72,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $4,122.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED NEEDLE BX BREAST,19083,CPT,402,RC,40200056,CDM,,,,both,,,5726.0000,3779.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3435.60,,,,,,,290.8300,5726.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,726.00 in Billed Charges for Rev 402 Proc 19083 = $3,435.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,AETNA,AETNA HSHS,150.52,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $150.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,AETNA,ALL COMMERCIAL AETNA,233.00,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $233.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,ANTHEM,ANTEHM MEDICAID,51.53,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76946 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,ANTHEM,ANTHEM POS/HMO,233.00,,,,,,,29.6000,233.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 Qty 1 * $500.00 = $500.00 (Limited to $233.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,ANTHEM,ANTHEM PPO,233.00,,,,,,,29.6000,233.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 Qty 1 * $500.00 = $500.00 (Limited to $233.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,233.00,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $233.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,CENPATICO,ALL MEDICAID CENPATICO,233.00,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $233.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,198.05,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $198.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,CIGNA,ALL COMMERCIAL CIGNA,163.10,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $163.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,COFINITY,COFINITY,233.00,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $233.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.53,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76946 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.53,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76946 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,221.35,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $221.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,195.72,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $195.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,165.43,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $165.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,170.09,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $170.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,113.24,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $113.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,198.05,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $198.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,HUMANA,HUMANA CHOICE CARE HMO,29.60,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.60 from Fee Schedule 005543_205 for Rev 402 Proc 76946 Mod TC * Qty 1 = $29.60 at 100% = $29.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,HUMANA,HUMANA CHOICE CARE PPO,198.05,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $198.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,HUMANA,HUMANA NATIIONAL POS HMO,29.60,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.60 from Fee Schedule 005543_205 for Rev 402 Proc 76946 Mod TC * Qty 1 = $29.60 at 100% = $29.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,170.09,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $170.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,233.00,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $233.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.53,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76946 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.53,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76946 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,54.62,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76946 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53... $51.53 at 106% = $54.62 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,116.50,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $116.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,195.72,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $195.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,174.75,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $174.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,214.36,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $214.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,233.00,,,,,,,29.6000,233.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $233.00, claim capped at $233.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,233.00,,,,,,,29.6000,233.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $233.00, claim capped at $233.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,PREVEA HEALTH NETWORK,PREVEA360,233.00,,,,,,,29.6000,233.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $233.00, claim capped at $233.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,233.00,,,,,,,29.6000,233.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $233.00, claim capped at $233.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,148.72,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $148.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,167.76,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $167.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,TRIOLOGY,TRILOGY MEDICAID,54.63,,,,,,,29.6000,233.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76946 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 106% = $54.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,233.00,,,,,,,29.6000,233.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $233.00, claim capped at $233.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,233.00,,,,,,,29.6000,233.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $233.00, claim capped at $233.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,233.00,,,,,,,29.6000,233.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76946 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $233.00, claim capped at $233.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,167.76,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $167.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,144.46,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $144.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,167.76,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $167.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,167.76,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $167.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED AMNIOCENTESIS,76946,CPT,402,RC,40200059,CDM,,,,both,,,233.0000,153.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,139.80,,,,,,,29.6000,233.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $233.00 in Billed Charges for Rev 402 Proc 76946 = $139.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,AETNA,AETNA HSHS,82.04,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $82.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,AETNA,ALL COMMERCIAL AETNA,127.00,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTEHM MEDICAID,51.53,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76965 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTHEM POS/HMO,127.00,,,,,,,51.5300,127.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 Qty 1 * $500.00 = $500.00 (Limited to $127.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,ANTHEM,ANTHEM PPO,127.00,,,,,,,51.5300,127.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 Qty 1 * $500.00 = $500.00 (Limited to $127.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,127.00,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,CENPATICO,ALL MEDICAID CENPATICO,127.00,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,107.95,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,CIGNA,ALL COMMERCIAL CIGNA,88.90,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $88.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,COFINITY,COFINITY,127.00,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.53,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76965 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.53,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76965 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,120.65,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $120.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,106.68,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $106.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,90.17,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $90.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,92.71,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $92.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,61.72,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $61.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,107.95,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA CHOICE CARE HMO,53.77,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $53.77 from Fee Schedule 005543_205 for Rev 402 Proc 76965 Mod TC * Qty 1 = $53.77 at 100% = $53.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA CHOICE CARE PPO,107.95,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $107.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,HUMANA,HUMANA NATIIONAL POS HMO,53.77,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $53.77 from Fee Schedule 005543_205 for Rev 402 Proc 76965 Mod TC * Qty 1 = $53.77 at 100% = $53.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,92.71,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $92.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,127.00,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.53,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76965 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.53,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76965 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,54.62,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76965 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53... $51.53 at 106% = $54.62 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,63.50,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $63.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,106.68,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $106.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,95.25,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $95.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,116.84,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $116.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,127.00,,,,,,,51.5300,127.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $127.00, claim capped at $127.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,127.00,,,,,,,51.5300,127.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $127.00, claim capped at $127.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA360,127.00,,,,,,,51.5300,127.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $127.00, claim capped at $127.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,127.00,,,,,,,51.5300,127.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $127.00, claim capped at $127.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,81.06,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $81.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,91.44,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,TRIOLOGY,TRILOGY MEDICAID,54.63,,,,,,,51.5300,127.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76965 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 106% = $54.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,127.00,,,,,,,51.5300,127.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $127.00, claim capped at $127.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,127.00,,,,,,,51.5300,127.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $127.00, claim capped at $127.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,127.00,,,,,,,51.5300,127.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76965 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $127.00, claim capped at $127.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,91.44,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,78.74,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $78.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,91.44,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,91.44,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $91.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED INTERSTITIAL THRPY,76965,CPT,402,RC,40200061,CDM,,,,both,,,127.0000,83.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,76.20,,,,,,,51.5300,127.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $127.00 in Billed Charges for Rev 402 Proc 76965 = $76.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,AETNA,AETNA HSHS,821.71,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $821.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,AETNA,ALL COMMERCIAL AETNA,1272.00,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,ANTHEM,ANTEHM MEDICAID,51.53,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76998 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,ANTHEM,ANTHEM PPO,500.00,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1272.00,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,CENPATICO,ALL MEDICAID CENPATICO,1272.00,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1081.20,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,081.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,CIGNA,ALL COMMERCIAL CIGNA,890.40,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,COFINITY,COFINITY,1272.00,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.53,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76998 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.53,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76998 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1208.40,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,208.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,1068.48,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,068.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,903.12,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $903.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,928.56,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $928.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,618.19,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $618.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1081.20,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,081.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,HUMANA,HUMANA CHOICE CARE HMO,103.16,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $103.16 from Fee Schedule 005543_205 for Rev 402 Proc 76998 Mod TC * Qty 1 = $103.16 at 100% = $103.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,HUMANA,HUMANA CHOICE CARE PPO,1081.20,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,081.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,HUMANA,HUMANA NATIIONAL POS HMO,103.16,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $103.16 from Fee Schedule 005543_205 for Rev 402 Proc 76998 Mod TC * Qty 1 = $103.16 at 100% = $103.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,928.56,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $928.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1272.00,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,272.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.53,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76998 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.53,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76998 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,54.62,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76998 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53... $51.53 at 106% = $54.62 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,636.00,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $636.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1068.48,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,068.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,954.00,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1170.24,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $1,170.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,811.92,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $811.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,915.84,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $915.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,TRIOLOGY,TRILOGY MEDICAID,54.63,,,,,,,51.5300,1272.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76998 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 106% = $54.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,51.5300,1272.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76998 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,915.84,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $915.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,788.64,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $788.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,915.84,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $915.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,915.84,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $915.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US INTRAOPERATIVE,76998,CPT,402,RC,40200062,CDM,,,,both,,,1272.0000,839.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,763.20,,,,,,,51.5300,1272.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,272.00 in Billed Charges for Rev 402 Proc 76998 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,AETNA,AETNA HSHS,287.47,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $287.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,AETNA,AETNA MEDICARE,84.53,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,AETNA,ALL COMMERCIAL AETNA,445.00,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76999 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,84.53,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,ANTHEM,ANTHEM POS/HMO,445.00,,,,,,,50.1000,445.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 Qty 1 * $500.00 = $500.00 (Limited to $445.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,ANTHEM,ANTHEM PPO,445.00,,,,,,,50.1000,445.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 Qty 1 * $500.00 = $500.00 (Limited to $445.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,445.00,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,CENPATICO,ALL MEDICAID CENPATICO,445.00,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,378.25,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $378.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,CIGNA,ALL COMMERCIAL CIGNA,311.50,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $311.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,COFINITY,COFINITY,445.00,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76999 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76999 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,422.75,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $422.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,373.80,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $373.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,315.95,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $315.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,324.85,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $324.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,216.27,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $216.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,378.25,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $378.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,HUMANA,HUMANA CHOICE CARE PPO,378.25,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $378.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,84.53,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,324.85,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $324.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,445.00,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76999 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,84.53,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76999 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76999 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,84.53,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,222.50,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $222.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,373.80,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $373.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,190.19,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,333.75,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $333.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,409.40,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $409.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,445.00,,,,,,,50.1000,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,445.00,,,,,,,50.1000,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,PREVEA HEALTH NETWORK,PREVEA360,445.00,,,,,,,50.1000,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,445.00,,,,,,,50.1000,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,284.04,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $284.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,85.38,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,320.40,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76999 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,445.00,,,,,,,50.1000,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,445.00,,,,,,,50.1000,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,84.53,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,445.00,,,,,,,50.1000,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76999 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,UNITY HEALTH PLAN,UNITY HOSPICE,84.53,,,,,,,50.1000,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,320.40,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,275.90,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $275.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,320.40,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,320.40,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UNLISTED PROCEDURE ULTRASOUND,76999,CPT,402,RC,40200063,CDM,,,,both,,,445.0000,293.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,267.00,,,,,,,50.1000,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $445.00 in Billed Charges for Rev 402 Proc 76999 = $267.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,AETNA,AETNA HSHS,684.76,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $684.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,AETNA,AETNA MEDICARE,101.55,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,AETNA,ALL COMMERCIAL AETNA,1060.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,ANTHEM,ANTEHM MEDICAID,77.18,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93976 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,ANTHEM,ANTHEM PPO,500.00,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1060.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,CENPATICO,ALL MEDICAID CENPATICO,1060.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,901.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,CIGNA,ALL COMMERCIAL CIGNA,742.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,COFINITY,COFINITY,1060.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.18,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93976 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.18,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93976 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1007.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $1,007.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,890.40,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,752.60,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $752.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,773.80,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $773.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,515.16,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $515.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,901.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HUMANA,HUMANA CHOICE CARE HMO,236.86,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $236.86 from Fee Schedule 005543_205 for Rev 402 Proc 93976 Mod TC * Qty 1 = $236.86 at 100% = $236.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HUMANA,HUMANA CHOICE CARE PPO,901.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $901.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,HUMANA,HUMANA NATIIONAL POS HMO,236.86,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $236.86 from Fee Schedule 005543_205 for Rev 402 Proc 93976 Mod TC * Qty 1 = $236.86 at 100% = $236.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,773.80,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $773.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1060.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $1,060.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.18,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93976 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.18,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93976 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,81.81,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93976 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18... $77.18 at 106% = $81.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,530.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $530.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,890.40,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $890.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,795.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $795.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,975.20,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $975.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,676.60,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $676.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,763.20,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,TRIOLOGY,TRILOGY MEDICAID,81.81,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93976 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 106% = $81.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,77.1800,1060.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93976 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,77.1800,1060.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,763.20,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,657.20,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $657.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,763.20,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,763.20,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $763.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93976,CPT,402,RC,40200068,CDM,,,,both,,,1060.0000,699.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,636.00,,,,,,,77.1800,1060.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,060.00 in Billed Charges for Rev 402 Proc 93976 = $636.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,AETNA,AETNA HSHS,588.51,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $588.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,AETNA,AETNA MEDICARE,231.76,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,AETNA,ALL COMMERCIAL AETNA,911.00,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $911.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,ANTHEM,ANTEHM MEDICAID,77.18,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93978 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,231.76,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,ANTHEM,ANTHEM POS/HMO,619.48,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $619.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,ANTHEM,ANTHEM PPO,619.48,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $619.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,911.00,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $911.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,CENPATICO,ALL MEDICAID CENPATICO,911.00,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $911.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,774.35,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $774.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,CIGNA,ALL COMMERCIAL CIGNA,637.70,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $637.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,COFINITY,COFINITY,911.00,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $911.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.18,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93978 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.18,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93978 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,865.45,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $865.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,765.24,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $765.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,646.81,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $646.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,665.03,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $665.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,442.75,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $442.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,774.35,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $774.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HUMANA,HUMANA CHOICE CARE HMO,578.49,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $578.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HUMANA,HUMANA CHOICE CARE PPO,774.35,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $774.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HUMANA,HUMANA MEDICARE ADVANTAGE,231.76,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,HUMANA,HUMANA NATIIONAL POS HMO,578.49,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $578.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,665.03,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $665.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,911.00,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $911.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.18,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93978 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,231.76,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.18,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93978 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,81.81,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93978 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18... $77.18 at 106% = $81.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,MOLINA HEALTHCARE,MOLINA MEDICARE,231.76,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,455.50,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $455.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,765.24,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $765.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,NAPHCARE,ALL COMMERICAL NAPHCARE,521.46,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,683.25,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $683.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,838.12,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $838.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,472.83,,,,,,,77.1800,911.0000,other,ST VINCENT HOSPITAL (ACU). Rev 921 Proc 93978 1 Visit at $472.83 per Visit = $472.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,472.83,,,,,,,77.1800,911.0000,other,ST VINCENT HOSPITAL (ACU). Rev 921 Proc 93978 1 Visit at $472.83 per Visit = $472.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,PREVEA HEALTH NETWORK,PREVEA360,472.83,,,,,,,77.1800,911.0000,other,ST VINCENT HOSPITAL (ACU). Rev 921 Proc 93978 1 Visit at $472.83 per Visit = $472.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,472.83,,,,,,,77.1800,911.0000,other,ST VINCENT HOSPITAL (ACU). Rev 921 Proc 93978 1 Visit at $472.83 per Visit = $472.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,581.49,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $581.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,234.08,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,655.92,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $655.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,TRIOLOGY,TRILOGY MEDICAID,81.81,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93978 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 106% = $81.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,494.50,,,,,,,77.1800,911.0000,other,ST VINCENT HOSPITAL (ACU). Rev 921 Proc 93978 1 Visit at $494.50 per Visit = $494.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,494.50,,,,,,,77.1800,911.0000,other,ST VINCENT HOSPITAL (ACU). Rev 921 Proc 93978 1 Visit at $494.50 per Visit = $494.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,231.76,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,494.50,,,,,,,77.1800,911.0000,other,ST VINCENT HOSPITAL (ACU). Rev 921 Proc 93978 1 Visit at $494.50 per Visit = $494.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,UNITY HEALTH PLAN,UNITY HOSPICE,231.76,,,,,,,77.1800,911.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,655.92,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $655.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,564.82,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $564.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,655.92,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $655.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,655.92,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $655.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT CMPL,93978,CPT,921,RC,40200073,CDM,,,,both,,,911.0000,601.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,546.60,,,,,,,77.1800,911.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $911.00 in Billed Charges for Rev 921 Proc 93978 = $546.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,AETNA,AETNA HSHS,225.45,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $225.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,AETNA,ALL COMMERCIAL AETNA,349.00,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $349.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76814 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,ANTHEM,ANTHEM POS/HMO,349.00,,,,,,,46.1600,349.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 Qty 1 * $500.00 = $500.00 (Limited to $349.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,ANTHEM,ANTHEM PPO,349.00,,,,,,,46.1600,349.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 Qty 1 * $500.00 = $500.00 (Limited to $349.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,349.00,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $349.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,CENPATICO,ALL MEDICAID CENPATICO,349.00,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $349.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,296.65,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $296.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,CIGNA,ALL COMMERCIAL CIGNA,244.30,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $244.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,COFINITY,COFINITY,349.00,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $349.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76814 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76814 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,331.55,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $331.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,293.16,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $293.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,247.79,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $247.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,254.77,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $254.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,169.61,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $169.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,296.65,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $296.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,HUMANA,HUMANA CHOICE CARE HMO,54.43,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $54.43 from Fee Schedule 005543_205 for Rev 402 Proc 76814 Mod TC * Qty 1 = $54.43 at 100% = $54.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,HUMANA,HUMANA CHOICE CARE PPO,296.65,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $296.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,HUMANA,HUMANA NATIIONAL POS HMO,54.43,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $54.43 from Fee Schedule 005543_205 for Rev 402 Proc 76814 Mod TC * Qty 1 = $54.43 at 100% = $54.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,254.77,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $254.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,349.00,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $349.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76814 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76814 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76814 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,174.50,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $174.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,293.16,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $293.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,261.75,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $261.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,321.08,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $321.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,349.00,,,,,,,46.1600,349.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $349.00, claim capped at $349.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,349.00,,,,,,,46.1600,349.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $349.00, claim capped at $349.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,PREVEA HEALTH NETWORK,PREVEA360,349.00,,,,,,,46.1600,349.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $349.00, claim capped at $349.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,349.00,,,,,,,46.1600,349.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $349.00, claim capped at $349.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,222.77,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $222.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,251.28,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $251.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,349.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76814 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,349.00,,,,,,,46.1600,349.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $349.00, claim capped at $349.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,349.00,,,,,,,46.1600,349.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $349.00, claim capped at $349.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,349.00,,,,,,,46.1600,349.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76814 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $349.00, claim capped at $349.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,251.28,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $251.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,216.38,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $216.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,251.28,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $251.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,251.28,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $251.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY ADDL,76814,CPT,402,RC,40200093,CDM,,,,both,,,349.0000,230.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,209.40,,,,,,,46.1600,349.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $349.00 in Billed Charges for Rev 402 Proc 76814 = $209.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,AETNA,AETNA HSHS,166.02,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $166.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,AETNA,AETNA MEDICARE,84.53,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,AETNA,ALL COMMERCIAL AETNA,257.00,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $257.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,ANTHEM,ANTEHM MEDICAID,25.66,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00156 Proc 76529 at $125.60 (Base Rate) * 0.2043 (Relative Weight) = $25.66 (Total Line Payment) at 100% = $25.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,84.53,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,ANTHEM,ANTHEM POS/HMO,257.00,,,,,,,25.6600,257.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 Qty 1 * $500.00 = $500.00 (Limited to $257.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,ANTHEM,ANTHEM PPO,257.00,,,,,,,25.6600,257.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 Qty 1 * $500.00 = $500.00 (Limited to $257.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,257.00,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $257.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,CENPATICO,ALL MEDICAID CENPATICO,257.00,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $257.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,218.45,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $218.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,CIGNA,ALL COMMERCIAL CIGNA,179.90,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $179.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,COFINITY,COFINITY,257.00,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $257.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,25.66,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00156 Proc 76529 at $125.60 (Base Rate) * 0.2043 (Relative Weight) = $25.66 (Total Line Payment) at 100% = $25.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,25.66,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00156 Proc 76529 at $125.60 (Base Rate) * 0.2043 (Relative Weight) = $25.66 (Total Line Payment) at 100% = $25.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,244.15,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $244.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,215.88,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $215.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,182.47,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $182.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,187.61,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $187.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,124.90,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $124.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,218.45,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $218.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HUMANA,HUMANA CHOICE CARE HMO,105.37,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $105.37 from Fee Schedule 005543_205 for Rev 402 Proc 76529 Mod TC * Qty 1 = $105.37 at 100% = $105.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HUMANA,HUMANA CHOICE CARE PPO,218.45,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $218.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HUMANA,HUMANA MEDICARE ADVANTAGE,84.53,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,HUMANA,HUMANA NATIIONAL POS HMO,105.37,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $105.37 from Fee Schedule 005543_205 for Rev 402 Proc 76529 Mod TC * Qty 1 = $105.37 at 100% = $105.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,187.61,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $187.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,257.00,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $257.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,25.66,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00156 Proc 76529 at $125.60 (Base Rate) * 0.2043 (Relative Weight) = $25.66 (Total Line Payment) at 100% = $25.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,84.53,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,25.66,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00156 Proc 76529 at $125.60 (Base Rate) * 0.2043 (Relative Weight) = $25.66 (Total Line Payment) at 100% = $25.66. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,MOLINA HEALTHCARE,MOLINA MEDICAID,27.20,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00156 Proc 76529 at $125.60 (Base Rate) * 0.2043 (Relative Weight) = $25.66 (Total Line Payment) at 100% = $25.66... $25.66 at 106% = $27.20 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,MOLINA HEALTHCARE,MOLINA MEDICARE,84.53,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,128.50,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $128.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,215.88,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $215.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,NAPHCARE,ALL COMMERICAL NAPHCARE,190.19,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,192.75,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $192.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,236.44,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $236.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,257.00,,,,,,,25.6600,257.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $257.00, claim capped at $257.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,257.00,,,,,,,25.6600,257.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $257.00, claim capped at $257.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,PREVEA HEALTH NETWORK,PREVEA360,257.00,,,,,,,25.6600,257.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $257.00, claim capped at $257.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,257.00,,,,,,,25.6600,257.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $257.00, claim capped at $257.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,164.04,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $164.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,85.38,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,185.04,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $185.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,TRIOLOGY,TRILOGY MEDICAID,27.20,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00156 Proc 76529 at $125.60 (Base Rate) * 0.2043 (Relative Weight) = $25.66 (Total Line Payment) at 106% = $27.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,257.00,,,,,,,25.6600,257.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $257.00, claim capped at $257.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,UNITED HEALTHCARE,UHC ONEIDA NATION,257.00,,,,,,,25.6600,257.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $257.00, claim capped at $257.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,84.53,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,UNITED HEALTHCARE,UNITED HEALTHCARE,257.00,,,,,,,25.6600,257.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76529 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $257.00, claim capped at $257.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,UNITY HEALTH PLAN,UNITY HOSPICE,84.53,,,,,,,25.6600,257.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,185.04,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $185.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,159.34,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $159.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,185.04,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $185.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,185.04,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $185.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPTH US FOREIGN BODY LOCALIZATION,76529,CPT,402,RC,40200099,CDM,,,,both,,,257.0000,169.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,154.20,,,,,,,25.6600,257.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $257.00 in Billed Charges for Rev 402 Proc 76529 = $154.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,AETNA,AETNA HSHS,303.62,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $303.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,AETNA,AETNA MEDICARE,87.14,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,AETNA,ALL COMMERCIAL AETNA,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,ANTHEM,ANTEHM MEDICAID,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77067 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,87.14,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,ANTHEM,ANTHEM POS/HMO,350.00,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 403 Proc 77067 1 Visit at $350.00 per Visit = $350.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,ANTHEM,ANTHEM PPO,350.00,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 403 Proc 77067 1 Visit at $350.00 per Visit = $350.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,CENPATICO,ALL MEDICAID CENPATICO,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,399.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $399.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,CIGNA,ALL COMMERCIAL CIGNA,329.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,COFINITY,COFINITY,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77067 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77067 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,446.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $446.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,394.80,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $394.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,333.70,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $333.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,343.10,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $343.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,228.42,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $228.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,399.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $399.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HUMANA,HUMANA CHOICE CARE HMO,180.46,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $180.46 from Fee Schedule 005543_205 for Rev 403 Proc 77067 Mod TC * Qty 1 = $180.46 at 100% = $180.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HUMANA,HUMANA CHOICE CARE PPO,399.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $399.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,87.14,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,HUMANA,HUMANA NATIIONAL POS HMO,180.46,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $180.46 from Fee Schedule 005543_205 for Rev 403 Proc 77067 Mod TC * Qty 1 = $180.46 at 100% = $180.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,343.10,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $343.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77067 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,87.14,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77067 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,23.18,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77067 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87... $21.87 at 106% = $23.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,87.14,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,235.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,394.80,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $394.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,196.07,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,352.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $352.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,432.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $432.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,PREVEA HEALTH NETWORK,PREVEA360,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,300.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,88.01,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,338.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,TRIOLOGY,TRILOGY MEDICAID,23.18,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77067 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 106% = $23.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,193.80,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 403 Proc 77067 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,193.80,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 403 Proc 77067 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,87.14,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,193.80,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 403 Proc 77067 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,UNITY HEALTH PLAN,UNITY HOSPICE,87.14,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,338.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,291.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $291.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,338.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,338.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCR MAMMO BI INCL CAD,77067,CPT,403,RC,40300003,CDM,,,,both,,,470.0000,310.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 403 Proc 77067 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,AETNA,AETNA HSHS,4797.84,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $4,797.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,AETNA,AETNA MEDICARE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,AETNA,ALL COMMERCIAL AETNA,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,ANTHEM,ANTEHM MEDICAID,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78814 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,ANTHEM,ANTHEM POS/HMO,4600.00,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,ANTHEM,ANTHEM PPO,4600.00,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,CENPATICO,ALL MEDICAID CENPATICO,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6312.95,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $6,312.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,CIGNA,ALL COMMERCIAL CIGNA,5198.90,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,198.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,COFINITY,COFINITY,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78814 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78814 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7055.65,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $7,055.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,6238.68,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $6,238.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5273.17,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,273.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5421.71,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,421.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,3609.52,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $3,609.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6312.95,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $6,312.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,HUMANA CHOICE CARE HMO,5794.84,,,,,,,611.5800,7427.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,794.84 from Fee Schedule 005543_205 for Rev 404 Proc 78814 Mod TC * Qty 1 = $5,794.84 at 100% = $5,794.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,HUMANA CHOICE CARE PPO,6312.95,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $6,312.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,HUMANA NATIIONAL POS HMO,5794.84,,,,,,,611.5800,7427.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,794.84 from Fee Schedule 005543_205 for Rev 404 Proc 78814 Mod TC * Qty 1 = $5,794.84 at 100% = $5,794.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5421.71,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,421.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78814 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78814 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,648.27,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78814 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58... $611.58 at 106% = $648.27 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3713.50,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $3,713.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6238.68,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $6,238.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,3125.15,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5570.25,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,570.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6832.84,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $6,832.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3928.74,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3928.74,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,PREVEA HEALTH NETWORK,PREVEA360,3928.74,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3928.74,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4740.65,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $4,740.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1402.85,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5347.44,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,347.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,TRIOLOGY,TRILOGY MEDICAID,648.28,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78814 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 106% = $648.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,4115.50,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78814 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,UNITY HEALTH PLAN,UNITY HOSPICE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5347.44,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,347.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4604.74,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $4,604.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5347.44,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,347.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5347.44,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $5,347.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR LIMITED AREA,78814,CPT,404,RC,40400003,CDM,,,,both,,,7427.0000,4901.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4456.20,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,427.00 in Billed Charges for Rev 404 Proc 78814 = $4,456.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,AETNA,AETNA HSHS,435.40,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $435.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,AETNA,AETNA MEDICARE,230.06,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,AETNA,ALL COMMERCIAL AETNA,674.00,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $674.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,ANTHEM,ANTEHM MEDICAID,77.65,,,,,,,77.6500,674.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00249 Proc 31502 at $125.60 (Base Rate) * 0.6182 (Relative Weight) = $77.65 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $77.65 at 100% = $77.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,230.06,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,ANTHEM,ANTHEM POS/HMO,458.32,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $458.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,ANTHEM,ANTHEM PPO,458.32,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $458.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,674.00,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $674.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,CENPATICO,ALL MEDICAID CENPATICO,674.00,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $674.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,572.90,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $572.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,CIGNA,ALL COMMERCIAL CIGNA,471.80,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $471.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,COFINITY,COFINITY,674.00,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $674.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.65,,,,,,,77.6500,674.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00249 Proc 31502 at $125.60 (Base Rate) * 0.6182 (Relative Weight) = $77.65 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $77.65 at 100% = $77.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.65,,,,,,,77.6500,674.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00249 Proc 31502 at $125.60 (Base Rate) * 0.6182 (Relative Weight) = $77.65 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $77.65 at 100% = $77.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,640.30,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $640.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,566.16,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $566.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,478.54,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $478.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,492.02,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $492.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,327.56,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $327.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,572.90,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $572.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HUMANA,HUMANA CHOICE CARE HMO,427.99,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $427.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HUMANA,HUMANA CHOICE CARE PPO,572.90,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $572.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,230.06,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,HUMANA,HUMANA NATIIONAL POS HMO,427.99,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $427.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,492.02,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $492.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,674.00,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $674.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.65,,,,,,,77.6500,674.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00249 Proc 31502 at $125.60 (Base Rate) * 0.6182 (Relative Weight) = $77.65 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $77.65 at 100% = $77.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,230.06,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.65,,,,,,,77.6500,674.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00249 Proc 31502 at $125.60 (Base Rate) * 0.6182 (Relative Weight) = $77.65 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $77.65 at 100% = $77.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,82.31,,,,,,,77.6500,674.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00249 Proc 31502 at $125.60 (Base Rate) * 0.6182 (Relative Weight) = $77.65 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $77.65 at 100% = $77.65... $77.65 at 106% = $82.31 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,230.06,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,337.00,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,566.16,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $566.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,517.64,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,505.50,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $505.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,620.08,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $620.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,77.6500,674.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 31502 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,77.6500,674.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 31502 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,77.6500,674.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 31502 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,77.6500,674.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 31502 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,430.21,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $430.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,232.36,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,485.28,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $485.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,TRIOLOGY,TRILOGY MEDICAID,82.30,,,,,,,77.6500,674.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00249 Proc 31502 at $125.60 (Base Rate) * 0.6182 (Relative Weight) = $77.65 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $77.65 at 106% = $82.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,77.6500,674.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 31502 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,77.6500,674.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 31502 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,230.06,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,77.6500,674.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 31502 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,UNITY HEALTH PLAN,UNITY HOSPICE,230.06,,,,,,,77.6500,674.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,485.28,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $485.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,417.88,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $417.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,485.28,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $485.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,485.28,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $485.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CHG TUBE TRACHEOTOMY,31502,CPT,410,RC,41000002,CDM,,,,both,,,674.0000,444.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,404.40,,,,,,,77.6500,674.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $674.00 in Billed Charges for Rev 410 Proc 31502 = $404.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,AETNA,AETNA HSHS,64.60,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $100.00 in Billed Charges for Rev 410 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,AETNA,ALL COMMERCIAL AETNA,100.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $100.00 in Billed Charges for Rev 410 = $100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,ANTHEM,ANTHEM POS/HMO,68.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $100.00 in Billed Charges for Rev 410 = $68.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,ANTHEM,ANTHEM PPO,68.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $100.00 in Billed Charges for Rev 410 = $68.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,100.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $100.00 in Billed Charges for Rev 410 = $100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,CENPATICO,ALL MEDICAID CENPATICO,100.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $100.00 in Billed Charges for Rev 410 = $100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,85.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $100.00 in Billed Charges for Rev 410 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,CIGNA,ALL COMMERCIAL CIGNA,70.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $100.00 in Billed Charges for Rev 410 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,COFINITY,COFINITY,100.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $100.00 in Billed Charges for Rev 410 = $100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,95.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $100.00 in Billed Charges for Rev 410 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,84.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $100.00 in Billed Charges for Rev 410 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,71.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $100.00 in Billed Charges for Rev 410 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,73.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $100.00 in Billed Charges for Rev 410 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,48.60,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $100.00 in Billed Charges for Rev 410 = $48.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,85.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $100.00 in Billed Charges for Rev 410 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,HUMANA,HUMANA CHOICE CARE HMO,63.50,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $100.00 in Billed Charges for Rev 410 = $63.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,HUMANA,HUMANA CHOICE CARE PPO,85.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $100.00 in Billed Charges for Rev 410 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,HUMANA,HUMANA NATIIONAL POS HMO,63.50,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $100.00 in Billed Charges for Rev 410 = $63.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,73.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $100.00 in Billed Charges for Rev 410 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,100.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $100.00 in Billed Charges for Rev 410 = $100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,50.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $100.00 in Billed Charges for Rev 410 = $50.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,84.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $100.00 in Billed Charges for Rev 410 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,75.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $100.00 in Billed Charges for Rev 410 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,92.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $100.00 in Billed Charges for Rev 410 = $92.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,48.6000,100.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,48.6000,100.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,48.6000,100.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,48.6000,100.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,63.83,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $100.00 in Billed Charges for Rev 410 = $63.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,72.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $100.00 in Billed Charges for Rev 410 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.00,,,,,,,48.6000,100.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $100.00, claim capped at $100.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,100.00,,,,,,,48.6000,100.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $100.00, claim capped at $100.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,100.00,,,,,,,48.6000,100.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $100.00, claim capped at $100.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,72.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $100.00 in Billed Charges for Rev 410 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,62.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $100.00 in Billed Charges for Rev 410 = $62.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,72.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $100.00 in Billed Charges for Rev 410 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,72.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $100.00 in Billed Charges for Rev 410 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH FLOW OXYGEN CANNULA,410,RC,41000008,CDM,,,,,,both,,,100.0000,66.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,60.00,,,,,,,48.6000,100.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $100.00 in Billed Charges for Rev 410 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,AETNA,AETNA HSHS,896.00,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,387.00 in Billed Charges for Rev 410 = $896.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,AETNA,ALL COMMERCIAL AETNA,1387.00,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.00 in Billed Charges for Rev 410 = $1,387.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1387.00,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.00 in Billed Charges for Rev 410 = $1,387.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1178.95,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,387.00 in Billed Charges for Rev 410 = $1,178.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,CIGNA,ALL COMMERCIAL CIGNA,970.90,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,387.00 in Billed Charges for Rev 410 = $970.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,COFINITY,COFINITY,1387.00,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.00 in Billed Charges for Rev 410 = $1,387.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1317.65,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,387.00 in Billed Charges for Rev 410 = $1,317.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,1165.08,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,387.00 in Billed Charges for Rev 410 = $1,165.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,984.77,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,387.00 in Billed Charges for Rev 410 = $984.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1012.51,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,387.00 in Billed Charges for Rev 410 = $1,012.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,674.08,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,387.00 in Billed Charges for Rev 410 = $674.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1178.95,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,387.00 in Billed Charges for Rev 410 = $1,178.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,HUMANA,HUMANA CHOICE CARE PPO,1178.95,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,387.00 in Billed Charges for Rev 410 = $1,178.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1012.51,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,387.00 in Billed Charges for Rev 410 = $1,012.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1387.00,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,387.00 in Billed Charges for Rev 410 = $1,387.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,693.50,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,387.00 in Billed Charges for Rev 410 = $693.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1165.08,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,387.00 in Billed Charges for Rev 410 = $1,165.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1040.25,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,387.00 in Billed Charges for Rev 410 = $1,040.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1276.04,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,387.00 in Billed Charges for Rev 410 = $1,276.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,885.32,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,387.00 in Billed Charges for Rev 410 = $885.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,998.64,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,387.00 in Billed Charges for Rev 410 = $998.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,998.64,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,387.00 in Billed Charges for Rev 410 = $998.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,859.94,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,387.00 in Billed Charges for Rev 410 = $859.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,998.64,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,387.00 in Billed Charges for Rev 410 = $998.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT INIT DAY,410,RC,41000009,CDM,,,,,,inpatient,,,1387.0000,915.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,998.64,,,,,,,674.0800,1387.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,387.00 in Billed Charges for Rev 410 = $998.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,AETNA,AETNA HSHS,80.75,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $125.00 in Billed Charges for Rev 410 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,AETNA,ALL COMMERCIAL AETNA,125.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $125.00 in Billed Charges for Rev 410 = $125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,ANTHEM,ANTHEM POS/HMO,85.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $125.00 in Billed Charges for Rev 410 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,ANTHEM,ANTHEM PPO,85.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $125.00 in Billed Charges for Rev 410 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,125.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $125.00 in Billed Charges for Rev 410 = $125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,CENPATICO,ALL MEDICAID CENPATICO,125.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $125.00 in Billed Charges for Rev 410 = $125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,106.25,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $125.00 in Billed Charges for Rev 410 = $106.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,CIGNA,ALL COMMERCIAL CIGNA,87.50,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $125.00 in Billed Charges for Rev 410 = $87.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,COFINITY,COFINITY,125.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $125.00 in Billed Charges for Rev 410 = $125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,118.75,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $125.00 in Billed Charges for Rev 410 = $118.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,105.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $125.00 in Billed Charges for Rev 410 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,88.75,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $125.00 in Billed Charges for Rev 410 = $88.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,91.25,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $125.00 in Billed Charges for Rev 410 = $91.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,60.75,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $125.00 in Billed Charges for Rev 410 = $60.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,106.25,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $125.00 in Billed Charges for Rev 410 = $106.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,HUMANA,HUMANA CHOICE CARE HMO,79.38,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $125.00 in Billed Charges for Rev 410 = $79.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,HUMANA,HUMANA CHOICE CARE PPO,106.25,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $125.00 in Billed Charges for Rev 410 = $106.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,HUMANA,HUMANA NATIIONAL POS HMO,79.38,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $125.00 in Billed Charges for Rev 410 = $79.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,91.25,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $125.00 in Billed Charges for Rev 410 = $91.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,125.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $125.00 in Billed Charges for Rev 410 = $125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,62.50,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $125.00 in Billed Charges for Rev 410 = $62.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,105.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $125.00 in Billed Charges for Rev 410 = $105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,93.75,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $125.00 in Billed Charges for Rev 410 = $93.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,115.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $125.00 in Billed Charges for Rev 410 = $115.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,60.7500,125.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,60.7500,125.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,60.7500,125.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,60.7500,125.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,79.79,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $125.00 in Billed Charges for Rev 410 = $79.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,90.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $125.00 in Billed Charges for Rev 410 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,60.7500,125.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,60.7500,125.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,60.7500,125.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,90.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $125.00 in Billed Charges for Rev 410 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,77.50,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $125.00 in Billed Charges for Rev 410 = $77.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,90.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $125.00 in Billed Charges for Rev 410 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,90.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $125.00 in Billed Charges for Rev 410 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INPATIENT TRACH TUBE CHANGE,410,RC,41000011,CDM,,,,,,both,,,125.0000,82.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,75.00,,,,,,,60.7500,125.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $125.00 in Billed Charges for Rev 410 = $75.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,AETNA,AETNA HSHS,645.35,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $999.00 in Billed Charges for Rev 410 = $645.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,AETNA,ALL COMMERCIAL AETNA,999.00,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $999.00 in Billed Charges for Rev 410 = $999.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,999.00,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $999.00 in Billed Charges for Rev 410 = $999.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,849.15,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $999.00 in Billed Charges for Rev 410 = $849.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,CIGNA,ALL COMMERCIAL CIGNA,699.30,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $999.00 in Billed Charges for Rev 410 = $699.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,COFINITY,COFINITY,999.00,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $999.00 in Billed Charges for Rev 410 = $999.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,949.05,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $999.00 in Billed Charges for Rev 410 = $949.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,839.16,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $999.00 in Billed Charges for Rev 410 = $839.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,709.29,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $999.00 in Billed Charges for Rev 410 = $709.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,729.27,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $999.00 in Billed Charges for Rev 410 = $729.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,485.51,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $999.00 in Billed Charges for Rev 410 = $485.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,849.15,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $999.00 in Billed Charges for Rev 410 = $849.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,HUMANA,HUMANA CHOICE CARE PPO,849.15,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $999.00 in Billed Charges for Rev 410 = $849.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,729.27,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $999.00 in Billed Charges for Rev 410 = $729.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,999.00,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $999.00 in Billed Charges for Rev 410 = $999.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,499.50,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $999.00 in Billed Charges for Rev 410 = $499.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,839.16,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $999.00 in Billed Charges for Rev 410 = $839.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,749.25,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $999.00 in Billed Charges for Rev 410 = $749.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,919.08,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $999.00 in Billed Charges for Rev 410 = $919.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,637.66,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $999.00 in Billed Charges for Rev 410 = $637.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,719.28,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $999.00 in Billed Charges for Rev 410 = $719.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,719.28,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $999.00 in Billed Charges for Rev 410 = $719.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,619.38,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $999.00 in Billed Charges for Rev 410 = $619.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,719.28,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $999.00 in Billed Charges for Rev 410 = $719.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000016,CDM,,,,,,inpatient,,,999.0000,659.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,719.28,,,,,,,485.5100,999.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $999.00 in Billed Charges for Rev 410 = $719.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,AETNA,AETNA HSHS,60.72,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $94.00 in Billed Charges for Rev 410 = $60.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,AETNA,ALL COMMERCIAL AETNA,94.00,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.00 in Billed Charges for Rev 410 = $94.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,ANTHEM,ANTHEM POS/HMO,63.92,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $94.00 in Billed Charges for Rev 410 = $63.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,ANTHEM,ANTHEM PPO,63.92,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $94.00 in Billed Charges for Rev 410 = $63.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,94.00,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.00 in Billed Charges for Rev 410 = $94.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,CENPATICO,ALL MEDICAID CENPATICO,94.00,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.00 in Billed Charges for Rev 410 = $94.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.90,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.00 in Billed Charges for Rev 410 = $79.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,CIGNA,ALL COMMERCIAL CIGNA,65.80,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $94.00 in Billed Charges for Rev 410 = $65.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,COFINITY,COFINITY,94.00,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.00 in Billed Charges for Rev 410 = $94.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,89.30,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $94.00 in Billed Charges for Rev 410 = $89.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,78.96,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $94.00 in Billed Charges for Rev 410 = $78.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.74,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $94.00 in Billed Charges for Rev 410 = $66.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,68.62,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $94.00 in Billed Charges for Rev 410 = $68.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,45.68,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $94.00 in Billed Charges for Rev 410 = $45.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.90,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.00 in Billed Charges for Rev 410 = $79.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,HUMANA,HUMANA CHOICE CARE HMO,59.69,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $94.00 in Billed Charges for Rev 410 = $59.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,HUMANA,HUMANA CHOICE CARE PPO,79.90,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $94.00 in Billed Charges for Rev 410 = $79.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,HUMANA,HUMANA NATIIONAL POS HMO,59.69,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $94.00 in Billed Charges for Rev 410 = $59.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,68.62,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $94.00 in Billed Charges for Rev 410 = $68.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,94.00,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $94.00 in Billed Charges for Rev 410 = $94.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,47.00,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $94.00 in Billed Charges for Rev 410 = $47.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.96,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $94.00 in Billed Charges for Rev 410 = $78.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,70.50,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $94.00 in Billed Charges for Rev 410 = $70.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,86.48,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $94.00 in Billed Charges for Rev 410 = $86.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,45.6800,94.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,45.6800,94.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,45.6800,94.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,45.6800,94.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,60.00,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $94.00 in Billed Charges for Rev 410 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,67.68,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.00 in Billed Charges for Rev 410 = $67.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,94.00,,,,,,,45.6800,94.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $94.00, claim capped at $94.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,94.00,,,,,,,45.6800,94.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $94.00, claim capped at $94.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,94.00,,,,,,,45.6800,94.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $94.00, claim capped at $94.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,67.68,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.00 in Billed Charges for Rev 410 = $67.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.28,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $94.00 in Billed Charges for Rev 410 = $58.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,67.68,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.00 in Billed Charges for Rev 410 = $67.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,67.68,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $94.00 in Billed Charges for Rev 410 = $67.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP INIT VISIT,410,RC,41000020,CDM,,,,,,both,,,94.0000,62.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,56.40,,,,,,,45.6800,94.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $94.00 in Billed Charges for Rev 410 = $56.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,AETNA,AETNA HSHS,747.42,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,157.00 in Billed Charges for Rev 410 = $747.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,AETNA,ALL COMMERCIAL AETNA,1157.00,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.00 in Billed Charges for Rev 410 = $1,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1157.00,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.00 in Billed Charges for Rev 410 = $1,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,983.45,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,157.00 in Billed Charges for Rev 410 = $983.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,CIGNA,ALL COMMERCIAL CIGNA,809.90,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,157.00 in Billed Charges for Rev 410 = $809.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,COFINITY,COFINITY,1157.00,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.00 in Billed Charges for Rev 410 = $1,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1099.15,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,157.00 in Billed Charges for Rev 410 = $1,099.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,971.88,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,157.00 in Billed Charges for Rev 410 = $971.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,821.47,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,157.00 in Billed Charges for Rev 410 = $821.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,844.61,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,157.00 in Billed Charges for Rev 410 = $844.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,562.30,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,157.00 in Billed Charges for Rev 410 = $562.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,983.45,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,157.00 in Billed Charges for Rev 410 = $983.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,HUMANA,HUMANA CHOICE CARE PPO,983.45,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,157.00 in Billed Charges for Rev 410 = $983.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,844.61,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,157.00 in Billed Charges for Rev 410 = $844.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1157.00,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,157.00 in Billed Charges for Rev 410 = $1,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,578.50,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,157.00 in Billed Charges for Rev 410 = $578.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,971.88,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,157.00 in Billed Charges for Rev 410 = $971.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,867.75,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,157.00 in Billed Charges for Rev 410 = $867.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1064.44,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,157.00 in Billed Charges for Rev 410 = $1,064.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,738.51,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,157.00 in Billed Charges for Rev 410 = $738.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,833.04,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,157.00 in Billed Charges for Rev 410 = $833.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,833.04,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,157.00 in Billed Charges for Rev 410 = $833.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,717.34,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,157.00 in Billed Charges for Rev 410 = $717.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,833.04,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,157.00 in Billed Charges for Rev 410 = $833.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VENT MGMT INPAT SUBQ DAY,410,RC,41000027,CDM,,,,,,inpatient,,,1157.0000,763.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,833.04,,,,,,,562.3000,1157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,157.00 in Billed Charges for Rev 410 = $833.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,AETNA,AETNA HSHS,200.26,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $200.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,AETNA,AETNA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,AETNA,ALL COMMERCIAL AETNA,310.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,ANTHEM,ANTHEM POS/HMO,210.80,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,ANTHEM,ANTHEM PPO,210.80,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,310.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,CENPATICO,ALL MEDICAID CENPATICO,310.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,263.50,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,CIGNA,ALL COMMERCIAL CIGNA,217.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,COFINITY,COFINITY,310.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,294.50,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $294.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,260.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,220.10,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $220.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,226.30,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $226.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,150.66,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $150.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,263.50,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HUMANA,HUMANA CHOICE CARE HMO,196.85,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $196.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HUMANA,HUMANA CHOICE CARE PPO,263.50,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,HUMANA,HUMANA NATIIONAL POS HMO,196.85,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $196.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,226.30,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $226.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,310.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,155.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,260.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,232.50,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $232.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,285.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $285.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,197.87,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $197.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,223.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,223.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,192.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $192.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,223.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,223.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000036,CDM,,,,both,,,310.0000,204.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,186.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $310.00 in Billed Charges for Rev 410 Proc 94640 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,AETNA,AETNA HSHS,38.76,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,AETNA,ALL COMMERCIAL AETNA,60.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94645 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTHEM POS/HMO,40.80,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $40.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,ANTHEM,ANTHEM PPO,40.80,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $40.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,60.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,CENPATICO,ALL MEDICAID CENPATICO,60.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,51.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,CIGNA,ALL COMMERCIAL CIGNA,42.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,COFINITY,COFINITY,60.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94645 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94645 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,57.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,50.40,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42.60,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $42.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,43.80,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $43.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,29.16,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $29.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,51.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA CHOICE CARE HMO,38.10,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $38.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA CHOICE CARE PPO,51.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,HUMANA,HUMANA NATIIONAL POS HMO,38.10,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $38.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,43.80,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $43.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,60.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94645 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94645 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94645 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,30.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $30.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,50.40,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,45.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $45.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,55.20,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $55.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,60.00,,,,,,,26.4300,60.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94645 1 Visit at $90.89 per Visit = $90.89 (Service Line reduced to $60.00, claim capped at $60.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,60.00,,,,,,,26.4300,60.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94645 1 Visit at $90.89 per Visit = $90.89 (Service Line reduced to $60.00, claim capped at $60.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA360,60.00,,,,,,,26.4300,60.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94645 1 Visit at $90.89 per Visit = $90.89 (Service Line reduced to $60.00, claim capped at $60.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,60.00,,,,,,,26.4300,60.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94645 1 Visit at $90.89 per Visit = $90.89 (Service Line reduced to $60.00, claim capped at $60.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38.30,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $38.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,43.20,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,60.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94645 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.00,,,,,,,26.4300,60.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94645 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $60.00, claim capped at $60.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,60.00,,,,,,,26.4300,60.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94645 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $60.00, claim capped at $60.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,60.00,,,,,,,26.4300,60.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94645 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $60.00, claim capped at $60.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,43.20,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37.20,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $37.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,43.20,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,43.20,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $43.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS ADDL HR,94645,CPT,410,RC,41000051,CDM,,,,both,,,60.0000,39.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,36.00,,,,,,,26.4300,60.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $60.00 in Billed Charges for Rev 410 Proc 94645 = $36.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,AETNA,AETNA HSHS,200.26,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $200.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,AETNA,AETNA MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,AETNA,ALL COMMERCIAL AETNA,310.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,ANTHEM,ANTEHM MEDICAID,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,ANTHEM,ANTHEM POS/HMO,210.80,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,ANTHEM,ANTHEM PPO,210.80,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,310.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,CENPATICO,ALL MEDICAID CENPATICO,310.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,263.50,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,CIGNA,ALL COMMERCIAL CIGNA,217.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,COFINITY,COFINITY,310.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,294.50,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $294.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,260.40,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,220.10,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $220.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,226.30,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $226.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,150.66,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $150.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,263.50,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HUMANA,HUMANA CHOICE CARE HMO,196.85,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $196.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HUMANA,HUMANA CHOICE CARE PPO,263.50,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,HUMANA,HUMANA NATIIONAL POS HMO,196.85,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $196.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,226.30,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $226.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,310.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,64.61,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95... $60.95 at 106% = $64.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,155.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,260.40,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,232.50,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $232.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,285.20,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $285.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,197.87,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $197.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,223.20,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,TRIOLOGY,TRILOGY MEDICAID,64.61,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 106% = $64.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,223.20,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,192.20,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $192.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,223.20,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,223.20,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP DAILY EST PT,94660,CPT,410,RC,41000053,CDM,,,,both,,,310.0000,204.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,186.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $310.00 in Billed Charges for Rev 410 Proc 94660 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,AETNA,AETNA HSHS,267.44,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $267.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,AETNA,AETNA MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,AETNA,ALL COMMERCIAL AETNA,414.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,ANTHEM,ANTEHM MEDICAID,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,ANTHEM,ANTHEM POS/HMO,281.52,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $281.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,ANTHEM,ANTHEM PPO,281.52,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $281.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,414.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,CENPATICO,ALL MEDICAID CENPATICO,414.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,351.90,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $351.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,CIGNA,ALL COMMERCIAL CIGNA,289.80,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $289.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,COFINITY,COFINITY,414.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,393.30,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $393.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,347.76,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $347.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,293.94,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $293.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,302.22,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $302.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,201.20,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $201.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,351.90,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $351.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HUMANA,HUMANA CHOICE CARE HMO,262.89,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $262.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HUMANA,HUMANA CHOICE CARE PPO,351.90,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $351.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,HUMANA,HUMANA NATIIONAL POS HMO,262.89,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $262.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,302.22,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $302.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,414.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,64.61,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95... $60.95 at 106% = $64.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,207.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,347.76,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $347.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,310.50,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $310.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,380.88,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $380.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,264.26,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $264.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,298.08,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $298.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,TRIOLOGY,TRILOGY MEDICAID,64.61,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 106% = $64.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,298.08,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $298.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,256.68,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $256.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,298.08,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $298.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,298.08,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $298.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP NEONATAL/DAY,94660,CPT,410,RC,41000054,CDM,,,,both,,,414.0000,273.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,248.40,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $414.00 in Billed Charges for Rev 410 Proc 94660 = $248.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,AETNA,AETNA HSHS,229.98,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $229.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,AETNA,AETNA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,AETNA,ALL COMMERCIAL AETNA,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94664 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,ANTHEM,ANTHEM POS/HMO,242.08,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $242.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,ANTHEM,ANTHEM PPO,242.08,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $242.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,CENPATICO,ALL MEDICAID CENPATICO,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,302.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $302.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,CIGNA,ALL COMMERCIAL CIGNA,249.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $249.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,COFINITY,COFINITY,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94664 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94664 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,338.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $338.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,299.04,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $299.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,252.76,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $252.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,259.88,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,173.02,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $173.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,302.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $302.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HUMANA,HUMANA CHOICE CARE HMO,226.06,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $226.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HUMANA,HUMANA CHOICE CARE PPO,302.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $302.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,HUMANA,HUMANA NATIIONAL POS HMO,226.06,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $226.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,259.88,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94664 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94664 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94664 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,178.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $178.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,299.04,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $299.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,267.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $267.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,327.52,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $327.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94664 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94664 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94664 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94664 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,227.23,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $227.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,256.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $256.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94664 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94664 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94664 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94664 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,256.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $256.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,220.72,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $220.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,256.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $256.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,256.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $256.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DEMO/EVAL/MDI/NEB DAILY,94664,CPT,410,RC,41000057,CDM,,,,both,,,356.0000,234.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,213.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $356.00 in Billed Charges for Rev 410 Proc 94664 = $213.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,AETNA,AETNA HSHS,135.01,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $135.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,AETNA,AETNA MEDICARE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,AETNA,ALL COMMERCIAL AETNA,209.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94667 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM POS/HMO,142.12,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $142.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM PPO,142.12,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $142.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,209.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,CENPATICO,ALL MEDICAID CENPATICO,209.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,177.65,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,CIGNA,ALL COMMERCIAL CIGNA,146.30,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $146.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,COFINITY,COFINITY,209.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94667 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94667 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,198.55,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $198.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,175.56,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $175.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,148.39,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $148.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,152.57,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $152.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,101.57,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $101.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,177.65,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA CHOICE CARE HMO,132.72,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $132.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA CHOICE CARE PPO,177.65,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA NATIIONAL POS HMO,132.72,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $132.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,152.57,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $152.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,209.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94667 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94667 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94667 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,104.50,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $104.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,175.56,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $175.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,290.78,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,156.75,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $156.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,192.28,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $192.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94667 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94667 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94667 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94667 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,133.40,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $133.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.52,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,150.48,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94667 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94667 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94667 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94667 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,UNITY HEALTH PLAN,UNITY HOSPICE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,150.48,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,129.58,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $129.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,150.48,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,150.48,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL 1ST,94667,CPT,410,RC,41000058,CDM,,,,both,,,209.0000,137.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,125.40,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 410 Proc 94667 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,AETNA,AETNA HSHS,11168.69,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $17,289.00 in Billed Charges for Rev 360 = $11,168.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,AETNA,ALL COMMERCIAL AETNA,17289.00,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,289.00 in Billed Charges for Rev 360 = $17,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17289.00,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,289.00 in Billed Charges for Rev 360 = $17,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,CENPATICO,ALL MEDICAID CENPATICO,17289.00,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,289.00 in Billed Charges for Rev 360 = $17,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14695.65,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,289.00 in Billed Charges for Rev 360 = $14,695.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,CIGNA,ALL COMMERCIAL CIGNA,12102.30,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $17,289.00 in Billed Charges for Rev 360 = $12,102.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,COFINITY,COFINITY,17289.00,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,289.00 in Billed Charges for Rev 360 = $17,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16424.55,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $17,289.00 in Billed Charges for Rev 360 = $16,424.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,14522.76,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $17,289.00 in Billed Charges for Rev 360 = $14,522.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12275.19,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $17,289.00 in Billed Charges for Rev 360 = $12,275.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12620.97,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $17,289.00 in Billed Charges for Rev 360 = $12,620.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,8402.45,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $17,289.00 in Billed Charges for Rev 360 = $8,402.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14695.65,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,289.00 in Billed Charges for Rev 360 = $14,695.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,HUMANA,HUMANA CHOICE CARE PPO,14695.65,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $17,289.00 in Billed Charges for Rev 360 = $14,695.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12620.97,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $17,289.00 in Billed Charges for Rev 360 = $12,620.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,17289.00,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $17,289.00 in Billed Charges for Rev 360 = $17,289.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8644.50,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $17,289.00 in Billed Charges for Rev 360 = $8,644.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14522.76,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $17,289.00 in Billed Charges for Rev 360 = $14,522.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12966.75,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $17,289.00 in Billed Charges for Rev 360 = $12,966.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15905.88,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $17,289.00 in Billed Charges for Rev 360 = $15,905.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10373.40,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $17,289.00 in Billed Charges for Rev 360 = $10,373.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10373.40,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $17,289.00 in Billed Charges for Rev 360 = $10,373.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,PREVEA HEALTH NETWORK,PREVEA360,10373.40,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $17,289.00 in Billed Charges for Rev 360 = $10,373.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10373.40,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $17,289.00 in Billed Charges for Rev 360 = $10,373.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11035.57,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $17,289.00 in Billed Charges for Rev 360 = $11,035.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12448.08,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,289.00 in Billed Charges for Rev 360 = $12,448.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12448.08,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,289.00 in Billed Charges for Rev 360 = $12,448.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10719.18,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $17,289.00 in Billed Charges for Rev 360 = $10,719.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12448.08,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,289.00 in Billed Charges for Rev 360 = $12,448.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12448.08,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $17,289.00 in Billed Charges for Rev 360 = $12,448.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC GASTRECTOMY SLEEVE,360,RC,36030128,CDM,,,,,,both,,,17289.0000,11410.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10373.40,,,,,,,8402.4500,17289.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $17,289.00 in Billed Charges for Rev 360 = $10,373.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,AETNA,AETNA HSHS,338.50,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $338.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,AETNA,AETNA MEDICARE,433.92,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,AETNA,ALL COMMERCIAL AETNA,524.00,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,ANTHEM,ANTEHM MEDICAID,185.11,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,433.92,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,ANTHEM,ANTHEM POS/HMO,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,ANTHEM,ANTHEM PPO,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,524.00,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,CENPATICO,ALL MEDICAID CENPATICO,524.00,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,445.40,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $445.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,CIGNA,ALL COMMERCIAL CIGNA,366.80,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $366.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,COFINITY,COFINITY,524.00,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,185.11,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,185.11,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,497.80,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $497.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,440.16,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $440.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,372.04,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $372.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,382.52,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $382.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,254.66,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $254.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,445.40,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $445.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HUMANA,HUMANA CHOICE CARE HMO,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HUMANA,HUMANA CHOICE CARE PPO,445.40,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $445.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,433.92,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,HUMANA,HUMANA NATIIONAL POS HMO,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,382.52,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $382.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,524.00,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,185.11,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,433.92,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,185.11,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,196.22,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11... $185.11 at 106% = $196.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,433.92,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,262.00,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $262.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,440.16,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $440.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,976.31,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,393.00,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $393.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,482.08,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $482.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,PREVEA HEALTH NETWORK,PREVEA360,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,334.47,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $334.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,438.26,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,377.28,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $377.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,TRIOLOGY,TRILOGY MEDICAID,196.22,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 106% = $196.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,433.92,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,524.00,,,,,,,185.1100,976.3100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $524.00 in Billed Charges - $0.00 in ASG Allowed Amount = $524.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,UNITY HEALTH PLAN,UNITY HOSPICE,433.92,,,,,,,185.1100,976.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,377.28,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $377.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,324.88,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $324.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,377.28,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $377.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,377.28,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $377.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION PLATELET RICH PLASMA,0232T,CPT,360,RC,36030405,CDM,,,SE,both,,,524.0000,345.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,314.40,,,,,,,185.1100,976.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $524.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $314.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,AETNA,AETNA HSHS,1063.96,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,063.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,AETNA,AETNA MEDICARE,433.92,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,AETNA,ALL COMMERCIAL AETNA,1647.00,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,ANTHEM,ANTEHM MEDICAID,185.11,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,433.92,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM POS/HMO,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM PPO,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1647.00,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,CENPATICO,ALL MEDICAID CENPATICO,1647.00,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1399.95,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,CIGNA,ALL COMMERCIAL CIGNA,1152.90,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,152.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,COFINITY,COFINITY,1647.00,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,185.11,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,185.11,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1564.65,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,564.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,1383.48,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,383.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1169.37,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,169.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1202.31,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,202.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,800.44,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $800.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1399.95,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HUMANA,HUMANA CHOICE CARE HMO,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HUMANA,HUMANA CHOICE CARE PPO,1399.95,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,433.92,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,HUMANA,HUMANA NATIIONAL POS HMO,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1202.31,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,202.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1647.00,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,185.11,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,433.92,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,185.11,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,196.22,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11... $185.11 at 106% = $196.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,433.92,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,823.50,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $823.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1383.48,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,383.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,976.31,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1235.25,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,235.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1515.24,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,515.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA360,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1051.28,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,051.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,438.26,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1185.84,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,TRIOLOGY,TRILOGY MEDICAID,196.22,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 0232T at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 106% = $196.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,433.92,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,1647.00,,,,,,,185.1100,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 0232T Mod SE ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,UNITY HEALTH PLAN,UNITY HOSPICE,433.92,,,,,,,185.1100,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1185.84,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1021.14,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,021.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1185.84,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1185.84,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJECTION BONE MARROW,0232T,CPT,360,RC,36030406,CDM,,,SE,both,,,1647.0000,1087.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,988.20,,,,,,,185.1100,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,647.00 in Billed Charges for Rev 360 Proc 0232T Mod SE = $988.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,AETNA,AETNA HSHS,712.54,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,103.00 in Billed Charges for Rev 360 = $712.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,AETNA,ALL COMMERCIAL AETNA,1103.00,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,103.00 in Billed Charges for Rev 360 = $1,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1103.00,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,103.00 in Billed Charges for Rev 360 = $1,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,CENPATICO,ALL MEDICAID CENPATICO,1103.00,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,103.00 in Billed Charges for Rev 360 = $1,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,937.55,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,103.00 in Billed Charges for Rev 360 = $937.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,CIGNA,ALL COMMERCIAL CIGNA,772.10,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,103.00 in Billed Charges for Rev 360 = $772.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,COFINITY,COFINITY,1103.00,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,103.00 in Billed Charges for Rev 360 = $1,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1047.85,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,103.00 in Billed Charges for Rev 360 = $1,047.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,926.52,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,103.00 in Billed Charges for Rev 360 = $926.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,783.13,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,103.00 in Billed Charges for Rev 360 = $783.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,805.19,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,103.00 in Billed Charges for Rev 360 = $805.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,536.06,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,103.00 in Billed Charges for Rev 360 = $536.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,937.55,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,103.00 in Billed Charges for Rev 360 = $937.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,HUMANA,HUMANA CHOICE CARE PPO,937.55,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,103.00 in Billed Charges for Rev 360 = $937.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,805.19,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,103.00 in Billed Charges for Rev 360 = $805.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1103.00,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,103.00 in Billed Charges for Rev 360 = $1,103.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,551.50,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,103.00 in Billed Charges for Rev 360 = $551.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,926.52,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,103.00 in Billed Charges for Rev 360 = $926.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,827.25,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,103.00 in Billed Charges for Rev 360 = $827.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1014.76,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,103.00 in Billed Charges for Rev 360 = $1,014.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,661.80,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,103.00 in Billed Charges for Rev 360 = $661.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,661.80,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,103.00 in Billed Charges for Rev 360 = $661.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,PREVEA HEALTH NETWORK,PREVEA360,661.80,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,103.00 in Billed Charges for Rev 360 = $661.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,661.80,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,103.00 in Billed Charges for Rev 360 = $661.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,704.04,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,103.00 in Billed Charges for Rev 360 = $704.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,794.16,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,103.00 in Billed Charges for Rev 360 = $794.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,794.16,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,103.00 in Billed Charges for Rev 360 = $794.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,683.86,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,103.00 in Billed Charges for Rev 360 = $683.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,794.16,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,103.00 in Billed Charges for Rev 360 = $794.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,794.16,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,103.00 in Billed Charges for Rev 360 = $794.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SURGICAL PROCEDURE PER 15 MINS CATH/RAD ONC,360,RC,36040027,CDM,,,,,,both,,,1103.0000,727.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,661.80,,,,,,,536.0600,1103.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,103.00 in Billed Charges for Rev 360 = $661.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,AETNA,AETNA HSHS,1268.10,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,963.00 in Billed Charges for Rev 360 = $1,268.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,AETNA,ALL COMMERCIAL AETNA,1963.00,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,963.00 in Billed Charges for Rev 360 = $1,963.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1963.00,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,963.00 in Billed Charges for Rev 360 = $1,963.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,CENPATICO,ALL MEDICAID CENPATICO,1963.00,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,963.00 in Billed Charges for Rev 360 = $1,963.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1668.55,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,963.00 in Billed Charges for Rev 360 = $1,668.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,CIGNA,ALL COMMERCIAL CIGNA,1374.10,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,963.00 in Billed Charges for Rev 360 = $1,374.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,COFINITY,COFINITY,1963.00,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,963.00 in Billed Charges for Rev 360 = $1,963.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1864.85,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,963.00 in Billed Charges for Rev 360 = $1,864.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,1648.92,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,963.00 in Billed Charges for Rev 360 = $1,648.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1393.73,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,963.00 in Billed Charges for Rev 360 = $1,393.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1432.99,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,963.00 in Billed Charges for Rev 360 = $1,432.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,954.02,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,963.00 in Billed Charges for Rev 360 = $954.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1668.55,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,963.00 in Billed Charges for Rev 360 = $1,668.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,HUMANA,HUMANA CHOICE CARE PPO,1668.55,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,963.00 in Billed Charges for Rev 360 = $1,668.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1432.99,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,963.00 in Billed Charges for Rev 360 = $1,432.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1963.00,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,963.00 in Billed Charges for Rev 360 = $1,963.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,981.50,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,963.00 in Billed Charges for Rev 360 = $981.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1648.92,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,963.00 in Billed Charges for Rev 360 = $1,648.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1472.25,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,963.00 in Billed Charges for Rev 360 = $1,472.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1805.96,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,963.00 in Billed Charges for Rev 360 = $1,805.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1177.80,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,963.00 in Billed Charges for Rev 360 = $1,177.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1177.80,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,963.00 in Billed Charges for Rev 360 = $1,177.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,PREVEA HEALTH NETWORK,PREVEA360,1177.80,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,963.00 in Billed Charges for Rev 360 = $1,177.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1177.80,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,963.00 in Billed Charges for Rev 360 = $1,177.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1252.98,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,963.00 in Billed Charges for Rev 360 = $1,252.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1413.36,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,963.00 in Billed Charges for Rev 360 = $1,413.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1413.36,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,963.00 in Billed Charges for Rev 360 = $1,413.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1217.06,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,963.00 in Billed Charges for Rev 360 = $1,217.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1413.36,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,963.00 in Billed Charges for Rev 360 = $1,413.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1413.36,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,963.00 in Billed Charges for Rev 360 = $1,413.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ELECTRODE LIGASURE SEALER/DIV,360,RC,36050117,CDM,,,,,,both,,,1963.0000,1295.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1177.80,,,,,,,954.0200,1963.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,963.00 in Billed Charges for Rev 360 = $1,177.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,AETNA,AETNA HSHS,469.64,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $727.00 in Billed Charges for Rev 360 Mod SE = $469.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,AETNA,ALL COMMERCIAL AETNA,727.00,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $727.00 in Billed Charges for Rev 360 Mod SE = $727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,727.00,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $727.00 in Billed Charges for Rev 360 Mod SE = $727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,CENPATICO,ALL MEDICAID CENPATICO,727.00,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $727.00 in Billed Charges for Rev 360 Mod SE = $727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,617.95,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $727.00 in Billed Charges for Rev 360 Mod SE = $617.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,CIGNA,ALL COMMERCIAL CIGNA,508.90,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $727.00 in Billed Charges for Rev 360 Mod SE = $508.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,COFINITY,COFINITY,727.00,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $727.00 in Billed Charges for Rev 360 Mod SE = $727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,690.65,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $727.00 in Billed Charges for Rev 360 Mod SE = $690.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,610.68,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $727.00 in Billed Charges for Rev 360 Mod SE = $610.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,516.17,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $727.00 in Billed Charges for Rev 360 Mod SE = $516.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,530.71,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $727.00 in Billed Charges for Rev 360 Mod SE = $530.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,353.32,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $727.00 in Billed Charges for Rev 360 Mod SE = $353.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,617.95,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $727.00 in Billed Charges for Rev 360 Mod SE = $617.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,HUMANA,HUMANA CHOICE CARE PPO,617.95,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $727.00 in Billed Charges for Rev 360 Mod SE = $617.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,530.71,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $727.00 in Billed Charges for Rev 360 Mod SE = $530.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,727.00,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $727.00 in Billed Charges for Rev 360 Mod SE = $727.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,363.50,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $727.00 in Billed Charges for Rev 360 Mod SE = $363.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,610.68,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $727.00 in Billed Charges for Rev 360 Mod SE = $610.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,545.25,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $727.00 in Billed Charges for Rev 360 Mod SE = $545.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,668.84,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $727.00 in Billed Charges for Rev 360 Mod SE = $668.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,436.20,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $727.00 in Billed Charges for Rev 360 Mod SE = $436.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,436.20,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $727.00 in Billed Charges for Rev 360 Mod SE = $436.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,PREVEA HEALTH NETWORK,PREVEA360,436.20,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $727.00 in Billed Charges for Rev 360 Mod SE = $436.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,436.20,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $727.00 in Billed Charges for Rev 360 Mod SE = $436.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,464.04,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $727.00 in Billed Charges for Rev 360 Mod SE = $464.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,523.44,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $727.00 in Billed Charges for Rev 360 Mod SE = $523.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,523.44,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $727.00 in Billed Charges for Rev 360 Mod SE = $523.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,450.74,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $727.00 in Billed Charges for Rev 360 Mod SE = $450.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,523.44,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $727.00 in Billed Charges for Rev 360 Mod SE = $523.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,523.44,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $727.00 in Billed Charges for Rev 360 Mod SE = $523.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC LASER FOR CATARACT SURGERY,360,RC,36050640,CDM,,,,,SE,both,,,727.0000,479.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,436.20,,,,,,,353.3200,727.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $727.00 in Billed Charges for Rev 360 Mod SE = $436.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,AETNA,AETNA HSHS,6224.21,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $9,635.00 in Billed Charges for Rev 360 = $6,224.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,AETNA,ALL COMMERCIAL AETNA,9635.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,635.00 in Billed Charges for Rev 360 = $9,635.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9635.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,635.00 in Billed Charges for Rev 360 = $9,635.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,CENPATICO,ALL MEDICAID CENPATICO,9635.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,635.00 in Billed Charges for Rev 360 = $9,635.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8189.75,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,635.00 in Billed Charges for Rev 360 = $8,189.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,CIGNA,ALL COMMERCIAL CIGNA,6744.50,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $9,635.00 in Billed Charges for Rev 360 = $6,744.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,COFINITY,COFINITY,9635.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,635.00 in Billed Charges for Rev 360 = $9,635.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9153.25,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $9,635.00 in Billed Charges for Rev 360 = $9,153.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,8093.40,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,635.00 in Billed Charges for Rev 360 = $8,093.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6840.85,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $9,635.00 in Billed Charges for Rev 360 = $6,840.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7033.55,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,635.00 in Billed Charges for Rev 360 = $7,033.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,4682.61,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $9,635.00 in Billed Charges for Rev 360 = $4,682.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8189.75,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,635.00 in Billed Charges for Rev 360 = $8,189.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,HUMANA,HUMANA CHOICE CARE PPO,8189.75,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,635.00 in Billed Charges for Rev 360 = $8,189.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7033.55,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,635.00 in Billed Charges for Rev 360 = $7,033.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,9635.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,635.00 in Billed Charges for Rev 360 = $9,635.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4817.50,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,635.00 in Billed Charges for Rev 360 = $4,817.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8093.40,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,635.00 in Billed Charges for Rev 360 = $8,093.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7226.25,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $9,635.00 in Billed Charges for Rev 360 = $7,226.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8864.20,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $9,635.00 in Billed Charges for Rev 360 = $8,864.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5781.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,635.00 in Billed Charges for Rev 360 = $5,781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5781.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,635.00 in Billed Charges for Rev 360 = $5,781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,PREVEA HEALTH NETWORK,PREVEA360,5781.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,635.00 in Billed Charges for Rev 360 = $5,781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5781.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,635.00 in Billed Charges for Rev 360 = $5,781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6150.02,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $9,635.00 in Billed Charges for Rev 360 = $6,150.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6937.20,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,635.00 in Billed Charges for Rev 360 = $6,937.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6937.20,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,635.00 in Billed Charges for Rev 360 = $6,937.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5973.70,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $9,635.00 in Billed Charges for Rev 360 = $5,973.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6937.20,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,635.00 in Billed Charges for Rev 360 = $6,937.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6937.20,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,635.00 in Billed Charges for Rev 360 = $6,937.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 3 BASE,360,RC,36060003,CDM,,,,,,both,,,9635.0000,6359.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5781.00,,,,,,,4682.6100,9635.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,635.00 in Billed Charges for Rev 360 = $5,781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,AETNA,AETNA HSHS,8638.96,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $13,373.00 in Billed Charges for Rev 360 = $8,638.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,AETNA,ALL COMMERCIAL AETNA,13373.00,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,373.00 in Billed Charges for Rev 360 = $13,373.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13373.00,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,373.00 in Billed Charges for Rev 360 = $13,373.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,CENPATICO,ALL MEDICAID CENPATICO,13373.00,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,373.00 in Billed Charges for Rev 360 = $13,373.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11367.05,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,373.00 in Billed Charges for Rev 360 = $11,367.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,CIGNA,ALL COMMERCIAL CIGNA,9361.10,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $13,373.00 in Billed Charges for Rev 360 = $9,361.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,COFINITY,COFINITY,13373.00,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,373.00 in Billed Charges for Rev 360 = $13,373.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12704.35,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $13,373.00 in Billed Charges for Rev 360 = $12,704.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,11233.32,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $13,373.00 in Billed Charges for Rev 360 = $11,233.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9494.83,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $13,373.00 in Billed Charges for Rev 360 = $9,494.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9762.29,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $13,373.00 in Billed Charges for Rev 360 = $9,762.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,6499.28,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $13,373.00 in Billed Charges for Rev 360 = $6,499.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11367.05,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,373.00 in Billed Charges for Rev 360 = $11,367.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,HUMANA,HUMANA CHOICE CARE PPO,11367.05,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $13,373.00 in Billed Charges for Rev 360 = $11,367.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9762.29,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $13,373.00 in Billed Charges for Rev 360 = $9,762.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,13373.00,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $13,373.00 in Billed Charges for Rev 360 = $13,373.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6686.50,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $13,373.00 in Billed Charges for Rev 360 = $6,686.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11233.32,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $13,373.00 in Billed Charges for Rev 360 = $11,233.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10029.75,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $13,373.00 in Billed Charges for Rev 360 = $10,029.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12303.16,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $13,373.00 in Billed Charges for Rev 360 = $12,303.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8023.80,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $13,373.00 in Billed Charges for Rev 360 = $8,023.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8023.80,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $13,373.00 in Billed Charges for Rev 360 = $8,023.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,PREVEA HEALTH NETWORK,PREVEA360,8023.80,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $13,373.00 in Billed Charges for Rev 360 = $8,023.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8023.80,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $13,373.00 in Billed Charges for Rev 360 = $8,023.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8535.99,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $13,373.00 in Billed Charges for Rev 360 = $8,535.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9628.56,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,373.00 in Billed Charges for Rev 360 = $9,628.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9628.56,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,373.00 in Billed Charges for Rev 360 = $9,628.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8291.26,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $13,373.00 in Billed Charges for Rev 360 = $8,291.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9628.56,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,373.00 in Billed Charges for Rev 360 = $9,628.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9628.56,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $13,373.00 in Billed Charges for Rev 360 = $9,628.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 4 BASE,360,RC,36060004,CDM,,,,,,both,,,13373.0000,8826.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8023.80,,,,,,,6499.2800,13373.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $13,373.00 in Billed Charges for Rev 360 = $8,023.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,AETNA,AETNA HSHS,34.24,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $53.00 in Billed Charges for Rev 360 = $34.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,AETNA,ALL COMMERCIAL AETNA,53.00,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 360 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,53.00,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 360 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,CENPATICO,ALL MEDICAID CENPATICO,53.00,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 360 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,45.05,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.00 in Billed Charges for Rev 360 = $45.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,CIGNA,ALL COMMERCIAL CIGNA,37.10,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $53.00 in Billed Charges for Rev 360 = $37.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,COFINITY,COFINITY,53.00,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 360 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,50.35,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $53.00 in Billed Charges for Rev 360 = $50.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,44.52,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $53.00 in Billed Charges for Rev 360 = $44.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,37.63,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $53.00 in Billed Charges for Rev 360 = $37.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,38.69,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $53.00 in Billed Charges for Rev 360 = $38.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,25.76,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $53.00 in Billed Charges for Rev 360 = $25.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,45.05,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.00 in Billed Charges for Rev 360 = $45.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,HUMANA,HUMANA CHOICE CARE PPO,45.05,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.00 in Billed Charges for Rev 360 = $45.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,38.69,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $53.00 in Billed Charges for Rev 360 = $38.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,53.00,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.00 in Billed Charges for Rev 360 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.50,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $53.00 in Billed Charges for Rev 360 = $26.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,44.52,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $53.00 in Billed Charges for Rev 360 = $44.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,39.75,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $53.00 in Billed Charges for Rev 360 = $39.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,48.76,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $53.00 in Billed Charges for Rev 360 = $48.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,31.80,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $53.00 in Billed Charges for Rev 360 = $31.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,31.80,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $53.00 in Billed Charges for Rev 360 = $31.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,PREVEA HEALTH NETWORK,PREVEA360,31.80,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $53.00 in Billed Charges for Rev 360 = $31.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,31.80,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $53.00 in Billed Charges for Rev 360 = $31.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,33.83,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $53.00 in Billed Charges for Rev 360 = $33.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,38.16,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.00 in Billed Charges for Rev 360 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,38.16,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.00 in Billed Charges for Rev 360 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.86,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $53.00 in Billed Charges for Rev 360 = $32.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,38.16,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.00 in Billed Charges for Rev 360 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,38.16,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.00 in Billed Charges for Rev 360 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 2 PER MIN,360,RC,36060008,CDM,,,,,,both,,,53.0000,34.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.80,,,,,,,25.7600,53.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $53.00 in Billed Charges for Rev 360 = $31.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,AETNA,AETNA HSHS,47.80,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $74.00 in Billed Charges for Rev 360 = $47.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,AETNA,ALL COMMERCIAL AETNA,74.00,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 360 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,74.00,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 360 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,CENPATICO,ALL MEDICAID CENPATICO,74.00,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 360 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,62.90,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.00 in Billed Charges for Rev 360 = $62.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,CIGNA,ALL COMMERCIAL CIGNA,51.80,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $74.00 in Billed Charges for Rev 360 = $51.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,COFINITY,COFINITY,74.00,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 360 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,70.30,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $74.00 in Billed Charges for Rev 360 = $70.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,62.16,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.00 in Billed Charges for Rev 360 = $62.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.54,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $74.00 in Billed Charges for Rev 360 = $52.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.02,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.00 in Billed Charges for Rev 360 = $54.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,35.96,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $74.00 in Billed Charges for Rev 360 = $35.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,62.90,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.00 in Billed Charges for Rev 360 = $62.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,HUMANA,HUMANA CHOICE CARE PPO,62.90,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.00 in Billed Charges for Rev 360 = $62.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.02,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.00 in Billed Charges for Rev 360 = $54.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,74.00,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.00 in Billed Charges for Rev 360 = $74.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.00,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $74.00 in Billed Charges for Rev 360 = $37.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,62.16,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.00 in Billed Charges for Rev 360 = $62.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.50,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $74.00 in Billed Charges for Rev 360 = $55.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,68.08,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $74.00 in Billed Charges for Rev 360 = $68.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,44.40,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.00 in Billed Charges for Rev 360 = $44.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,44.40,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.00 in Billed Charges for Rev 360 = $44.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,PREVEA HEALTH NETWORK,PREVEA360,44.40,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.00 in Billed Charges for Rev 360 = $44.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,44.40,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.00 in Billed Charges for Rev 360 = $44.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.23,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $74.00 in Billed Charges for Rev 360 = $47.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.28,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.00 in Billed Charges for Rev 360 = $53.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.28,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.00 in Billed Charges for Rev 360 = $53.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.88,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $74.00 in Billed Charges for Rev 360 = $45.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.28,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.00 in Billed Charges for Rev 360 = $53.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.28,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.00 in Billed Charges for Rev 360 = $53.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 3 PER MIN,360,RC,36060009,CDM,,,,,,both,,,74.0000,48.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.40,,,,,,,35.9600,74.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.00 in Billed Charges for Rev 360 = $44.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,AETNA,AETNA HSHS,83.98,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $130.00 in Billed Charges for Rev 360 = $83.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,AETNA,ALL COMMERCIAL AETNA,130.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 360 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,130.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 360 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,CENPATICO,ALL MEDICAID CENPATICO,130.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 360 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,110.50,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 360 = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,CIGNA,ALL COMMERCIAL CIGNA,91.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $130.00 in Billed Charges for Rev 360 = $91.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,COFINITY,COFINITY,130.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 360 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,123.50,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $130.00 in Billed Charges for Rev 360 = $123.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,109.20,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.00 in Billed Charges for Rev 360 = $109.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,92.30,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $130.00 in Billed Charges for Rev 360 = $92.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,94.90,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.00 in Billed Charges for Rev 360 = $94.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,63.18,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $130.00 in Billed Charges for Rev 360 = $63.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,110.50,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 360 = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,HUMANA,HUMANA CHOICE CARE PPO,110.50,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.00 in Billed Charges for Rev 360 = $110.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,94.90,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.00 in Billed Charges for Rev 360 = $94.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,130.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.00 in Billed Charges for Rev 360 = $130.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $130.00 in Billed Charges for Rev 360 = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,109.20,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.00 in Billed Charges for Rev 360 = $109.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,97.50,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $130.00 in Billed Charges for Rev 360 = $97.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,119.60,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $130.00 in Billed Charges for Rev 360 = $119.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,78.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.00 in Billed Charges for Rev 360 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,78.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.00 in Billed Charges for Rev 360 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA360,78.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.00 in Billed Charges for Rev 360 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,78.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.00 in Billed Charges for Rev 360 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,82.98,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $130.00 in Billed Charges for Rev 360 = $82.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,93.60,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 360 = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,93.60,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 360 = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,80.60,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $130.00 in Billed Charges for Rev 360 = $80.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,93.60,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 360 = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,93.60,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.00 in Billed Charges for Rev 360 = $93.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 5 PER MIN,360,RC,36060011,CDM,,,,,,both,,,130.0000,85.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,78.00,,,,,,,63.1800,130.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.00 in Billed Charges for Rev 360 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,AETNA,AETNA HSHS,93.02,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $144.00 in Billed Charges for Rev 360 = $93.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,AETNA,ALL COMMERCIAL AETNA,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 360 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 360 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,CENPATICO,ALL MEDICAID CENPATICO,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 360 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,122.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $144.00 in Billed Charges for Rev 360 = $122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,CIGNA,ALL COMMERCIAL CIGNA,100.80,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $144.00 in Billed Charges for Rev 360 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,COFINITY,COFINITY,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 360 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,136.80,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $144.00 in Billed Charges for Rev 360 = $136.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,120.96,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $144.00 in Billed Charges for Rev 360 = $120.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,102.24,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $144.00 in Billed Charges for Rev 360 = $102.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,105.12,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $144.00 in Billed Charges for Rev 360 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,69.98,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $144.00 in Billed Charges for Rev 360 = $69.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,122.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $144.00 in Billed Charges for Rev 360 = $122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,HUMANA,HUMANA CHOICE CARE PPO,122.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $144.00 in Billed Charges for Rev 360 = $122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,105.12,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $144.00 in Billed Charges for Rev 360 = $105.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,144.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $144.00 in Billed Charges for Rev 360 = $144.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,72.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $144.00 in Billed Charges for Rev 360 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,120.96,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $144.00 in Billed Charges for Rev 360 = $120.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,108.00,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $144.00 in Billed Charges for Rev 360 = $108.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,132.48,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $144.00 in Billed Charges for Rev 360 = $132.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,86.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $144.00 in Billed Charges for Rev 360 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,86.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $144.00 in Billed Charges for Rev 360 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,PREVEA HEALTH NETWORK,PREVEA360,86.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $144.00 in Billed Charges for Rev 360 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,86.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $144.00 in Billed Charges for Rev 360 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,91.92,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $144.00 in Billed Charges for Rev 360 = $91.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,103.68,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $144.00 in Billed Charges for Rev 360 = $103.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,103.68,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $144.00 in Billed Charges for Rev 360 = $103.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,89.28,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $144.00 in Billed Charges for Rev 360 = $89.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,103.68,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $144.00 in Billed Charges for Rev 360 = $103.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,103.68,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $144.00 in Billed Charges for Rev 360 = $103.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OR LEVEL 6 PER MIN,360,RC,36060012,CDM,,,,,,both,,,144.0000,95.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,86.40,,,,,,,69.9800,144.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $144.00 in Billed Charges for Rev 360 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,AETNA,AETNA HSHS,726.75,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $726.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,AETNA,AETNA MEDICARE,298.15,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,AETNA,ALL COMMERCIAL AETNA,1125.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $1,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,ANTHEM,ANTEHM MEDICAID,182.86,,,,,,,182.8600,1125.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64400 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,298.15,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,ANTHEM,ANTHEM POS/HMO,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,ANTHEM,ANTHEM PPO,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1125.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $1,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,CENPATICO,ALL MEDICAID CENPATICO,1125.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $1,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,956.25,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $956.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,CIGNA,ALL COMMERCIAL CIGNA,787.50,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $787.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,COFINITY,COFINITY,1125.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $1,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,182.86,,,,,,,182.8600,1125.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64400 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,182.86,,,,,,,182.8600,1125.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64400 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1068.75,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $1,068.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,945.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $945.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,798.75,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $798.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,821.25,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $821.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,546.75,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $546.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,956.25,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $956.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HUMANA,HUMANA CHOICE CARE HMO,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HUMANA,HUMANA CHOICE CARE PPO,956.25,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $956.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,298.15,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,HUMANA,HUMANA NATIIONAL POS HMO,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,821.25,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $821.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1125.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $1,125.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,182.86,,,,,,,182.8600,1125.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64400 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,298.15,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,182.86,,,,,,,182.8600,1125.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64400 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,193.83,,,,,,,182.8600,1125.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64400 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86... $182.86 at 106% = $193.83 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,298.15,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,562.50,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $562.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,945.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $945.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,670.84,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,843.75,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $843.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1035.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $1,035.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,PREVEA HEALTH NETWORK,PREVEA360,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,718.09,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $718.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,301.13,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,810.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $810.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,TRIOLOGY,TRILOGY MEDICAID,193.83,,,,,,,182.8600,1125.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64400 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 106% = $193.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,298.15,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,1125.00,,,,,,,182.8600,1125.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 360 Proc 64400 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,125.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,125.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,UNITY HEALTH PLAN,UNITY HOSPICE,298.15,,,,,,,182.8600,1125.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,810.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $810.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,697.50,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $697.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,810.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $810.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,810.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $810.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC NERVE BLOCK TRIGEMINAL,64400,CPT,360,RC,36080006,CDM,,,,both,,,1125.0000,742.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,675.00,,,,,,,182.8600,1125.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,125.00 in Billed Charges for Rev 360 Proc 64400 = $675.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,AETNA,AETNA HSHS,7450.96,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $7,450.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,AETNA,AETNA MEDICARE,5872.22,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,AETNA,ALL COMMERCIAL AETNA,11534.00,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $11,534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,ANTHEM,ANTEHM MEDICAID,1015.38,,,,,,,1015.3800,13212.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47538 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment) at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5872.22,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,ANTHEM,ANTHEM POS/HMO,11534.00,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $12,888.00 at 100% of $12,888.00 = $12,888.00 Total (Limited to $11,534.00 in Billed Charges - $0.00 in ASG Allowed Amount = $11,534.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,ANTHEM,ANTHEM PPO,11534.00,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $15,700.00 at 100% of $15,700.00 = $15,700.00 Total (Limited to $11,534.00 in Billed Charges - $0.00 in ASG Allowed Amount = $11,534.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11534.00,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $11,534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,CENPATICO,ALL MEDICAID CENPATICO,11534.00,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $11,534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9803.90,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $9,803.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,CIGNA,ALL COMMERCIAL CIGNA,8073.80,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,073.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,COFINITY,COFINITY,11534.00,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $11,534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1015.38,,,,,,,1015.3800,13212.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47538 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment) at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1015.38,,,,,,,1015.3800,13212.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47538 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment) at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10957.30,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $10,957.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,9688.56,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $9,688.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8189.14,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,189.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8419.82,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,419.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,5605.52,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $5,605.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9803.90,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $9,803.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HUMANA,HUMANA CHOICE CARE PPO,9803.90,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $9,803.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,5872.22,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8419.82,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,419.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,11534.00,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $11,534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1015.38,,,,,,,1015.3800,13212.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47538 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment) at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5872.22,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1015.38,,,,,,,1015.3800,13212.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47538 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment) at 100% = $1,015.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,1076.30,,,,,,,1015.3800,13212.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47538 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment) at 100% = $1,015.38... $1,015.38 at 106% = $1,076.30 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,5872.22,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5767.00,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $5,767.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9688.56,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $9,688.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,13212.49,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8650.50,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,650.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10611.28,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $10,611.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9798.59,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9798.59,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,PREVEA HEALTH NETWORK,PREVEA360,9798.59,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9798.59,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7362.15,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $7,362.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5930.94,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8304.48,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,304.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,TRIOLOGY,TRILOGY MEDICAID,1076.30,,,,,,,1015.3800,13212.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00151 Proc 47538 at $125.60 (Base Rate) * 8.0842 (Relative Weight) = $1,015.38 (Total Line Payment) at 106% = $1,076.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10678.60,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,10678.60,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5872.22,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,10678.60,,,,,,,1015.3800,13212.4900,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47538 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,UNITY HEALTH PLAN,UNITY HOSPICE,5872.22,,,,,,,1015.3800,13212.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8304.48,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,304.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7151.08,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $7,151.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8304.48,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,304.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8304.48,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $8,304.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLC BILE SNT W G SI EX/REMOVAL CHOLANG,47538,CPT,361,RC,36100002,CDM,,,,both,,,11534.0000,7612.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6920.40,,,,,,,1015.3800,13212.4900,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $11,534.00 in Billed Charges for Rev 361 Proc 47538 = $6,920.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,AETNA,AETNA HSHS,5976.79,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $5,976.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,AETNA,AETNA MEDICARE,2030.46,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,AETNA,ALL COMMERCIAL AETNA,9252.00,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $9,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,ANTHEM,ANTEHM MEDICAID,671.16,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50434 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2030.46,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,ANTHEM,ANTHEM POS/HMO,4804.00,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,ANTHEM,ANTHEM PPO,5200.00,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9252.00,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $9,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,CENPATICO,ALL MEDICAID CENPATICO,9252.00,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $9,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7864.20,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $7,864.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,CIGNA,ALL COMMERCIAL CIGNA,6476.40,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,476.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,COFINITY,COFINITY,9252.00,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $9,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,671.16,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50434 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,671.16,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50434 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8789.40,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $8,789.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,7771.68,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $7,771.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6568.92,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,568.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6753.96,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,753.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,4496.47,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $4,496.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7864.20,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $7,864.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HUMANA,HUMANA CHOICE CARE PPO,7864.20,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $7,864.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,2030.46,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6753.96,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,753.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,9252.00,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $9,252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,671.16,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50434 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2030.46,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,671.16,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50434 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,711.43,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50434 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 100% = $671.16... $671.16 at 106% = $711.43 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,2030.46,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4626.00,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $4,626.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7771.68,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $7,771.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,4568.53,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6939.00,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,939.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8511.84,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $8,511.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3002.55,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3002.55,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,PREVEA HEALTH NETWORK,PREVEA360,3002.55,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3002.55,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5905.55,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $5,905.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2050.76,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6661.44,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,661.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,TRIOLOGY,TRILOGY MEDICAID,711.43,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00170 Proc 50434 at $125.60 (Base Rate) * 5.3436 (Relative Weight) = $671.16 (Total Line Payment) at 106% = $711.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3110.50,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,3110.50,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2030.46,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,3110.50,,,,,,,671.1600,9252.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50434 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,UNITY HEALTH PLAN,UNITY HOSPICE,2030.46,,,,,,,671.1600,9252.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6661.44,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,661.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5736.24,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $5,736.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6661.44,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,661.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6661.44,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $6,661.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CONVERT NEPH CTH NEPHUR CTH WG S&I EXST TRACT,50434,CPT,361,RC,36100006,CDM,,,,both,,,9252.0000,6106.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5551.20,,,,,,,671.1600,9252.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,252.00 in Billed Charges for Rev 361 Proc 50434 = $5,551.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,AETNA,AETNA HSHS,17419.39,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $17,419.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,AETNA,AETNA MEDICARE,3423.93,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,AETNA,ALL COMMERCIAL AETNA,26965.00,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $26,965.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,ANTHEM,ANTEHM MEDICAID,1327.06,,,,,,,1327.0600,26965.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50695 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3423.93,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,ANTHEM,ANTHEM POS/HMO,8466.00,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,ANTHEM,ANTHEM PPO,8850.00,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,26965.00,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $26,965.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,CENPATICO,ALL MEDICAID CENPATICO,26965.00,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $26,965.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,22920.25,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $22,920.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,CIGNA,ALL COMMERCIAL CIGNA,18875.50,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $18,875.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,COFINITY,COFINITY,26965.00,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $26,965.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1327.06,,,,,,,1327.0600,26965.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50695 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1327.06,,,,,,,1327.0600,26965.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50695 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,25616.75,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $25,616.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,22650.60,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $22,650.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19145.15,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $19,145.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,19684.45,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $19,684.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,13104.99,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $13,104.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,22920.25,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $22,920.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HUMANA,HUMANA CHOICE CARE PPO,22920.25,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $22,920.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,3423.93,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,19684.45,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $19,684.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,26965.00,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $26,965.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1327.06,,,,,,,1327.0600,26965.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50695 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3423.93,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1327.06,,,,,,,1327.0600,26965.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50695 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,1406.68,,,,,,,1327.0600,26965.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50695 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 100% = $1,327.06... $1,327.06 at 106% = $1,406.68 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,3423.93,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13482.50,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $13,482.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,22650.60,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $22,650.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,7703.84,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20223.75,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $20,223.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,24807.80,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $24,807.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7350.03,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7350.03,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,PREVEA HEALTH NETWORK,PREVEA360,7350.03,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7350.03,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17211.76,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $17,211.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3458.17,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,19414.80,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $19,414.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,TRIOLOGY,TRILOGY MEDICAID,1406.69,,,,,,,1327.0600,26965.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00171 Proc 50695 at $125.60 (Base Rate) * 10.5658 (Relative Weight) = $1,327.06 (Total Line Payment) at 106% = $1,406.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8009.70,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,8009.70,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3423.93,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,8009.70,,,,,,,1327.0600,26965.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 50695 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,UNITY HEALTH PLAN,UNITY HOSPICE,3423.93,,,,,,,1327.0600,26965.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,19414.80,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $19,414.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16718.30,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $16,718.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,19414.80,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $19,414.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,19414.80,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $19,414.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PL URT STNT W G SI NEW ACCESS WITH NEPH CATH,50695,CPT,361,RC,36100009,CDM,,,,both,,,26965.0000,17796.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16179.00,,,,,,,1327.0600,26965.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $26,965.00 in Billed Charges for Rev 361 Proc 50695 = $16,179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,AETNA,AETNA HSHS,7054.32,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,054.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,AETNA,AETNA MEDICARE,6288.23,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,AETNA,ALL COMMERCIAL AETNA,10920.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $10,920.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,ANTHEM,ANTEHM MEDICAID,2485.28,,,,,,,2485.2800,14148.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47541 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,6288.23,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,ANTHEM,ANTHEM POS/HMO,8466.00,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,ANTHEM,ANTHEM PPO,8850.00,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10920.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $10,920.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,CENPATICO,ALL MEDICAID CENPATICO,10920.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $10,920.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9282.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $9,282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,CIGNA,ALL COMMERCIAL CIGNA,7644.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,644.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,COFINITY,COFINITY,10920.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $10,920.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2485.28,,,,,,,2485.2800,14148.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47541 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2485.28,,,,,,,2485.2800,14148.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47541 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10374.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $10,374.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,9172.80,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $9,172.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7753.20,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,753.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7971.60,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,971.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,5307.12,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $5,307.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9282.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $9,282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HUMANA,HUMANA CHOICE CARE PPO,9282.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $9,282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,6288.23,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7971.60,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,971.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,10920.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $10,920.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2485.28,,,,,,,2485.2800,14148.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47541 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,6288.23,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2485.28,,,,,,,2485.2800,14148.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47541 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,2634.40,,,,,,,2485.2800,14148.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47541 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 100% = $2,485.28... $2,485.28 at 106% = $2,634.40 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,6288.23,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5460.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $5,460.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9172.80,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $9,172.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,14148.52,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8190.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $8,190.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10046.40,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $10,046.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7350.03,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7350.03,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,PREVEA HEALTH NETWORK,PREVEA360,7350.03,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7350.03,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $7,350.03 at 100% of $7,350.03 = $7,350.03 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6970.24,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $6,970.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,6351.11,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7862.40,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,862.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,TRIOLOGY,TRILOGY MEDICAID,2634.40,,,,,,,2485.2800,14148.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00152 Proc 47541 at $125.60 (Base Rate) * 19.7873 (Relative Weight) = $2,485.28 (Total Line Payment) at 106% = $2,634.40. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8009.70,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,8009.70,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,6288.23,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,8009.70,,,,,,,2485.2800,14148.5200,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 47541 ASG Rate of $8,009.70 at 100% of $8,009.70 = $8,009.70 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,UNITY HEALTH PLAN,UNITY HOSPICE,6288.23,,,,,,,2485.2800,14148.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7862.40,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,862.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6770.40,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $6,770.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7862.40,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,862.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7862.40,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $7,862.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLCMENT ACCESS BILIARY TREE BOWEL PERC IG SI,47541,CPT,361,RC,36100013,CDM,,,,both,,,10920.0000,7207.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6552.00,,,,,,,2485.2800,14148.5200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $10,920.00 in Billed Charges for Rev 361 Proc 47541 = $6,552.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,AETNA,AETNA HSHS,99.48,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $99.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,AETNA,ALL COMMERCIAL AETNA,154.00,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,ANTHEM,ANTEHM MEDICAID,34.44,,,,,,,34.4400,154.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36510 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,ANTHEM,ANTHEM POS/HMO,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,ANTHEM,ANTHEM PPO,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,154.00,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,CENPATICO,ALL MEDICAID CENPATICO,154.00,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,130.90,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $130.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,CIGNA,ALL COMMERCIAL CIGNA,107.80,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $107.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,COFINITY,COFINITY,154.00,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,34.44,,,,,,,34.4400,154.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36510 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,34.44,,,,,,,34.4400,154.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36510 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,146.30,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $146.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,129.36,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $129.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,109.34,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $109.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,112.42,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $112.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,74.84,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $74.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,130.90,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $130.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,HUMANA,HUMANA CHOICE CARE HMO,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,HUMANA,HUMANA CHOICE CARE PPO,130.90,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $130.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,HUMANA,HUMANA NATIIONAL POS HMO,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,112.42,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $112.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,154.00,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $154.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,34.44,,,,,,,34.4400,154.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36510 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,34.44,,,,,,,34.4400,154.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36510 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,36.51,,,,,,,34.4400,154.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36510 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44... $34.44 at 106% = $36.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,77.00,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $77.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,129.36,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $129.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,115.50,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $115.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,141.68,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $141.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,PREVEA HEALTH NETWORK,PREVEA360,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,98.30,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $98.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,110.88,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $110.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,TRIOLOGY,TRILOGY MEDICAID,36.51,,,,,,,34.4400,154.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36510 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 106% = $36.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,154.00,,,,,,,34.4400,154.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36510 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $154.00 in Billed Charges - $0.00 in ASG Allowed Amount = $154.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,110.88,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $110.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,95.48,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $95.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,110.88,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $110.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,110.88,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $110.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC UMBILICAL CATHETER INSERTION NEWBORN,36510,CPT,361,RC,36100026,CDM,,,,both,,,154.0000,101.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,92.40,,,,,,,34.4400,154.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $154.00 in Billed Charges for Rev 361 Proc 36510 = $92.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,AETNA,AETNA HSHS,1386.32,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,386.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,AETNA,AETNA MEDICARE,447.23,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,AETNA,ALL COMMERCIAL AETNA,2146.00,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $2,146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,ANTHEM,ANTEHM MEDICAID,169.26,,,,,,,169.2600,2146.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $169.26 at 100% = $169.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,447.23,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,ANTHEM,ANTHEM POS/HMO,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,ANTHEM,ANTHEM PPO,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2146.00,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $2,146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,CENPATICO,ALL MEDICAID CENPATICO,2146.00,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $2,146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1824.10,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,824.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,CIGNA,ALL COMMERCIAL CIGNA,1502.20,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,502.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,COFINITY,COFINITY,2146.00,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $2,146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,169.26,,,,,,,169.2600,2146.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $169.26 at 100% = $169.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,169.26,,,,,,,169.2600,2146.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $169.26 at 100% = $169.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2038.70,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $2,038.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,1802.64,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,802.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1523.66,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,523.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1566.58,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,566.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,1042.96,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,042.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1824.10,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,824.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HUMANA,HUMANA CHOICE CARE HMO,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $3,061.00 at 100% of $3,061.00 + 50% of $3,061.00 = $4,591.50 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HUMANA,HUMANA CHOICE CARE PPO,1824.10,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,824.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,447.23,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,HUMANA,HUMANA NATIIONAL POS HMO,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $3,061.00 at 100% of $3,061.00 + 50% of $3,061.00 = $4,591.50 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1566.58,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,566.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2146.00,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $2,146.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,169.26,,,,,,,169.2600,2146.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $169.26 at 100% = $169.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,447.23,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,169.26,,,,,,,169.2600,2146.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $169.26 at 100% = $169.26. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,179.42,,,,,,,169.2600,2146.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $169.26 at 100% = $169.26... $169.26 at 106% = $179.42 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,447.23,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1073.00,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,073.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1802.64,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,802.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,1006.26,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1609.50,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,609.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1974.32,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,974.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $2,048.23 at 150% (50 @ 150%) Mod Percentage = $3,072.35 at 100% of $3,072.35 = $3,072.35 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $2,048.23 at 150% (50 @ 150%) Mod Percentage = $3,072.35 at 100% of $3,072.35 = $3,072.35 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,PREVEA HEALTH NETWORK,PREVEA360,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $2,048.23 at 100% of $2,048.23 + 50% of $2,048.23 = $3,072.35 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $2,048.23 at 150% (50 @ 150%) Mod Percentage = $3,072.35 at 100% of $3,072.35 = $3,072.35 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1369.79,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,369.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,451.70,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1545.12,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,545.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,TRIOLOGY,TRILOGY MEDICAID,179.41,,,,,,,169.2600,2146.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00049 Proc 20610 at $125.60 (Base Rate) * 0.8984 (Relative Weight) = $112.84 (Total Line Payment), Adjusted by ((1 + 0.5) / 1) = $169.26 at 106% = $179.41. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $2,153.10 at 100% of $2,153.10 + 50% of $2,153.10 = $3,229.65 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $2,153.10 at 100% of $2,153.10 + 50% of $2,153.10 = $3,229.65 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,447.23,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,2146.00,,,,,,,169.2600,2146.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20610 Mod 50 ASG Rate of $2,153.10 at 100% of $2,153.10 + 50% of $2,153.10 = $3,229.65 Total (Limited to $2,146.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,146.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,UNITY HEALTH PLAN,UNITY HOSPICE,447.23,,,,,,,169.2600,2146.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1545.12,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,545.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1330.52,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,330.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1545.12,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,545.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1545.12,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,545.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ARTHROCNT/ASP/INJ JNT MAJOR W/O US GUID-BIL,20610,CPT,361,RC,36100044,CDM,,,50,both,,,2146.0000,1416.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1287.60,,,,,,,169.2600,2146.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,146.00 in Billed Charges for Rev 361 Proc 20610 Mod 50 = $1,287.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,AETNA,AETNA HSHS,1838.52,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $1,838.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,AETNA,AETNA MEDICARE,685.65,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,AETNA,ALL COMMERCIAL AETNA,2846.00,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,846.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,ANTHEM,ANTEHM MEDICAID,350.17,,,,,,,350.1700,2846.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62321 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,685.65,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,ANTHEM,ANTHEM POS/HMO,2832.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,ANTHEM,ANTHEM PPO,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2846.00,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,846.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,CENPATICO,ALL MEDICAID CENPATICO,2846.00,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,846.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2419.10,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,419.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,CIGNA,ALL COMMERCIAL CIGNA,1992.20,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $1,992.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,COFINITY,COFINITY,2846.00,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,846.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,350.17,,,,,,,350.1700,2846.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62321 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,350.17,,,,,,,350.1700,2846.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62321 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2703.70,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,703.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,2390.64,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,390.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2020.66,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,020.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2077.58,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,077.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,1383.16,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $1,383.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2419.10,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,419.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HUMANA,HUMANA CHOICE CARE HMO,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HUMANA,HUMANA CHOICE CARE PPO,2419.10,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,419.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,685.65,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,HUMANA,HUMANA NATIIONAL POS HMO,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2077.58,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,077.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2846.00,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,846.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,350.17,,,,,,,350.1700,2846.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62321 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,685.65,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,350.17,,,,,,,350.1700,2846.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62321 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,371.18,,,,,,,350.1700,2846.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62321 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17... $350.17 at 106% = $371.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,685.65,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1423.00,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $1,423.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2390.64,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,390.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,1542.70,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2134.50,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,134.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2618.32,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,618.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,PREVEA HEALTH NETWORK,PREVEA360,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1816.60,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $1,816.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,692.51,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2049.12,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,049.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,TRIOLOGY,TRILOGY MEDICAID,371.18,,,,,,,350.1700,2846.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62321 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 106% = $371.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,685.65,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,2846.00,,,,,,,350.1700,2846.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62321 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $2,846.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,846.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,UNITY HEALTH PLAN,UNITY HOSPICE,685.65,,,,,,,350.1700,2846.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2049.12,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,049.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1764.52,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $1,764.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2049.12,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,049.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2049.12,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $2,049.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR CERV/THOR W/GUIDE,62321,CPT,361,RC,36100101,CDM,,,,both,,,2846.0000,1878.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1707.60,,,,,,,350.1700,2846.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,846.00 in Billed Charges for Rev 361 Proc 62321 = $1,707.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,AETNA,AETNA HSHS,1161.51,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,161.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,AETNA,AETNA MEDICARE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,AETNA,ALL COMMERCIAL AETNA,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTEHM MEDICAID,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62322 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM POS/HMO,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM PPO,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,CENPATICO,ALL MEDICAID CENPATICO,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1528.30,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,CIGNA,ALL COMMERCIAL CIGNA,1258.60,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,258.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,COFINITY,COFINITY,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62322 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62322 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1708.10,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,708.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,1510.32,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1276.58,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,276.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1312.54,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,312.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,873.83,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $873.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1528.30,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA CHOICE CARE HMO,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA CHOICE CARE PPO,1528.30,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA NATIIONAL POS HMO,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1312.54,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,312.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62322 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62322 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,371.18,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62322 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17... $350.17 at 106% = $371.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,899.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $899.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1510.32,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,1933.01,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1348.50,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,348.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1654.16,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,654.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA360,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1147.66,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,147.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,867.71,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1294.56,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,TRIOLOGY,TRILOGY MEDICAID,371.18,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62322 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 106% = $371.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62322 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,UNITY HEALTH PLAN,UNITY HOSPICE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1294.56,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1114.76,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,114.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1294.56,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1294.56,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ INTRLAMNR LUM/SAC W/O GUIDE,62322,CPT,361,RC,36100102,CDM,,,,both,,,1798.0000,1186.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1078.80,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,798.00 in Billed Charges for Rev 361 Proc 62322 = $1,078.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,AETNA,AETNA HSHS,1161.51,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,161.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,AETNA,AETNA MEDICARE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,AETNA,ALL COMMERCIAL AETNA,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTEHM MEDICAID,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62326 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM POS/HMO,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,ANTHEM,ANTHEM PPO,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,CENPATICO,ALL MEDICAID CENPATICO,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1528.30,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,CIGNA,ALL COMMERCIAL CIGNA,1258.60,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,258.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,COFINITY,COFINITY,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62326 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62326 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1708.10,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,708.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,1510.32,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1276.58,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,276.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1312.54,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,312.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,873.83,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $873.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1528.30,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA CHOICE CARE HMO,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA CHOICE CARE PPO,1528.30,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,528.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,HUMANA,HUMANA NATIIONAL POS HMO,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1312.54,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,312.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1798.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,798.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62326 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,350.17,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62326 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE,MOLINA MEDICAID,371.18,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62326 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 100% = $350.17... $350.17 at 106% = $371.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,899.00,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $899.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1510.32,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,510.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,1933.01,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1348.50,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,348.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1654.16,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,654.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA360,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1147.66,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,147.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,867.71,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1294.56,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,TRIOLOGY,TRILOGY MEDICAID,371.18,,,,,,,350.1700,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00053 Proc 62326 at $125.60 (Base Rate) * 2.788 (Relative Weight) = $350.17 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $350.17 at 106% = $371.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,1798.00,,,,,,,350.1700,1933.0100,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 62326 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,798.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,798.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,UNITY HEALTH PLAN,UNITY HOSPICE,859.12,,,,,,,350.1700,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1294.56,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1114.76,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,114.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1294.56,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1294.56,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,294.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ W/CATH LUM/SAC W/O GUIDE,62326,CPT,361,RC,36100106,CDM,,,,both,,,1798.0000,1186.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1078.80,,,,,,,350.1700,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,798.00 in Billed Charges for Rev 361 Proc 62326 = $1,078.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,AETNA,AETNA HSHS,1985.80,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $1,985.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,AETNA,ALL COMMERCIAL AETNA,3074.00,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,ANTHEM,ANTHEM POS/HMO,3074.00,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,ANTHEM,ANTHEM PPO,3074.00,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3074.00,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,CENPATICO,ALL MEDICAID CENPATICO,3074.00,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2612.90,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,612.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,CIGNA,ALL COMMERCIAL CIGNA,2151.80,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,151.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,COFINITY,COFINITY,3074.00,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2920.30,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,920.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,2582.16,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,582.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2182.54,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,182.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2244.02,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,244.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,1493.96,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $1,493.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2612.90,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,612.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,HUMANA CHOICE CARE HMO,3074.00,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,HUMANA CHOICE CARE PPO,2612.90,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,612.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,HUMANA,HUMANA NATIIONAL POS HMO,3074.00,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $3,074.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,074.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2244.02,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,244.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3074.00,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $3,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1537.00,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $1,537.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2582.16,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,582.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2305.50,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,305.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2828.08,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,828.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2048.23,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2048.23,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,PREVEA HEALTH NETWORK,PREVEA360,2048.23,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2048.23,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1962.13,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $1,962.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2213.28,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,213.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2153.10,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,2153.10,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,2153.10,,,,,,,1493.9600,3074.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31627 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2213.28,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,213.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1905.88,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $1,905.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2213.28,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,213.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2213.28,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $2,213.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY NAVIGATIONAL,31627,CPT,361,RC,36100136,CDM,,,,both,,,3074.0000,2028.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1844.40,,,,,,,1493.9600,3074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,074.00 in Billed Charges for Rev 361 Proc 31627 = $1,844.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,AETNA,AETNA HSHS,2283.61,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,283.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,AETNA,AETNA MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,AETNA,ALL COMMERCIAL AETNA,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,ANTHEM,ANTEHM MEDICAID,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31623 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,ANTHEM,ANTHEM POS/HMO,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,ANTHEM,ANTHEM PPO,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,CENPATICO,ALL MEDICAID CENPATICO,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3004.75,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,004.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,CIGNA,ALL COMMERCIAL CIGNA,2474.50,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,474.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,COFINITY,COFINITY,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31623 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31623 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3358.25,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,358.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,2969.40,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,969.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2509.85,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,509.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2580.55,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,580.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,1718.01,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $1,718.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3004.75,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,004.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,HUMANA CHOICE CARE HMO,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,HUMANA CHOICE CARE PPO,3004.75,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,004.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,HUMANA NATIIONAL POS HMO,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2580.55,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,580.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31623 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31623 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,870.80,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31623 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51... $821.51 at 106% = $870.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1767.50,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $1,767.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2969.40,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,969.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,3889.96,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2651.25,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,651.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3252.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $3,252.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,PREVEA HEALTH NETWORK,PREVEA360,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2256.39,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,256.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1746.16,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2545.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,545.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,TRIOLOGY,TRILOGY MEDICAID,870.80,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31623 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 106% = $870.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31623 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,UNITY HEALTH PLAN,UNITY HOSPICE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2545.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,545.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2191.70,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,191.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2545.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,545.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2545.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,545.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/BRUSHING,31623,CPT,361,RC,36100140,CDM,,,,both,,,3535.0000,2333.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2121.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,535.00 in Billed Charges for Rev 361 Proc 31623 = $2,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,AETNA,AETNA HSHS,2283.61,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,283.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,AETNA,AETNA MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,AETNA,ALL COMMERCIAL AETNA,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,ANTHEM,ANTEHM MEDICAID,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31624 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,ANTHEM,ANTHEM POS/HMO,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,ANTHEM,ANTHEM PPO,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,CENPATICO,ALL MEDICAID CENPATICO,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3004.75,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,004.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,CIGNA,ALL COMMERCIAL CIGNA,2474.50,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,474.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,COFINITY,COFINITY,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31624 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31624 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3358.25,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,358.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,2969.40,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,969.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2509.85,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,509.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2580.55,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,580.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,1718.01,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $1,718.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3004.75,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,004.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,HUMANA CHOICE CARE HMO,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,HUMANA CHOICE CARE PPO,3004.75,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,004.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,HUMANA,HUMANA NATIIONAL POS HMO,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $5,023.00 at 100% of $5,023.00 = $5,023.00 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2580.55,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,580.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3535.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,535.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31624 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,821.51,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31624 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,870.80,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31624 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 100% = $821.51... $821.51 at 106% = $870.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1767.50,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $1,767.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2969.40,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,969.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,3889.96,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2651.25,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,651.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3252.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $3,252.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,PREVEA HEALTH NETWORK,PREVEA360,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2256.39,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,256.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1746.16,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2545.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,545.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,TRIOLOGY,TRILOGY MEDICAID,870.80,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00064 Proc 31624 at $125.60 (Base Rate) * 6.5407 (Relative Weight) = $821.51 (Total Line Payment) at 106% = $870.80. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,3535.00,,,,,,,821.5100,3889.9600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31624 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total (Limited to $3,535.00 in Billed Charges - $0.00 in ASG Allowed Amount = $3,535.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,UNITY HEALTH PLAN,UNITY HOSPICE,1728.87,,,,,,,821.5100,3889.9600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2545.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,545.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2191.70,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,191.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2545.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,545.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2545.20,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,545.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BRONCHOSCOPY W/LAVAGE ALVEOLAR,31624,CPT,361,RC,36100143,CDM,,,,both,,,3535.0000,2333.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2121.00,,,,,,,821.5100,3889.9600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,535.00 in Billed Charges for Rev 361 Proc 31624 = $2,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,AETNA,AETNA HSHS,942.51,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $942.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,AETNA,ALL COMMERCIAL AETNA,1459.00,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,459.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,ANTHEM,ANTEHM MEDICAID,586.55,,,,,,,586.5500,1459.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64488 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment) at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,ANTHEM,ANTHEM POS/HMO,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,ANTHEM,ANTHEM PPO,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1459.00,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,459.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,CENPATICO,ALL MEDICAID CENPATICO,1459.00,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,459.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1240.15,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,240.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,CIGNA,ALL COMMERCIAL CIGNA,1021.30,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,021.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,COFINITY,COFINITY,1459.00,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,459.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,586.55,,,,,,,586.5500,1459.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64488 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment) at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,586.55,,,,,,,586.5500,1459.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64488 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment) at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1386.05,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,386.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,1225.56,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,225.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1035.89,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,035.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1065.07,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,065.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,709.07,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $709.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1240.15,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,240.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,HUMANA,HUMANA CHOICE CARE HMO,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,HUMANA,HUMANA CHOICE CARE PPO,1240.15,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,240.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,HUMANA,HUMANA NATIIONAL POS HMO,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1065.07,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,065.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1459.00,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,459.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,586.55,,,,,,,586.5500,1459.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64488 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment) at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,586.55,,,,,,,586.5500,1459.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64488 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment) at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,621.74,,,,,,,586.5500,1459.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64488 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment) at 100% = $586.55... $586.55 at 106% = $621.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,729.50,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $729.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1225.56,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,225.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1094.25,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,094.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1342.28,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,342.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,PREVEA HEALTH NETWORK,PREVEA360,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,931.28,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $931.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1050.48,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,050.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,TRIOLOGY,TRILOGY MEDICAID,621.75,,,,,,,586.5500,1459.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64488 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment) at 106% = $621.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,1459.00,,,,,,,586.5500,1459.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64488 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,459.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,459.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1050.48,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,050.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,904.58,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $904.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1050.48,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,050.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1050.48,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $1,050.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INJ TAP BLOCK W/GUIDE- BIL,64488,CPT,361,RC,36100148,CDM,,,,both,,,1459.0000,962.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,875.40,,,,,,,586.5500,1459.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,459.00 in Billed Charges for Rev 361 Proc 64488 = $875.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,AETNA,AETNA HSHS,8076.29,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $8,076.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,AETNA,AETNA MEDICARE,7048.20,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,AETNA,ALL COMMERCIAL AETNA,12502.00,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $12,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,ANTHEM,ANTEHM MEDICAID,820.29,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 20983 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7048.20,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,ANTHEM,ANTHEM POS/HMO,12502.00,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $15,576.00 at 100% of $15,576.00 = $15,576.00 Total (Limited to $12,502.00 in Billed Charges - $0.00 in ASG Allowed Amount = $12,502.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,ANTHEM,ANTHEM PPO,12502.00,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $22,750.00 at 100% of $22,750.00 = $22,750.00 Total (Limited to $12,502.00 in Billed Charges - $0.00 in ASG Allowed Amount = $12,502.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12502.00,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $12,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,CENPATICO,ALL MEDICAID CENPATICO,12502.00,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $12,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10626.70,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $10,626.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,CIGNA,ALL COMMERCIAL CIGNA,8751.40,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $8,751.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,COFINITY,COFINITY,12502.00,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $12,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,820.29,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 20983 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,820.29,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 20983 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11876.90,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $11,876.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,10501.68,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $10,501.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8876.42,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $8,876.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9126.46,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $9,126.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,6075.97,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $6,075.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10626.70,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $10,626.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HUMANA,HUMANA CHOICE CARE PPO,10626.70,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $10,626.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,7048.20,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9126.46,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $9,126.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,12502.00,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $12,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,820.29,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 20983 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7048.20,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,820.29,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 20983 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,869.51,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 20983 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29... $820.29 at 106% = $869.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,7048.20,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6251.00,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $6,251.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10501.68,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $10,501.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,15858.44,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9376.50,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $9,376.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11501.84,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $11,501.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9798.59,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9798.59,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,PREVEA HEALTH NETWORK,PREVEA360,9798.59,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9798.59,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $9,798.59 at 100% of $9,798.59 = $9,798.59 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7980.03,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $7,980.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7118.68,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9001.44,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $9,001.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,TRIOLOGY,TRILOGY MEDICAID,869.51,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 20983 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 106% = $869.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10678.60,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,10678.60,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7048.20,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,10678.60,,,,,,,820.2900,15858.4400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 20983 ASG Rate of $10,678.60 at 100% of $10,678.60 = $10,678.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,UNITY HEALTH PLAN,UNITY HOSPICE,7048.20,,,,,,,820.2900,15858.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9001.44,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $9,001.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7751.24,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $7,751.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9001.44,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $9,001.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9001.44,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $9,001.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION TUMOR BONE PERC W/GUIDANCE CRYO,20983,CPT,361,RC,36100158,CDM,,,,both,,,12502.0000,8251.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7501.20,,,,,,,820.2900,15858.4400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $12,502.00 in Billed Charges for Rev 361 Proc 20983 = $7,501.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,AETNA,AETNA HSHS,877.91,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $877.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,AETNA,AETNA MEDICARE,242.69,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,AETNA,ALL COMMERCIAL AETNA,1359.00,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,ANTHEM,ANTEHM MEDICAID,60.77,,,,,,,60.7700,1359.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00213 Proc 51785 at $125.60 (Base Rate) * 0.4838 (Relative Weight) = $60.77 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $60.77 at 100% = $60.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,242.69,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,ANTHEM,ANTHEM POS/HMO,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,ANTHEM,ANTHEM PPO,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1359.00,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,CENPATICO,ALL MEDICAID CENPATICO,1359.00,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1155.15,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,155.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,CIGNA,ALL COMMERCIAL CIGNA,951.30,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $951.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,COFINITY,COFINITY,1359.00,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,60.77,,,,,,,60.7700,1359.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00213 Proc 51785 at $125.60 (Base Rate) * 0.4838 (Relative Weight) = $60.77 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $60.77 at 100% = $60.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,60.77,,,,,,,60.7700,1359.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00213 Proc 51785 at $125.60 (Base Rate) * 0.4838 (Relative Weight) = $60.77 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $60.77 at 100% = $60.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1291.05,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,291.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,1141.56,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,141.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,964.89,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $964.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,992.07,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $992.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,660.47,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $660.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1155.15,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,155.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HUMANA,HUMANA CHOICE CARE HMO,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HUMANA,HUMANA CHOICE CARE PPO,1155.15,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,155.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,242.69,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,HUMANA,HUMANA NATIIONAL POS HMO,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,992.07,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $992.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1359.00,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,359.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,60.77,,,,,,,60.7700,1359.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00213 Proc 51785 at $125.60 (Base Rate) * 0.4838 (Relative Weight) = $60.77 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $60.77 at 100% = $60.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,242.69,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,60.77,,,,,,,60.7700,1359.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00213 Proc 51785 at $125.60 (Base Rate) * 0.4838 (Relative Weight) = $60.77 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $60.77 at 100% = $60.77. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,64.42,,,,,,,60.7700,1359.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00213 Proc 51785 at $125.60 (Base Rate) * 0.4838 (Relative Weight) = $60.77 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $60.77 at 100% = $60.77... $60.77 at 106% = $64.42 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,242.69,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,679.50,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $679.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1141.56,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,141.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,546.04,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1019.25,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,019.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1250.28,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $1,250.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,PREVEA HEALTH NETWORK,PREVEA360,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,867.45,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $867.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,245.12,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,978.48,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $978.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,TRIOLOGY,TRILOGY MEDICAID,64.41,,,,,,,60.7700,1359.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00213 Proc 51785 at $125.60 (Base Rate) * 0.4838 (Relative Weight) = $60.77 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $60.77 at 106% = $64.41. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,242.69,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,1359.00,,,,,,,60.7700,1359.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 51785 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,359.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,359.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,UNITY HEALTH PLAN,UNITY HOSPICE,242.69,,,,,,,60.7700,1359.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,978.48,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $978.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,842.58,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $842.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,978.48,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $978.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,978.48,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $978.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC  EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ,51785,CPT,361,RC,36100204,CDM,,,,both,,,1359.0000,896.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,815.40,,,,,,,60.7700,1359.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,359.00 in Billed Charges for Rev 361 Proc 51785 = $815.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,AETNA,AETNA HSHS,3594.34,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $3,594.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,AETNA,AETNA MEDICARE,3144.33,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,AETNA,ALL COMMERCIAL AETNA,5564.00,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,ANTHEM,ANTEHM MEDICAID,1065.36,,,,,,,1065.3600,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58345 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3144.33,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,ANTHEM,ANTHEM POS/HMO,4804.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,ANTHEM,ANTHEM PPO,5200.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5564.00,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,CENPATICO,ALL MEDICAID CENPATICO,5564.00,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4729.40,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,729.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,CIGNA,ALL COMMERCIAL CIGNA,3894.80,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $3,894.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,COFINITY,COFINITY,5564.00,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1065.36,,,,,,,1065.3600,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58345 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1065.36,,,,,,,1065.3600,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58345 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5285.80,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $5,285.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,4673.76,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,673.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3950.44,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $3,950.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4061.72,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,061.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,2704.10,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $2,704.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4729.40,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,729.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,HUMANA CHOICE CARE HMO,3061.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,HUMANA CHOICE CARE PPO,4729.40,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,729.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,3144.33,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,HUMANA,HUMANA NATIIONAL POS HMO,3061.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4061.72,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,061.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,5564.00,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $5,564.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1065.36,,,,,,,1065.3600,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58345 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3144.33,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1065.36,,,,,,,1065.3600,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58345 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,1129.28,,,,,,,1065.3600,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58345 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 100% = $1,065.36... $1,065.36 at 106% = $1,129.28 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,3144.33,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2782.00,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $2,782.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4673.76,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,673.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,7074.73,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4173.00,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,173.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5118.88,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $5,118.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5564.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total (Service Line reduced to $5,564.00, claim capped at $5,564.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5564.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total (Service Line reduced to $5,564.00, claim capped at $5,564.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,PREVEA HEALTH NETWORK,PREVEA360,5564.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total (Service Line reduced to $5,564.00, claim capped at $5,564.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5564.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $5,600.43 at 100% of $5,600.43 = $5,600.43 Total (Service Line reduced to $5,564.00, claim capped at $5,564.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3551.50,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $3,551.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3175.77,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4006.08,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,006.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,TRIOLOGY,TRILOGY MEDICAID,1129.29,,,,,,,1065.3600,7074.7300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00207 Proc 58345 at $125.60 (Base Rate) * 8.4822 (Relative Weight) = $1,065.36 (Total Line Payment) at 106% = $1,129.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5564.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $5,564.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,564.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,5564.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $5,564.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,564.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3144.33,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,5564.00,,,,,,,1065.3600,7074.7300,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 58345 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $5,564.00 in Billed Charges - $0.00 in ASG Allowed Amount = $5,564.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,UNITY HEALTH PLAN,UNITY HOSPICE,3144.33,,,,,,,1065.3600,7074.7300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4006.08,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,006.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3449.68,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $3,449.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4006.08,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,006.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4006.08,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $4,006.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING,58345,CPT,361,RC,36100226,CDM,,,,both,,,5564.0000,3672.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3338.40,,,,,,,1065.3600,7074.7300,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,564.00 in Billed Charges for Rev 361 Proc 58345 = $3,338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,AETNA,AETNA HSHS,145.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $145.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,AETNA,ALL COMMERCIAL AETNA,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTEHM MEDICAID,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11103 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,CENPATICO,ALL MEDICAID CENPATICO,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,CIGNA,ALL COMMERCIAL CIGNA,157.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,COFINITY,COFINITY,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11103 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11103 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,213.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $213.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,159.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $159.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,109.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $109.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE HMO,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE PPO,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA NATIIONAL POS HMO,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11103 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11103 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,204.29,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11103 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73... $192.73 at 106% = $204.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,112.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,168.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,207.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA360,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,143.62,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $143.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,TRILOGY MEDICAID,204.30,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11103 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 106% = $204.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11103 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,139.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $139.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN TANGENTIAL ADDL LESN,11103,CPT,361,RC,36100232,CDM,,,,both,,,225.0000,148.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,135.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $225.00 in Billed Charges for Rev 361 Proc 11103 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,AETNA,AETNA HSHS,145.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $145.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,AETNA,ALL COMMERCIAL AETNA,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTEHM MEDICAID,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11105 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTHEM POS/HMO,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTHEM PPO,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,CENPATICO,ALL MEDICAID CENPATICO,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,CIGNA,ALL COMMERCIAL CIGNA,157.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,COFINITY,COFINITY,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11105 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11105 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,213.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $213.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,159.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $159.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,109.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $109.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE HMO,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE PPO,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA NATIIONAL POS HMO,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11105 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11105 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,204.29,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11105 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73... $192.73 at 106% = $204.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,112.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,168.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,207.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA360,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,143.62,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $143.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,TRILOGY MEDICAID,204.30,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11105 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 106% = $204.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11105 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,139.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $139.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN PUNCH ADDL LESN,11105,CPT,361,RC,36100233,CDM,,,,both,,,225.0000,148.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,135.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $225.00 in Billed Charges for Rev 361 Proc 11105 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,AETNA,AETNA HSHS,145.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $145.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,AETNA,ALL COMMERCIAL AETNA,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,ANTHEM,ANTEHM MEDICAID,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11107 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,CENPATICO,ALL MEDICAID CENPATICO,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,CIGNA,ALL COMMERCIAL CIGNA,157.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,COFINITY,COFINITY,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11107 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11107 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,213.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $213.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,159.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $159.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,109.35,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $109.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE HMO,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA CHOICE CARE PPO,191.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $191.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,HUMANA,HUMANA NATIIONAL POS HMO,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,164.25,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $164.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,225.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $225.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11107 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,192.73,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11107 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,204.29,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11107 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 100% = $192.73... $192.73 at 106% = $204.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,112.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $112.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,189.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $189.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,168.75,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $168.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,207.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA360,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,143.62,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $143.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,TRIOLOGY,TRILOGY MEDICAID,204.30,,,,,,,109.3500,225.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11107 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment) at 106% = $204.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,225.00,,,,,,,109.3500,225.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11107 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $225.00 in Billed Charges - $0.00 in ASG Allowed Amount = $225.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,139.50,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $139.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,162.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL ADDL LESN,11107,CPT,361,RC,36100234,CDM,,,,both,,,225.0000,148.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,135.00,,,,,,,109.3500,225.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $225.00 in Billed Charges for Rev 361 Proc 11107 = $135.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,AETNA,AETNA HSHS,691.87,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $691.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,AETNA,AETNA MEDICARE,717.88,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,AETNA,ALL COMMERCIAL AETNA,1071.00,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $1,071.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,ANTHEM,ANTEHM MEDICAID,192.73,,,,,,,192.7300,1615.2400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11106 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,717.88,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,ANTHEM,ANTHEM POS/HMO,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,ANTHEM,ANTHEM PPO,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1071.00,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $1,071.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,CENPATICO,ALL MEDICAID CENPATICO,1071.00,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $1,071.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,910.35,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $910.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,CIGNA,ALL COMMERCIAL CIGNA,749.70,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $749.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,COFINITY,COFINITY,1071.00,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $1,071.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,192.73,,,,,,,192.7300,1615.2400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11106 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,192.73,,,,,,,192.7300,1615.2400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11106 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1017.45,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $1,017.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,899.64,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $899.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,760.41,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $760.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,781.83,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $781.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,520.51,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $520.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,910.35,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $910.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HUMANA,HUMANA CHOICE CARE HMO,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HUMANA,HUMANA CHOICE CARE PPO,910.35,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $910.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,717.88,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,HUMANA,HUMANA NATIIONAL POS HMO,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,781.83,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $781.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1071.00,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $1,071.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,192.73,,,,,,,192.7300,1615.2400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11106 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,717.88,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,192.73,,,,,,,192.7300,1615.2400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11106 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,204.29,,,,,,,192.7300,1615.2400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11106 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 100% = $192.73... $192.73 at 106% = $204.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,717.88,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,535.50,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $535.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,899.64,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $899.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,1615.24,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,803.25,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $803.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,985.32,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $985.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,PREVEA HEALTH NETWORK,PREVEA360,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,683.62,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $683.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,725.06,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,771.12,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $771.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,TRIOLOGY,TRILOGY MEDICAID,204.30,,,,,,,192.7300,1615.2400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00009 Proc 11106 at $125.60 (Base Rate) * 1.5345 (Relative Weight) = $192.73 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $192.73 at 106% = $204.30. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,717.88,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,1071.00,,,,,,,192.7300,1615.2400,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 11106 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,071.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,071.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,UNITY HEALTH PLAN,UNITY HOSPICE,717.88,,,,,,,192.7300,1615.2400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,771.12,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $771.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,664.02,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $664.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,771.12,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $771.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,771.12,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $771.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BIOPSY SKIN INCISIONAL INIT LESN,11106,CPT,361,RC,36100237,CDM,,,,both,,,1071.0000,706.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,642.60,,,,,,,192.7300,1615.2400,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,071.00 in Billed Charges for Rev 361 Proc 11106 = $642.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,AETNA,AETNA HSHS,532.30,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $532.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,AETNA,ALL COMMERCIAL AETNA,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTEHM MEDICAID,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10006 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTHEM POS/HMO,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $9,690.00 at 100% of $9,690.00 = $9,690.00 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTHEM PPO,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $10,500.00 at 100% of $10,500.00 = $10,500.00 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,CENPATICO,ALL MEDICAID CENPATICO,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,CIGNA,ALL COMMERCIAL CIGNA,576.80,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $576.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,COFINITY,COFINITY,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10006 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10006 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,782.80,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $782.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,692.16,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $692.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,585.04,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $585.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,601.52,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $601.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,400.46,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $400.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA CHOICE CARE HMO,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA CHOICE CARE PPO,700.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA NATIIONAL POS HMO,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,601.52,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $601.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,824.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10006 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,313.03,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10006 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,331.81,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10006 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 100% = $313.03... $313.03 at 106% = $331.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,412.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $412.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,692.16,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $692.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,618.00,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $618.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,758.08,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $758.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA360,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,525.96,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $525.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,TRIOLOGY,TRILOGY MEDICAID,331.81,,,,,,,313.0300,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10006 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment) at 106% = $331.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,824.00,,,,,,,313.0300,824.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10006 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $824.00 in Billed Charges - $0.00 in ASG Allowed Amount = $824.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,510.88,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $510.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,593.28,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/US GUIDE EA ADDL LESN,10006,CPT,361,RC,36100239,CDM,,,,both,,,824.0000,543.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,494.40,,,,,,,313.0300,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $824.00 in Billed Charges for Rev 361 Proc 10006 = $494.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,AETNA,AETNA HSHS,1063.96,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,063.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,AETNA,AETNA MEDICARE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,AETNA,ALL COMMERCIAL AETNA,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,ANTHEM,ANTEHM MEDICAID,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10009 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM POS/HMO,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,ANTHEM,ANTHEM PPO,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,CENPATICO,ALL MEDICAID CENPATICO,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1399.95,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,CIGNA,ALL COMMERCIAL CIGNA,1152.90,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,152.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,COFINITY,COFINITY,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10009 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10009 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1564.65,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,564.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,1383.48,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,383.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1169.37,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,169.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1202.31,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,202.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,800.44,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $800.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1399.95,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,HUMANA CHOICE CARE HMO,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,HUMANA CHOICE CARE PPO,1399.95,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,399.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,HUMANA,HUMANA NATIIONAL POS HMO,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1202.31,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,202.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1647.00,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,647.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10009 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,313.03,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10009 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,331.81,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10009 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03... $313.03 at 106% = $331.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,823.50,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $823.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1383.48,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,383.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,1547.62,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1235.25,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,235.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1515.24,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,515.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA360,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $3,002.55 at 100% of $3,002.55 = $3,002.55 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1051.28,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,051.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,694.71,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1185.84,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,TRIOLOGY,TRILOGY MEDICAID,331.81,,,,,,,313.0300,1647.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 10009 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 106% = $331.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,1647.00,,,,,,,313.0300,1647.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 10009 ASG Rate of $3,110.50 at 100% of $3,110.50 = $3,110.50 Total (Limited to $1,647.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,647.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,UNITY HEALTH PLAN,UNITY HOSPICE,687.83,,,,,,,313.0300,1647.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1185.84,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1021.14,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,021.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1185.84,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1185.84,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $1,185.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP FINE NDL W/CT GUIDE INIT LESN,10009,CPT,361,RC,36100242,CDM,,,,both,,,1647.0000,1087.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,988.20,,,,,,,313.0300,1647.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,647.00 in Billed Charges for Rev 361 Proc 10009 = $988.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,AETNA,AETNA HSHS,20299.90,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $20,299.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,AETNA,AETNA MEDICARE,17806.11,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,AETNA,ALL COMMERCIAL AETNA,31424.00,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $31,424.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,ANTHEM,ANTEHM MEDICAID,1612.87,,,,,,,1612.8700,40063.7600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00059 Proc 36837 at $125.60 (Base Rate) * 12.8413 (Relative Weight) = $1,612.87 (Total Line Payment) at 100% = $1,612.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,17806.11,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,ANTHEM,ANTHEM POS/HMO,18410.00,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $18,410.00 at 100% of $18,410.00 = $18,410.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,ANTHEM,ANTHEM PPO,22500.00,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $22,500.00 at 100% of $22,500.00 = $22,500.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,31424.00,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $31,424.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,CENPATICO,ALL MEDICAID CENPATICO,31424.00,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $31,424.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,26710.40,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $26,710.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,CIGNA,ALL COMMERCIAL CIGNA,21996.80,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $21,996.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,COFINITY,COFINITY,31424.00,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $31,424.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,1612.87,,,,,,,1612.8700,40063.7600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00059 Proc 36837 at $125.60 (Base Rate) * 12.8413 (Relative Weight) = $1,612.87 (Total Line Payment) at 100% = $1,612.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,1612.87,,,,,,,1612.8700,40063.7600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00059 Proc 36837 at $125.60 (Base Rate) * 12.8413 (Relative Weight) = $1,612.87 (Total Line Payment) at 100% = $1,612.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,29852.80,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $29,852.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,26396.16,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $26,396.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,22311.04,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $22,311.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,22939.52,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $22,939.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,15272.06,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $15,272.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,26710.40,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $26,710.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HUMANA,HUMANA CHOICE CARE HMO,7604.00,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HUMANA,HUMANA CHOICE CARE PPO,26710.40,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $26,710.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,17806.11,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,HUMANA,HUMANA NATIIONAL POS HMO,7604.00,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,22939.52,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $22,939.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,31424.00,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $31,424.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,1612.87,,,,,,,1612.8700,40063.7600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00059 Proc 36837 at $125.60 (Base Rate) * 12.8413 (Relative Weight) = $1,612.87 (Total Line Payment) at 100% = $1,612.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17806.11,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,1612.87,,,,,,,1612.8700,40063.7600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00059 Proc 36837 at $125.60 (Base Rate) * 12.8413 (Relative Weight) = $1,612.87 (Total Line Payment) at 100% = $1,612.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,1709.64,,,,,,,1612.8700,40063.7600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00059 Proc 36837 at $125.60 (Base Rate) * 12.8413 (Relative Weight) = $1,612.87 (Total Line Payment) at 100% = $1,612.87... $1,612.87 at 106% = $1,709.64 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,17806.11,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,15712.00,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $15,712.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,26396.16,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $26,396.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,40063.76,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,23568.00,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $23,568.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,28910.08,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $28,910.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11200.86,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $11,200.86 at 100% of $11,200.86 = $11,200.86 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11200.86,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $11,200.86 at 100% of $11,200.86 = $11,200.86 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,PREVEA HEALTH NETWORK,PREVEA360,11200.86,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $11,200.86 at 100% of $11,200.86 = $11,200.86 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11200.86,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $11,200.86 at 100% of $11,200.86 = $11,200.86 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,20057.94,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $20,057.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17984.17,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,22625.28,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $22,625.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,TRIOLOGY,TRILOGY MEDICAID,1709.64,,,,,,,1612.8700,40063.7600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00059 Proc 36837 at $125.60 (Base Rate) * 12.8413 (Relative Weight) = $1,612.87 (Total Line Payment) at 106% = $1,709.64. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12669.60,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $12,669.60 at 100% of $12,669.60 = $12,669.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,12669.60,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $12,669.60 at 100% of $12,669.60 = $12,669.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,17806.11,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,12669.60,,,,,,,1612.8700,40063.7600,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 36837 ASG Rate of $12,669.60 at 100% of $12,669.60 = $12,669.60 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,UNITY HEALTH PLAN,UNITY HOSPICE,17806.11,,,,,,,1612.8700,40063.7600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,22625.28,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $22,625.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,19482.88,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $19,482.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,22625.28,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $22,625.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,22625.28,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $22,625.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CREATE AV FISTULA PERC W/RAD FREQ MAGNETIC GUIDE W/S&I,36837,CPT,361,RC,36100249,CDM,,,,both,,,31424.0000,20739.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,18854.40,,,,,,,1612.8700,40063.7600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $31,424.00 in Billed Charges for Rev 361 Proc 36837 = $18,854.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,AETNA,AETNA HSHS,4437.37,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,437.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,AETNA,AETNA MEDICARE,298.15,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,AETNA,ALL COMMERCIAL AETNA,6869.00,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $6,869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,ANTHEM,ANTEHM MEDICAID,182.86,,,,,,,182.8600,6869.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64999 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,298.15,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,ANTHEM,ANTHEM POS/HMO,6869.00,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $19,430.00 at 100% of $19,430.00 = $19,430.00 Total (Limited to $6,869.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,869.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,ANTHEM,ANTHEM PPO,6869.00,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $22,500.00 at 100% of $22,500.00 = $22,500.00 Total (Limited to $6,869.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,869.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6869.00,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $6,869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,CENPATICO,ALL MEDICAID CENPATICO,6869.00,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $6,869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5838.65,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $5,838.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,CIGNA,ALL COMMERCIAL CIGNA,4808.30,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,808.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,COFINITY,COFINITY,6869.00,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $6,869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,182.86,,,,,,,182.8600,6869.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64999 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,182.86,,,,,,,182.8600,6869.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64999 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6525.55,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $6,525.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,5769.96,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $5,769.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4876.99,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,876.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5014.37,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $5,014.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,3338.33,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $3,338.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5838.65,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $5,838.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HUMANA,HUMANA CHOICE CARE HMO,3061.00,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HUMANA,HUMANA CHOICE CARE PPO,5838.65,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $5,838.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HUMANA,HUMANA MEDICARE ADVANTAGE,298.15,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,HUMANA,HUMANA NATIIONAL POS HMO,3061.00,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5014.37,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $5,014.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,6869.00,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $6,869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,182.86,,,,,,,182.8600,6869.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64999 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,298.15,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,182.86,,,,,,,182.8600,6869.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64999 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,MOLINA HEALTHCARE,MOLINA MEDICAID,193.83,,,,,,,182.8600,6869.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64999 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 100% = $182.86... $182.86 at 106% = $193.83 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,MOLINA HEALTHCARE,MOLINA MEDICARE,298.15,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3434.50,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $3,434.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5769.96,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $5,769.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,NAPHCARE,ALL COMMERICAL NAPHCARE,670.84,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5151.75,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $5,151.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6319.48,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $6,319.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6869.00,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $6,869.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,869.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6869.00,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $6,869.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,869.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,PREVEA HEALTH NETWORK,PREVEA360,6869.00,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $6,869.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,869.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6869.00,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $6,869.00 in Billed Charges - $0.00 in ASG Allowed Amount = $6,869.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4384.48,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,384.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,301.13,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4945.68,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,945.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,TRIOLOGY,TRILOGY MEDICAID,193.83,,,,,,,182.8600,6869.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00214 Proc 64999 at $125.60 (Base Rate) * 1.4559 (Relative Weight) = $182.86 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $182.86 at 106% = $193.83. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2153.10,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,2153.10,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,298.15,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,2153.10,,,,,,,182.8600,6869.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64999 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,UNITY HEALTH PLAN,UNITY HOSPICE,298.15,,,,,,,182.8600,6869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4945.68,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,945.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4258.78,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,258.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4945.68,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,945.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4945.68,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,945.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION CYRO INTERCOSTAL NERVE,64999,CPT,361,RC,36100256,CDM,,,,both,,,6869.0000,4533.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4121.40,,,,,,,182.8600,6869.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $6,869.00 in Billed Charges for Rev 361 Proc 64999 = $4,121.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,AETNA,AETNA HSHS,1768.75,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,768.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,AETNA,ALL COMMERCIAL AETNA,2738.00,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,738.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,ANTHEM,ANTEHM MEDICAID,456.67,,,,,,,456.6700,2738.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33017 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,ANTHEM,ANTHEM POS/HMO,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $2,738.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,738.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,ANTHEM,ANTHEM PPO,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $2,738.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,738.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2738.00,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,738.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,CENPATICO,ALL MEDICAID CENPATICO,2738.00,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,738.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2327.30,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,327.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,CIGNA,ALL COMMERCIAL CIGNA,1916.60,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,916.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,COFINITY,COFINITY,2738.00,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,738.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,456.67,,,,,,,456.6700,2738.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33017 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,456.67,,,,,,,456.6700,2738.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33017 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2601.10,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,601.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,2299.92,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,299.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1943.98,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,943.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1998.74,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,998.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,1330.67,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,330.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2327.30,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,327.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,HUMANA,HUMANA CHOICE CARE HMO,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,738.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,738.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,HUMANA,HUMANA CHOICE CARE PPO,2327.30,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,327.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,HUMANA,HUMANA NATIIONAL POS HMO,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,738.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,738.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1998.74,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,998.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,2738.00,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,738.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,456.67,,,,,,,456.6700,2738.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33017 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,456.67,,,,,,,456.6700,2738.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33017 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,484.07,,,,,,,456.6700,2738.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33017 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67... $456.67 at 106% = $484.07 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1369.00,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,369.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2299.92,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,299.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2053.50,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,053.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2518.96,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $2,518.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,738.00, claim capped at $2,738.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,738.00, claim capped at $2,738.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,PREVEA HEALTH NETWORK,PREVEA360,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,738.00, claim capped at $2,738.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,738.00, claim capped at $2,738.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1747.67,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,747.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1971.36,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,971.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,TRIOLOGY,TRILOGY MEDICAID,484.07,,,,,,,456.6700,2738.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33017 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 106% = $484.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,738.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,738.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,738.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,738.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,2738.00,,,,,,,456.6700,2738.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33017 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,738.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,738.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1971.36,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,971.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1697.56,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,697.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1971.36,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,971.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1971.36,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,971.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE =>6 YRS W/O CONGENITAL CARDIAC ANOMALY,33017,CPT,361,RC,36100265,CDM,,,,both,,,2738.0000,1807.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1642.80,,,,,,,456.6700,2738.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,738.00 in Billed Charges for Rev 361 Proc 33017 = $1,642.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,AETNA,AETNA HSHS,1538.13,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,538.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,AETNA,ALL COMMERCIAL AETNA,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,ANTHEM,ANTEHM MEDICAID,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33018 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,ANTHEM,ANTHEM POS/HMO,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,ANTHEM,ANTHEM PPO,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,CENPATICO,ALL MEDICAID CENPATICO,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2023.85,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,023.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,CIGNA,ALL COMMERCIAL CIGNA,1666.70,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,666.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,COFINITY,COFINITY,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33018 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33018 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2261.95,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,261.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,2000.04,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,000.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1690.51,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,690.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1738.13,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,738.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,1157.17,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,157.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2023.85,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,023.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,HUMANA,HUMANA CHOICE CARE HMO,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,HUMANA,HUMANA CHOICE CARE PPO,2023.85,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,023.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,HUMANA,HUMANA NATIIONAL POS HMO,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1738.13,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,738.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33018 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33018 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,484.07,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33018 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67... $456.67 at 106% = $484.07 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1190.50,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,190.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2000.04,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,000.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1785.75,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,785.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2190.52,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $2,190.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,381.00, claim capped at $2,381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,381.00, claim capped at $2,381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,PREVEA HEALTH NETWORK,PREVEA360,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,381.00, claim capped at $2,381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,381.00, claim capped at $2,381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1519.79,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,519.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1714.32,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,714.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,TRIOLOGY,TRILOGY MEDICAID,484.07,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33018 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 106% = $484.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33018 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1714.32,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,714.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1476.22,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,476.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1714.32,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,714.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1714.32,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,714.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE <=5 YRS W/CONGENITAL CARDIAC ANOMALY,33018,CPT,361,RC,36100266,CDM,,,,both,,,2381.0000,1571.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1428.60,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,381.00 in Billed Charges for Rev 361 Proc 33018 = $1,428.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,AETNA,AETNA HSHS,1538.13,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,538.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,AETNA,ALL COMMERCIAL AETNA,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,ANTHEM,ANTEHM MEDICAID,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33019 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,ANTHEM,ANTHEM POS/HMO,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,ANTHEM,ANTHEM PPO,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,CENPATICO,ALL MEDICAID CENPATICO,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2023.85,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,023.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,CIGNA,ALL COMMERCIAL CIGNA,1666.70,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,666.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,COFINITY,COFINITY,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33019 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33019 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2261.95,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,261.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,2000.04,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,000.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1690.51,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,690.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1738.13,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,738.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,1157.17,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,157.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2023.85,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,023.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,HUMANA,HUMANA CHOICE CARE HMO,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,HUMANA,HUMANA CHOICE CARE PPO,2023.85,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,023.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,HUMANA,HUMANA NATIIONAL POS HMO,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1738.13,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,738.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,2381.00,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33019 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,456.67,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33019 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,484.07,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33019 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 100% = $456.67... $456.67 at 106% = $484.07 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1190.50,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,190.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2000.04,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,000.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1785.75,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,785.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2190.52,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $2,190.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,381.00, claim capped at $2,381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,381.00, claim capped at $2,381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,PREVEA HEALTH NETWORK,PREVEA360,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,381.00, claim capped at $2,381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $3,988.25 at 100% of $3,988.25 = $3,988.25 Total (Service Line reduced to $2,381.00, claim capped at $2,381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1519.79,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,519.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1714.32,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,714.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,TRIOLOGY,TRILOGY MEDICAID,484.07,,,,,,,456.6700,2381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00068 Proc 33019 at $125.60 (Base Rate) * 3.6359 (Relative Weight) = $456.67 (Total Line Payment) at 106% = $484.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,2381.00,,,,,,,456.6700,2381.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 33019 ASG Rate of $10,061.20 at 100% of $10,061.20 = $10,061.20 Total (Limited to $2,381.00 in Billed Charges - $0.00 in ASG Allowed Amount = $2,381.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1714.32,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,714.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1476.22,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,476.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1714.32,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,714.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1714.32,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,714.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PERICARDIAL DRAINAGE W/INS CATH PERC W/CT GUIDANCE,33019,CPT,361,RC,36100267,CDM,,,,both,,,2381.0000,1571.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1428.60,,,,,,,456.6700,2381.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,381.00 in Billed Charges for Rev 361 Proc 33019 = $1,428.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,AETNA,AETNA HSHS,3193.18,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,193.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,AETNA,AETNA MEDICARE,1896.75,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,AETNA,ALL COMMERCIAL AETNA,4943.00,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,943.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,ANTHEM,ANTEHM MEDICAID,617.20,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00217 Proc 64625 at $125.60 (Base Rate) * 4.914 (Relative Weight) = $617.20 (Total Line Payment) at 100% = $617.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1896.75,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,ANTHEM,ANTHEM POS/HMO,4804.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $4,804.00 at 100% of $4,804.00 = $4,804.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,ANTHEM,ANTHEM PPO,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $5,200.00 at 100% of $5,200.00 = $5,200.00 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4943.00,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,943.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,CENPATICO,ALL MEDICAID CENPATICO,4943.00,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,943.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4201.55,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,201.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,CIGNA,ALL COMMERCIAL CIGNA,3460.10,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,460.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,COFINITY,COFINITY,4943.00,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,943.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,617.20,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00217 Proc 64625 at $125.60 (Base Rate) * 4.914 (Relative Weight) = $617.20 (Total Line Payment) at 100% = $617.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,617.20,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00217 Proc 64625 at $125.60 (Base Rate) * 4.914 (Relative Weight) = $617.20 (Total Line Payment) at 100% = $617.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4695.85,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,695.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,4152.12,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,152.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3509.53,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,509.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3608.39,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,608.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,2402.30,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $2,402.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4201.55,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,201.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HUMANA,HUMANA CHOICE CARE HMO,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HUMANA,HUMANA CHOICE CARE PPO,4201.55,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,201.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HUMANA,HUMANA MEDICARE ADVANTAGE,1896.75,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,HUMANA,HUMANA NATIIONAL POS HMO,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $7,604.00 at 100% of $7,604.00 = $7,604.00 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3608.39,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,608.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,4943.00,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,943.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,617.20,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00217 Proc 64625 at $125.60 (Base Rate) * 4.914 (Relative Weight) = $617.20 (Total Line Payment) at 100% = $617.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1896.75,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,617.20,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00217 Proc 64625 at $125.60 (Base Rate) * 4.914 (Relative Weight) = $617.20 (Total Line Payment) at 100% = $617.20. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,MOLINA HEALTHCARE,MOLINA MEDICAID,654.23,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00217 Proc 64625 at $125.60 (Base Rate) * 4.914 (Relative Weight) = $617.20 (Total Line Payment) at 100% = $617.20... $617.20 at 106% = $654.23 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,MOLINA HEALTHCARE,MOLINA MEDICARE,1896.75,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2471.50,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $2,471.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4152.12,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,152.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,NAPHCARE,ALL COMMERICAL NAPHCARE,4267.68,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3707.25,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,707.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4547.56,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $4,547.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,PREVEA HEALTH NETWORK,PREVEA360,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3155.12,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,155.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1915.72,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3558.96,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,558.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,TRIOLOGY,TRILOGY MEDICAID,654.23,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00217 Proc 64625 at $125.60 (Base Rate) * 4.914 (Relative Weight) = $617.20 (Total Line Payment) at 106% = $654.23. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,UNITED HEALTHCARE,UHC ONEIDA NATION,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1896.75,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,UNITED HEALTHCARE,UNITED HEALTHCARE,4943.00,,,,,,,617.2000,4943.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64625 ASG Rate of $6,103.40 at 100% of $6,103.40 = $6,103.40 Total (Limited to $4,943.00 in Billed Charges - $0.00 in ASG Allowed Amount = $4,943.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,UNITY HEALTH PLAN,UNITY HOSPICE,1896.75,,,,,,,617.2000,4943.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3558.96,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,558.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3064.66,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,064.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3558.96,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,558.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3558.96,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $3,558.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ABLATION RF NERVES SI JOINT W/FLUORO OR CT GUID,64625,CPT,361,RC,36100275,CDM,,,,both,,,4943.0000,3262.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2965.80,,,,,,,617.2000,4943.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,943.00 in Billed Charges for Rev 361 Proc 64625 = $2,965.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,AETNA,AETNA HSHS,7239.72,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $7,239.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,AETNA,AETNA MEDICARE,8524.27,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,AETNA,ALL COMMERCIAL AETNA,11207.00,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $11,207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,ANTHEM,ANTEHM MEDICAID,2189.57,,,,,,,2189.5700,19179.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00218 Proc 64864 at $125.60 (Base Rate) * 17.4329 (Relative Weight) = $2,189.57 (Total Line Payment) at 100% = $2,189.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8524.27,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,ANTHEM,ANTHEM POS/HMO,10090.00,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $10,090.00 at 100% of $10,090.00 = $10,090.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,ANTHEM,ANTHEM PPO,11207.00,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $12,000.00 at 100% of $12,000.00 = $12,000.00 Total (Limited to $11,207.00 in Billed Charges - $0.00 in ASG Allowed Amount = $11,207.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11207.00,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $11,207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,CENPATICO,ALL MEDICAID CENPATICO,11207.00,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $11,207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9525.95,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $9,525.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,CIGNA,ALL COMMERCIAL CIGNA,7844.90,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $7,844.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,COFINITY,COFINITY,11207.00,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $11,207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2189.57,,,,,,,2189.5700,19179.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00218 Proc 64864 at $125.60 (Base Rate) * 17.4329 (Relative Weight) = $2,189.57 (Total Line Payment) at 100% = $2,189.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2189.57,,,,,,,2189.5700,19179.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00218 Proc 64864 at $125.60 (Base Rate) * 17.4329 (Relative Weight) = $2,189.57 (Total Line Payment) at 100% = $2,189.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10646.65,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $10,646.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,9413.88,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $9,413.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7956.97,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $7,956.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8181.11,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $8,181.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,5446.60,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $5,446.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9525.95,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $9,525.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HUMANA,HUMANA CHOICE CARE HMO,7250.00,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $7,250.00 at 100% of $7,250.00 = $7,250.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HUMANA,HUMANA CHOICE CARE PPO,9525.95,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $9,525.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HUMANA,HUMANA MEDICARE ADVANTAGE,8524.27,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,HUMANA,HUMANA NATIIONAL POS HMO,7250.00,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $7,250.00 at 100% of $7,250.00 = $7,250.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8181.11,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $8,181.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,11207.00,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $11,207.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2189.57,,,,,,,2189.5700,19179.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00218 Proc 64864 at $125.60 (Base Rate) * 17.4329 (Relative Weight) = $2,189.57 (Total Line Payment) at 100% = $2,189.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8524.27,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2189.57,,,,,,,2189.5700,19179.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00218 Proc 64864 at $125.60 (Base Rate) * 17.4329 (Relative Weight) = $2,189.57 (Total Line Payment) at 100% = $2,189.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,MOLINA HEALTHCARE,MOLINA MEDICAID,2320.94,,,,,,,2189.5700,19179.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00218 Proc 64864 at $125.60 (Base Rate) * 17.4329 (Relative Weight) = $2,189.57 (Total Line Payment) at 100% = $2,189.57... $2,189.57 at 106% = $2,320.94 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,MOLINA HEALTHCARE,MOLINA MEDICARE,8524.27,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5603.50,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $5,603.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9413.88,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $9,413.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,NAPHCARE,ALL COMMERICAL NAPHCARE,19179.60,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8405.25,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $8,405.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10310.44,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $10,310.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11207.00,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $11,207.00 in Billed Charges - $0.00 in ASG Allowed Amount = $11,207.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11207.00,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $11,207.00 in Billed Charges - $0.00 in ASG Allowed Amount = $11,207.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,PREVEA HEALTH NETWORK,PREVEA360,11207.00,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $11,207.00 in Billed Charges - $0.00 in ASG Allowed Amount = $11,207.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11207.00,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $17,857.33 at 100% of $17,857.33 = $17,857.33 Total (Limited to $11,207.00 in Billed Charges - $0.00 in ASG Allowed Amount = $11,207.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7153.43,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $7,153.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,8609.51,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8069.04,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $8,069.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,TRIOLOGY,TRILOGY MEDICAID,2320.95,,,,,,,2189.5700,19179.6000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00218 Proc 64864 at $125.60 (Base Rate) * 17.4329 (Relative Weight) = $2,189.57 (Total Line Payment) at 106% = $2,320.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9074.10,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $9,074.10 at 100% of $9,074.10 = $9,074.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,UNITED HEALTHCARE,UHC ONEIDA NATION,9074.10,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $9,074.10 at 100% of $9,074.10 = $9,074.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8524.27,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,UNITED HEALTHCARE,UNITED HEALTHCARE,9074.10,,,,,,,2189.5700,19179.6000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 64864 ASG Rate of $9,074.10 at 100% of $9,074.10 = $9,074.10 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,UNITY HEALTH PLAN,UNITY HOSPICE,8524.27,,,,,,,2189.5700,19179.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8069.04,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $8,069.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6948.34,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $6,948.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8069.04,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $8,069.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8069.04,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $8,069.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"HC REPR FACIAL NERVE, EXTRACRANINAL",64864,CPT,361,RC,36100282,CDM,,,,both,,,11207.0000,7396.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6724.20,,,,,,,2189.5700,19179.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $11,207.00 in Billed Charges for Rev 361 Proc 64864 = $6,724.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,AETNA,AETNA HSHS,6120.20,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,120.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,AETNA,AETNA MEDICARE,3423.93,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,AETNA,ALL COMMERCIAL AETNA,9474.00,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $9,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,ANTHEM,ANTEHM MEDICAID,713.73,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00173 Proc 52001 at $125.60 (Base Rate) * 5.6826 (Relative Weight) = $713.73 (Total Line Payment) at 100% = $713.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3423.93,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,ANTHEM,ANTHEM POS/HMO,8466.00,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $8,466.00 at 100% of $8,466.00 = $8,466.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,ANTHEM,ANTHEM PPO,8850.00,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $8,850.00 at 100% of $8,850.00 = $8,850.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9474.00,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $9,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,CENPATICO,ALL MEDICAID CENPATICO,9474.00,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $9,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8052.90,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $8,052.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,CIGNA,ALL COMMERCIAL CIGNA,6631.80,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,631.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,COFINITY,COFINITY,9474.00,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $9,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,713.73,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00173 Proc 52001 at $125.60 (Base Rate) * 5.6826 (Relative Weight) = $713.73 (Total Line Payment) at 100% = $713.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,713.73,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00173 Proc 52001 at $125.60 (Base Rate) * 5.6826 (Relative Weight) = $713.73 (Total Line Payment) at 100% = $713.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9000.30,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $9,000.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,7958.16,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $7,958.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6726.54,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,726.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6916.02,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,916.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,4604.36,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $4,604.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8052.90,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $8,052.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HUMANA,HUMANA CHOICE CARE HMO,3061.00,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HUMANA,HUMANA CHOICE CARE PPO,8052.90,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $8,052.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,3423.93,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,HUMANA,HUMANA NATIIONAL POS HMO,3061.00,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6916.02,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,916.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,9474.00,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $9,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,713.73,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00173 Proc 52001 at $125.60 (Base Rate) * 5.6826 (Relative Weight) = $713.73 (Total Line Payment) at 100% = $713.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3423.93,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,713.73,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00173 Proc 52001 at $125.60 (Base Rate) * 5.6826 (Relative Weight) = $713.73 (Total Line Payment) at 100% = $713.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,756.55,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00173 Proc 52001 at $125.60 (Base Rate) * 5.6826 (Relative Weight) = $713.73 (Total Line Payment) at 100% = $713.73... $713.73 at 106% = $756.55 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,3423.93,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4737.00,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $4,737.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7958.16,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $7,958.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,7703.84,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7105.50,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $7,105.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8716.08,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $8,716.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4366.95,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4366.95,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,PREVEA HEALTH NETWORK,PREVEA360,4366.95,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4366.95,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $4,366.95 at 100% of $4,366.95 = $4,366.95 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6047.25,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,047.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3458.17,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6821.28,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,821.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,TRIOLOGY,TRILOGY MEDICAID,756.56,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00173 Proc 52001 at $125.60 (Base Rate) * 5.6826 (Relative Weight) = $713.73 (Total Line Payment) at 106% = $756.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4523.30,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,4523.30,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3423.93,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,4523.30,,,,,,,713.7300,9474.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 52001 ASG Rate of $4,523.30 at 100% of $4,523.30 = $4,523.30 Total The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,UNITY HEALTH PLAN,UNITY HOSPICE,3423.93,,,,,,,713.7300,9474.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6821.28,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,821.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5873.88,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $5,873.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6821.28,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,821.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6821.28,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $6,821.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CYSTOSCOPY REMOVAL OF CLOTS,52001,CPT,361,RC,36100288,CDM,,,,both,,,9474.0000,6252.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5684.40,,,,,,,713.7300,9474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $9,474.00 in Billed Charges for Rev 361 Proc 52001 = $5,684.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,AETNA,AETNA HSHS,301.68,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $301.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,AETNA,AETNA MEDICARE,129.23,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,AETNA,ALL COMMERCIAL AETNA,467.00,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $467.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,ANTHEM,ANTEHM MEDICAID,34.44,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,129.23,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,ANTHEM,ANTHEM POS/HMO,317.56,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36592 $467.00 in Billed Charges at 68% = $317.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,ANTHEM,ANTHEM PPO,317.56,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 300 Proc 36592 $467.00 in Billed Charges at 68% = $317.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,467.00,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $467.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,CENPATICO,ALL MEDICAID CENPATICO,467.00,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $467.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,396.95,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $396.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,COFINITY,COFINITY,467.00,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $467.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,34.44,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,34.44,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,443.65,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $443.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,392.28,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $392.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,331.57,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $331.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,340.91,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $340.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,226.96,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $226.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,396.95,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $396.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HUMANA,HUMANA CHOICE CARE HMO,48.38,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.38 from Fee Schedule 005543_170 for Rev 300 Proc 36592 * Qty 1 = $48.38 at 100% = $48.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HUMANA,HUMANA CHOICE CARE PPO,396.95,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $396.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,129.23,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,HUMANA,HUMANA NATIIONAL POS HMO,48.38,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $48.38 from Fee Schedule 005543_170 for Rev 300 Proc 36592 * Qty 1 = $48.38 at 100% = $48.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,340.91,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $340.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,467.00,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $467.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,34.44,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,129.23,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,34.44,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,36.51,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 100% = $34.44... $34.44 at 106% = $36.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,129.23,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,233.50,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $233.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,392.28,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $392.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,290.78,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,350.25,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $350.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,429.64,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $429.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,280.20,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,280.20,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,PREVEA HEALTH NETWORK,PREVEA360,280.20,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,280.20,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 130.00% of Medicare CLIA The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,298.09,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $298.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.52,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,336.24,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $336.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,TRIOLOGY,TRILOGY MEDICAID,36.51,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00494 Proc 36592 at $125.60 (Base Rate) * 0.2742 (Relative Weight) = $34.44 (Total Line Payment) at 106% = $36.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,129.23,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,UNITY HEALTH PLAN,UNITY HOSPICE,129.23,,,,,,,34.4400,467.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,336.24,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $336.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,289.54,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $289.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,336.24,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $336.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,336.24,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $336.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COLLECT BLD CENTRL/PERP CATH-PRV 72 HR,36592,CPT,300,RC,36592072,CDM,,,,both,,,467.0000,308.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,280.20,,,,,,,34.4400,467.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $467.00 in Billed Charges for Rev 300 Proc 36592 = $280.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,AETNA,AETNA HSHS,710.60,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,100.00 in Billed Charges for Rev 370 = $710.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,AETNA,ALL COMMERCIAL AETNA,1100.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,100.00 in Billed Charges for Rev 370 = $1,100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,ANTHEM,ANTHEM POS/HMO,748.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,100.00 in Billed Charges for Rev 370 = $748.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,ANTHEM,ANTHEM PPO,748.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,100.00 in Billed Charges for Rev 370 = $748.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1100.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,100.00 in Billed Charges for Rev 370 = $1,100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,CENPATICO,ALL MEDICAID CENPATICO,1100.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,100.00 in Billed Charges for Rev 370 = $1,100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,935.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,100.00 in Billed Charges for Rev 370 = $935.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,CIGNA,ALL COMMERCIAL CIGNA,770.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,100.00 in Billed Charges for Rev 370 = $770.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,COFINITY,COFINITY,1100.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,100.00 in Billed Charges for Rev 370 = $1,100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1045.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,100.00 in Billed Charges for Rev 370 = $1,045.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,924.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,100.00 in Billed Charges for Rev 370 = $924.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,781.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,100.00 in Billed Charges for Rev 370 = $781.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,803.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,100.00 in Billed Charges for Rev 370 = $803.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,534.60,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,100.00 in Billed Charges for Rev 370 = $534.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,935.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,100.00 in Billed Charges for Rev 370 = $935.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,HUMANA,HUMANA CHOICE CARE HMO,698.50,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,100.00 in Billed Charges for Rev 370 = $698.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,HUMANA,HUMANA CHOICE CARE PPO,935.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,100.00 in Billed Charges for Rev 370 = $935.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,HUMANA,HUMANA NATIIONAL POS HMO,698.50,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,100.00 in Billed Charges for Rev 370 = $698.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,803.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,100.00 in Billed Charges for Rev 370 = $803.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1100.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,100.00 in Billed Charges for Rev 370 = $1,100.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,550.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,100.00 in Billed Charges for Rev 370 = $550.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,924.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,100.00 in Billed Charges for Rev 370 = $924.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,825.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,100.00 in Billed Charges for Rev 370 = $825.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1012.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,100.00 in Billed Charges for Rev 370 = $1,012.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,660.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,100.00 in Billed Charges for Rev 370 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,660.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,100.00 in Billed Charges for Rev 370 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,PREVEA HEALTH NETWORK,PREVEA360,660.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,100.00 in Billed Charges for Rev 370 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,660.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,100.00 in Billed Charges for Rev 370 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,702.13,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,100.00 in Billed Charges for Rev 370 = $702.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,792.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,100.00 in Billed Charges for Rev 370 = $792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,608.30,,,,,,,534.6000,1100.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,100.00 in Billed Charges for Rev 370 = $608.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,608.30,,,,,,,534.6000,1100.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,100.00 in Billed Charges for Rev 370 = $608.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,608.30,,,,,,,534.6000,1100.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,100.00 in Billed Charges for Rev 370 = $608.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,792.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,100.00 in Billed Charges for Rev 370 = $792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,682.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,100.00 in Billed Charges for Rev 370 = $682.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,792.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,100.00 in Billed Charges for Rev 370 = $792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,792.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,100.00 in Billed Charges for Rev 370 = $792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DIFFICULT AIRWAY CHARGE,370,RC,37000002,CDM,,,,,,both,,,1100.0000,726.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,660.00,,,,,,,534.6000,1100.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,100.00 in Billed Charges for Rev 370 = $660.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,AETNA,AETNA HSHS,1071.71,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,071.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,AETNA,AETNA MEDICARE,230.06,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,AETNA,ALL COMMERCIAL AETNA,1659.00,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,659.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,ANTHEM,ANTEHM MEDICAID,322.19,,,,,,,230.0600,1659.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00092 Proc 31500 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $322.19 at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,230.06,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,ANTHEM,ANTHEM POS/HMO,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $2,832.00 at 100% of $2,832.00 = $2,832.00 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,ANTHEM,ANTHEM PPO,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $3,050.00 at 100% of $3,050.00 = $3,050.00 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1659.00,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,659.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,CENPATICO,ALL MEDICAID CENPATICO,1659.00,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,659.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1410.15,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,410.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,CIGNA,ALL COMMERCIAL CIGNA,1161.30,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,161.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,COFINITY,COFINITY,1659.00,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,659.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,322.19,,,,,,,230.0600,1659.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00092 Proc 31500 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $322.19 at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,322.19,,,,,,,230.0600,1659.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00092 Proc 31500 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $322.19 at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1576.05,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,576.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,1393.56,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,393.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1177.89,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,177.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1211.07,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,211.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,806.27,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $806.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1410.15,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,410.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HUMANA,HUMANA CHOICE CARE HMO,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HUMANA,HUMANA CHOICE CARE PPO,1410.15,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,410.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,230.06,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,HUMANA,HUMANA NATIIONAL POS HMO,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $3,061.00 at 100% of $3,061.00 = $3,061.00 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1211.07,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,211.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1659.00,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,659.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,322.19,,,,,,,230.0600,1659.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00092 Proc 31500 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $322.19 at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,230.06,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,322.19,,,,,,,230.0600,1659.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00092 Proc 31500 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $322.19 at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,341.52,,,,,,,230.0600,1659.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00092 Proc 31500 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $322.19 at 100% = $322.19... $322.19 at 106% = $341.52 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,230.06,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,829.50,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $829.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1393.56,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,393.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,517.64,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1244.25,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,244.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1526.28,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,526.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,PREVEA HEALTH NETWORK,PREVEA360,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $2,048.23 at 100% of $2,048.23 = $2,048.23 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1058.94,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,058.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,232.36,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1194.48,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,194.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,TRIOLOGY,TRILOGY MEDICAID,341.52,,,,,,,230.0600,1659.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00092 Proc 31500 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $322.19 at 106% = $341.52. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,230.06,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,1659.00,,,,,,,230.0600,1659.0000,case rate,"ST VINCENT HOSPITAL (ACU). Rev 361 Proc 31500 ASG Rate of $2,153.10 at 100% of $2,153.10 = $2,153.10 Total (Limited to $1,659.00 in Billed Charges - $0.00 in ASG Allowed Amount = $1,659.00) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,UNITY HEALTH PLAN,UNITY HOSPICE,230.06,,,,,,,230.0600,1659.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1194.48,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,194.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1028.58,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,028.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1194.48,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,194.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1194.48,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $1,194.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTUBATION ENDOTRACHEAL,31500,CPT,361,RC,37000013,CDM,,,,both,,,1659.0000,1094.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,995.40,,,,,,,230.0600,1659.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,659.00 in Billed Charges for Rev 361 Proc 31500 = $995.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,AETNA,AETNA HSHS,73.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $73.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,AETNA,ALL COMMERCIAL AETNA,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,ANTHEM,ANTEHM MEDICAID,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99153 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,ANTHEM,ANTHEM POS/HMO,76.84,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $76.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,ANTHEM,ANTHEM PPO,76.84,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $76.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,CENPATICO,ALL MEDICAID CENPATICO,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,96.05,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $96.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,CIGNA,ALL COMMERCIAL CIGNA,79.10,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $79.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,COFINITY,COFINITY,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99153 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99153 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,107.35,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $107.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,94.92,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $94.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.23,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $80.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,82.49,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $82.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,54.92,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $54.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,96.05,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $96.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,HUMANA,HUMANA CHOICE CARE HMO,71.76,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $71.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,HUMANA,HUMANA CHOICE CARE PPO,96.05,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $96.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,HUMANA,HUMANA NATIIONAL POS HMO,71.76,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $71.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,82.49,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $82.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,113.00,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $113.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99153 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.42,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99153 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,MOLINA HEALTHCARE,MOLINA MEDICAID,11.05,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99153 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42... $10.42 at 106% = $11.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,56.50,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $56.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,94.92,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $94.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,84.75,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $84.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,103.96,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $103.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,PREVEA HEALTH NETWORK,PREVEA360,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,72.13,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $72.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,81.36,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $81.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,TRIOLOGY,TRILOGY MEDICAID,11.05,,,,,,,10.4200,113.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99153 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 106% = $11.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,62.49,,,,,,,10.4200,113.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $62.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,62.49,,,,,,,10.4200,113.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $62.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,62.49,,,,,,,10.4200,113.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $62.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,81.36,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $81.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,70.06,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $70.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,81.36,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $81.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,81.36,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $81.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION SAME PHY EA ADDL 15MIN,99153,CPT,370,RC,37000017,CDM,,,,both,,,113.0000,74.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,67.80,,,,,,,10.4200,113.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.00 in Billed Charges for Rev 370 Proc 99153 = $67.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,AETNA,AETNA HSHS,724.17,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $724.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,AETNA,AETNA MEDICARE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,AETNA,ALL COMMERCIAL AETNA,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,ANTHEM,ANTEHM MEDICAID,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,ANTHEM,ANTHEM POS/HMO,762.28,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $762.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,ANTHEM,ANTHEM PPO,762.28,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $762.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,CENPATICO,ALL MEDICAID CENPATICO,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,952.85,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $952.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,CIGNA,ALL COMMERCIAL CIGNA,784.70,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $784.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,COFINITY,COFINITY,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1064.95,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $1,064.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,941.64,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $941.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,795.91,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $795.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,818.33,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $818.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,544.81,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $544.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,952.85,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $952.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HUMANA,HUMANA CHOICE CARE HMO,711.84,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $711.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HUMANA,HUMANA CHOICE CARE PPO,952.85,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $952.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,HUMANA,HUMANA NATIIONAL POS HMO,711.84,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $711.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,818.33,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $818.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1121.00,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $1,121.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,586.55,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,621.74,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55... $586.55 at 106% = $621.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,560.50,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $560.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,941.64,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $941.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,1542.70,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,840.75,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $840.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1031.32,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $1,031.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,672.60,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $672.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,672.60,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $672.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,PREVEA HEALTH NETWORK,PREVEA360,672.60,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $672.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,672.60,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $672.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,715.53,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $715.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,692.51,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,807.12,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $807.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,TRIOLOGY,TRILOGY MEDICAID,621.75,,,,,,,544.8100,1542.7000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64447 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 106% = $621.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,619.91,,,,,,,544.8100,1542.7000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $619.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,619.91,,,,,,,544.8100,1542.7000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $619.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,619.91,,,,,,,544.8100,1542.7000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $619.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,UNITY HEALTH PLAN,UNITY HOSPICE,685.65,,,,,,,544.8100,1542.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,807.12,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $807.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,695.02,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $695.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,807.12,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $807.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,807.12,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $807.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC FEMORAL NERVE BLOCK SINGLE,64447,CPT,370,RC,37000021,CDM,,,,both,,,1121.0000,739.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,672.60,,,,,,,544.8100,1542.7000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,121.00 in Billed Charges for Rev 370 Proc 64447 = $672.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,AETNA,AETNA HSHS,929.59,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $929.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,AETNA,AETNA MEDICARE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,AETNA,ALL COMMERCIAL AETNA,1439.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,439.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,ANTHEM,ANTEHM MEDICAID,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64415 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,ANTHEM,ANTHEM POS/HMO,978.52,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $978.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,ANTHEM,ANTHEM PPO,978.52,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $978.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1439.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,439.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,CENPATICO,ALL MEDICAID CENPATICO,1439.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,439.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1223.15,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,223.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,CIGNA,ALL COMMERCIAL CIGNA,1007.30,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,007.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,COFINITY,COFINITY,1439.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,439.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64415 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64415 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1367.05,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,367.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,1208.76,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,208.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1021.69,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,021.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1050.47,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,050.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,699.35,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $699.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1223.15,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,223.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HUMANA,HUMANA CHOICE CARE HMO,913.77,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $913.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HUMANA,HUMANA CHOICE CARE PPO,1223.15,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,223.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,HUMANA,HUMANA NATIIONAL POS HMO,913.77,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $913.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1050.47,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,050.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1439.00,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,439.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64415 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,586.55,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64415 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,621.74,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64415 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55... $586.55 at 106% = $621.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,719.50,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $719.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1208.76,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,208.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,1933.01,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1079.25,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,079.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1323.88,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,323.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,863.40,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $863.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,863.40,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $863.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,PREVEA HEALTH NETWORK,PREVEA360,863.40,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $863.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,863.40,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $863.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,918.51,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $918.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,867.71,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1036.08,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,036.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,TRIOLOGY,TRILOGY MEDICAID,621.75,,,,,,,586.5500,1933.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64415 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 106% = $621.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,795.77,,,,,,,586.5500,1933.0100,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $795.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,795.77,,,,,,,586.5500,1933.0100,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $795.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,795.77,,,,,,,586.5500,1933.0100,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $795.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,UNITY HEALTH PLAN,UNITY HOSPICE,859.12,,,,,,,586.5500,1933.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1036.08,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,036.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,892.18,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $892.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1036.08,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,036.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1036.08,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $1,036.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK SINGLE,64415,CPT,370,RC,37000022,CDM,,,,both,,,1439.0000,949.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,863.40,,,,,,,586.5500,1933.0100,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,439.00 in Billed Charges for Rev 370 Proc 64415 = $863.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,AETNA,AETNA HSHS,2220.95,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,220.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,AETNA,AETNA MEDICARE,859.12,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,AETNA,ALL COMMERCIAL AETNA,3438.00,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $3,438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,ANTHEM,ANTEHM MEDICAID,586.55,,,,,,,586.5500,3438.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64416 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,859.12,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,ANTHEM,ANTHEM POS/HMO,2337.84,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,337.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,ANTHEM,ANTHEM PPO,2337.84,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,337.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3438.00,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $3,438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,CENPATICO,ALL MEDICAID CENPATICO,3438.00,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $3,438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2922.30,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,922.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,CIGNA,ALL COMMERCIAL CIGNA,2406.60,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,406.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,COFINITY,COFINITY,3438.00,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $3,438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,586.55,,,,,,,586.5500,3438.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64416 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,586.55,,,,,,,586.5500,3438.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64416 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3266.10,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $3,266.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,2887.92,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,887.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2440.98,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,440.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2509.74,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,509.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,1670.87,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $1,670.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2922.30,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,922.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HUMANA,HUMANA CHOICE CARE HMO,2183.13,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,183.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HUMANA,HUMANA CHOICE CARE PPO,2922.30,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,922.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HUMANA,HUMANA MEDICARE ADVANTAGE,859.12,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,HUMANA,HUMANA NATIIONAL POS HMO,2183.13,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,183.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2509.74,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,509.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,3438.00,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $3,438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,586.55,,,,,,,586.5500,3438.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64416 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,859.12,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,586.55,,,,,,,586.5500,3438.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64416 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,621.74,,,,,,,586.5500,3438.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64416 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 100% = $586.55... $586.55 at 106% = $621.74 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,MOLINA HEALTHCARE,MOLINA MEDICARE,859.12,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1719.00,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $1,719.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2887.92,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,887.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,NAPHCARE,ALL COMMERICAL NAPHCARE,1933.01,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2578.50,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,578.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3162.96,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $3,162.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2062.80,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,062.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2062.80,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,062.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,PREVEA HEALTH NETWORK,PREVEA360,2062.80,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,062.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2062.80,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,062.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2194.48,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,194.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,867.71,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2475.36,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,475.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,TRIOLOGY,TRILOGY MEDICAID,621.75,,,,,,,586.5500,3438.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00220 Proc 64416 at $125.60 (Base Rate) * 4.67 (Relative Weight) = $586.55 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $586.55 at 106% = $621.75. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1901.21,,,,,,,586.5500,3438.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $1,901.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,1901.21,,,,,,,586.5500,3438.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $1,901.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,859.12,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,1901.21,,,,,,,586.5500,3438.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $1,901.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,UNITY HEALTH PLAN,UNITY HOSPICE,859.12,,,,,,,586.5500,3438.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2475.36,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,475.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2131.56,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,131.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2475.36,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,475.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2475.36,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,475.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC INTRASCALENE BLOCK CONTINUOUS,64416,CPT,370,RC,37000023,CDM,,,,both,,,3438.0000,2269.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2062.80,,,,,,,586.5500,3438.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,438.00 in Billed Charges for Rev 370 Proc 64416 = $2,062.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,AETNA,AETNA HSHS,500.65,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $775.00 in Billed Charges for Rev 370 = $500.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,AETNA,ALL COMMERCIAL AETNA,775.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $775.00 in Billed Charges for Rev 370 = $775.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,ANTHEM,ANTHEM POS/HMO,527.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $775.00 in Billed Charges for Rev 370 = $527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,ANTHEM,ANTHEM PPO,527.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $775.00 in Billed Charges for Rev 370 = $527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,775.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $775.00 in Billed Charges for Rev 370 = $775.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,CENPATICO,ALL MEDICAID CENPATICO,775.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $775.00 in Billed Charges for Rev 370 = $775.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,658.75,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $775.00 in Billed Charges for Rev 370 = $658.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,CIGNA,ALL COMMERCIAL CIGNA,542.50,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $775.00 in Billed Charges for Rev 370 = $542.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,COFINITY,COFINITY,775.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $775.00 in Billed Charges for Rev 370 = $775.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,736.25,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $775.00 in Billed Charges for Rev 370 = $736.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,651.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $775.00 in Billed Charges for Rev 370 = $651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,550.25,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $775.00 in Billed Charges for Rev 370 = $550.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,565.75,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $775.00 in Billed Charges for Rev 370 = $565.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,376.65,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $775.00 in Billed Charges for Rev 370 = $376.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,658.75,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $775.00 in Billed Charges for Rev 370 = $658.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,HUMANA,HUMANA CHOICE CARE HMO,492.13,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $775.00 in Billed Charges for Rev 370 = $492.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,HUMANA,HUMANA CHOICE CARE PPO,658.75,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $775.00 in Billed Charges for Rev 370 = $658.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,HUMANA,HUMANA NATIIONAL POS HMO,492.13,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $775.00 in Billed Charges for Rev 370 = $492.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,565.75,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $775.00 in Billed Charges for Rev 370 = $565.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,775.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $775.00 in Billed Charges for Rev 370 = $775.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,387.50,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $775.00 in Billed Charges for Rev 370 = $387.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,651.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $775.00 in Billed Charges for Rev 370 = $651.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,581.25,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $775.00 in Billed Charges for Rev 370 = $581.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,713.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $775.00 in Billed Charges for Rev 370 = $713.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,465.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $775.00 in Billed Charges for Rev 370 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,465.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $775.00 in Billed Charges for Rev 370 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,PREVEA HEALTH NETWORK,PREVEA360,465.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $775.00 in Billed Charges for Rev 370 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,465.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $775.00 in Billed Charges for Rev 370 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,494.68,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $775.00 in Billed Charges for Rev 370 = $494.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,558.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $775.00 in Billed Charges for Rev 370 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,428.58,,,,,,,376.6500,775.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $775.00 in Billed Charges for Rev 370 = $428.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,428.58,,,,,,,376.6500,775.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $775.00 in Billed Charges for Rev 370 = $428.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,428.58,,,,,,,376.6500,775.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $775.00 in Billed Charges for Rev 370 = $428.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,558.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $775.00 in Billed Charges for Rev 370 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,480.50,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $775.00 in Billed Charges for Rev 370 = $480.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,558.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $775.00 in Billed Charges for Rev 370 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,558.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $775.00 in Billed Charges for Rev 370 = $558.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC EPIDURAL NERVE BLOCK,370,RC,37000024,CDM,,,,,,both,,,775.0000,511.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,465.00,,,,,,,376.6500,775.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $775.00 in Billed Charges for Rev 370 = $465.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,AETNA,AETNA HSHS,176.36,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $273.00 in Billed Charges for Rev 370 = $176.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,AETNA,ALL COMMERCIAL AETNA,273.00,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 370 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,ANTHEM,ANTHEM POS/HMO,185.64,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $273.00 in Billed Charges for Rev 370 = $185.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,ANTHEM,ANTHEM PPO,185.64,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $273.00 in Billed Charges for Rev 370 = $185.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,273.00,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 370 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,CENPATICO,ALL MEDICAID CENPATICO,273.00,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 370 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,232.05,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $273.00 in Billed Charges for Rev 370 = $232.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,CIGNA,ALL COMMERCIAL CIGNA,191.10,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $273.00 in Billed Charges for Rev 370 = $191.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,COFINITY,COFINITY,273.00,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 370 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,259.35,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $273.00 in Billed Charges for Rev 370 = $259.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,229.32,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $273.00 in Billed Charges for Rev 370 = $229.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,193.83,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $273.00 in Billed Charges for Rev 370 = $193.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,199.29,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $273.00 in Billed Charges for Rev 370 = $199.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,132.68,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $273.00 in Billed Charges for Rev 370 = $132.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,232.05,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $273.00 in Billed Charges for Rev 370 = $232.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,HUMANA,HUMANA CHOICE CARE HMO,173.36,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $273.00 in Billed Charges for Rev 370 = $173.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,HUMANA,HUMANA CHOICE CARE PPO,232.05,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $273.00 in Billed Charges for Rev 370 = $232.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,HUMANA,HUMANA NATIIONAL POS HMO,173.36,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $273.00 in Billed Charges for Rev 370 = $173.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,199.29,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $273.00 in Billed Charges for Rev 370 = $199.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,273.00,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $273.00 in Billed Charges for Rev 370 = $273.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,136.50,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $273.00 in Billed Charges for Rev 370 = $136.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,229.32,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $273.00 in Billed Charges for Rev 370 = $229.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,204.75,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $273.00 in Billed Charges for Rev 370 = $204.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,251.16,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $273.00 in Billed Charges for Rev 370 = $251.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,163.80,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $273.00 in Billed Charges for Rev 370 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,163.80,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $273.00 in Billed Charges for Rev 370 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,PREVEA HEALTH NETWORK,PREVEA360,163.80,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $273.00 in Billed Charges for Rev 370 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,163.80,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $273.00 in Billed Charges for Rev 370 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,174.26,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $273.00 in Billed Charges for Rev 370 = $174.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,196.56,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $273.00 in Billed Charges for Rev 370 = $196.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,150.97,,,,,,,132.6800,273.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $273.00 in Billed Charges for Rev 370 = $150.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,150.97,,,,,,,132.6800,273.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $273.00 in Billed Charges for Rev 370 = $150.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,150.97,,,,,,,132.6800,273.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $273.00 in Billed Charges for Rev 370 = $150.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,196.56,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $273.00 in Billed Charges for Rev 370 = $196.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,169.26,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $273.00 in Billed Charges for Rev 370 = $169.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,196.56,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $273.00 in Billed Charges for Rev 370 = $196.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,196.56,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $273.00 in Billed Charges for Rev 370 = $196.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC GENERAL ANESTHESIA ADDL 15 MIN,370,RC,37000053,CDM,,,,,,both,,,273.0000,180.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,163.80,,,,,,,132.6800,273.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $273.00 in Billed Charges for Rev 370 = $163.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,AETNA,AETNA HSHS,1243.55,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,925.00 in Billed Charges for Rev 370 = $1,243.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,AETNA,ALL COMMERCIAL AETNA,1925.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,925.00 in Billed Charges for Rev 370 = $1,925.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,ANTHEM,ANTHEM POS/HMO,1309.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,925.00 in Billed Charges for Rev 370 = $1,309.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,ANTHEM,ANTHEM PPO,1309.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,925.00 in Billed Charges for Rev 370 = $1,309.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1925.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,925.00 in Billed Charges for Rev 370 = $1,925.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,CENPATICO,ALL MEDICAID CENPATICO,1925.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,925.00 in Billed Charges for Rev 370 = $1,925.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1636.25,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,925.00 in Billed Charges for Rev 370 = $1,636.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,CIGNA,ALL COMMERCIAL CIGNA,1347.50,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,925.00 in Billed Charges for Rev 370 = $1,347.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,COFINITY,COFINITY,1925.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,925.00 in Billed Charges for Rev 370 = $1,925.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1828.75,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,925.00 in Billed Charges for Rev 370 = $1,828.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,1617.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,925.00 in Billed Charges for Rev 370 = $1,617.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1366.75,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,925.00 in Billed Charges for Rev 370 = $1,366.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1405.25,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,925.00 in Billed Charges for Rev 370 = $1,405.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,935.55,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,925.00 in Billed Charges for Rev 370 = $935.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1636.25,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,925.00 in Billed Charges for Rev 370 = $1,636.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,HUMANA,HUMANA CHOICE CARE HMO,1222.38,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,925.00 in Billed Charges for Rev 370 = $1,222.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,HUMANA,HUMANA CHOICE CARE PPO,1636.25,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,925.00 in Billed Charges for Rev 370 = $1,636.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,HUMANA,HUMANA NATIIONAL POS HMO,1222.38,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,925.00 in Billed Charges for Rev 370 = $1,222.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1405.25,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,925.00 in Billed Charges for Rev 370 = $1,405.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1925.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,925.00 in Billed Charges for Rev 370 = $1,925.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,962.50,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,925.00 in Billed Charges for Rev 370 = $962.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1617.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,925.00 in Billed Charges for Rev 370 = $1,617.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1443.75,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,925.00 in Billed Charges for Rev 370 = $1,443.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1771.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,925.00 in Billed Charges for Rev 370 = $1,771.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1155.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,925.00 in Billed Charges for Rev 370 = $1,155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1155.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,925.00 in Billed Charges for Rev 370 = $1,155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,PREVEA HEALTH NETWORK,PREVEA360,1155.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,925.00 in Billed Charges for Rev 370 = $1,155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1155.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,925.00 in Billed Charges for Rev 370 = $1,155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1228.73,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,925.00 in Billed Charges for Rev 370 = $1,228.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1386.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,925.00 in Billed Charges for Rev 370 = $1,386.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1064.53,,,,,,,935.5500,1925.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,925.00 in Billed Charges for Rev 370 = $1,064.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,1064.53,,,,,,,935.5500,1925.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,925.00 in Billed Charges for Rev 370 = $1,064.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,1064.53,,,,,,,935.5500,1925.0000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,925.00 in Billed Charges for Rev 370 = $1,064.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1386.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,925.00 in Billed Charges for Rev 370 = $1,386.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1193.50,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,925.00 in Billed Charges for Rev 370 = $1,193.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1386.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,925.00 in Billed Charges for Rev 370 = $1,386.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1386.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,925.00 in Billed Charges for Rev 370 = $1,386.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC SPINAL ANES INIT,370,RC,37000056,CDM,,,,,,both,,,1925.0000,1270.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1155.00,,,,,,,935.5500,1925.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,925.00 in Billed Charges for Rev 370 = $1,155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,AETNA,AETNA HSHS,343.67,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $343.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,AETNA,ALL COMMERCIAL AETNA,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTEHM MEDICAID,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99152 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM POS/HMO,361.76,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM PPO,361.76,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,CENPATICO,ALL MEDICAID CENPATICO,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,CIGNA,ALL COMMERCIAL CIGNA,372.40,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $372.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,COFINITY,COFINITY,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99152 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99152 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,505.40,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $505.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,446.88,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,377.72,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $377.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,388.36,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,258.55,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $258.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE HMO,337.82,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $337.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE PPO,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA NATIIONAL POS HMO,337.82,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $337.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,388.36,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99152 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99152 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,11.05,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99152 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42... $10.42 at 106% = $11.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,266.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $266.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,446.88,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,399.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $399.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,489.44,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $489.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,339.58,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $339.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,TRILOGY MEDICAID,11.05,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99152 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 106% = $11.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,329.84,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $329.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MOD SED SAME PHYS/QHP 5/>YRS,99152,CPT,370,RC,37000073,CDM,,,,both,,,532.0000,351.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99152 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,AETNA,AETNA HSHS,343.67,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $343.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,AETNA,ALL COMMERCIAL AETNA,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTEHM MEDICAID,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99155 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM POS/HMO,361.76,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM PPO,361.76,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,CENPATICO,ALL MEDICAID CENPATICO,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,CIGNA,ALL COMMERCIAL CIGNA,372.40,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $372.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,COFINITY,COFINITY,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99155 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99155 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,505.40,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $505.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,446.88,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,377.72,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $377.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,388.36,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,258.55,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $258.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE HMO,337.82,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $337.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE PPO,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA NATIIONAL POS HMO,337.82,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $337.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,388.36,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99155 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99155 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,11.05,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99155 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42... $10.42 at 106% = $11.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,266.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $266.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,446.88,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,399.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $399.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,489.44,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $489.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,339.58,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $339.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,TRILOGY MEDICAID,11.05,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99155 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 106% = $11.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,329.84,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $329.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY <5YR 1ST 15MIN,99155,CPT,370,RC,37000074,CDM,,,,both,,,532.0000,351.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99155 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,AETNA,AETNA HSHS,343.67,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $343.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,AETNA,ALL COMMERCIAL AETNA,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTEHM MEDICAID,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99156 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM POS/HMO,361.76,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,ANTHEM,ANTHEM PPO,361.76,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,CENPATICO,ALL MEDICAID CENPATICO,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,CIGNA,ALL COMMERCIAL CIGNA,372.40,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $372.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,COFINITY,COFINITY,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99156 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99156 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,505.40,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $505.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,446.88,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,377.72,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $377.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,388.36,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,258.55,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $258.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE HMO,337.82,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $337.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA CHOICE CARE PPO,452.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $452.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,HUMANA,HUMANA NATIIONAL POS HMO,337.82,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $337.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,388.36,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $388.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,532.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99156 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.42,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99156 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,11.05,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99156 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 100% = $10.42... $10.42 at 106% = $11.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,266.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $266.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,446.88,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $446.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,399.00,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $399.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,489.44,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $489.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,339.58,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $339.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,TRIOLOGY,TRILOGY MEDICAID,11.05,,,,,,,10.4200,532.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00380 Proc 99156 at $125.60 (Base Rate) * 0.083 (Relative Weight) = $10.42 (Total Line Payment) at 106% = $11.05. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,294.20,,,,,,,10.4200,532.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $294.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,329.84,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $329.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,383.04,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $383.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MODERATE SEDATION DIFF PHY >5YR 1ST 15MIN,99156,CPT,370,RC,37000075,CDM,,,,both,,,532.0000,351.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,319.20,,,,,,,10.4200,532.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $532.00 in Billed Charges for Rev 370 Proc 99156 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,AETNA,AETNA HSHS,338.50,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $338.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,AETNA,AETNA MEDICARE,184.91,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,AETNA,ALL COMMERCIAL AETNA,524.00,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,ANTHEM,ANTEHM MEDICAID,449.49,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,184.91,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,ANTHEM,ANTHEM POS/HMO,356.32,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $356.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,ANTHEM,ANTHEM PPO,356.32,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $356.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,524.00,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,CENPATICO,ALL MEDICAID CENPATICO,524.00,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,445.40,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $445.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,CIGNA,ALL COMMERCIAL CIGNA,366.80,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $366.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,COFINITY,COFINITY,524.00,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,449.49,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,449.49,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,497.80,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $497.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,440.16,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $440.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,372.04,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $372.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,382.52,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $382.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,254.66,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $254.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,445.40,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $445.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HUMANA,HUMANA CHOICE CARE HMO,332.74,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $332.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HUMANA,HUMANA CHOICE CARE PPO,445.40,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $445.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,184.91,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,HUMANA,HUMANA NATIIONAL POS HMO,332.74,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $332.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,382.52,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $382.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,524.00,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,449.49,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,184.91,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,449.49,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,476.46,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 100% = $449.49... $449.49 at 106% = $476.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,184.91,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,262.00,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $262.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,440.16,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $440.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,416.05,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,393.00,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $393.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,482.08,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $482.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,314.40,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $314.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,314.40,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $314.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,PREVEA HEALTH NETWORK,PREVEA360,314.40,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $314.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,314.40,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $314.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,334.47,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $334.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,186.76,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,377.28,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $377.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,TRIOLOGY,TRILOGY MEDICAID,476.46,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9016 at $449.49 (Fee Schedule) = $449.49 (Total Line Payment) at 106% = $476.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,184.9100,524.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,184.9100,524.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,184.91,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,184.9100,524.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9016 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,UNITY HEALTH PLAN,UNITY HOSPICE,184.91,,,,,,,184.9100,524.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,377.28,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $377.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,324.88,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $324.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,377.28,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $377.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,377.28,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $377.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RED CELLS L/R EA,P9016,HCPCS,390,RC,39000107,CDM,,,,both,,,524.0000,345.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,314.40,,,,,,,184.9100,524.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $524.00 in Billed Charges for Rev 390 Proc P9016 = $314.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,AETNA,AETNA HSHS,1233.21,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,233.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,AETNA,AETNA MEDICARE,680.61,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,AETNA,ALL COMMERCIAL AETNA,1909.00,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,909.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,680.61,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,ANTHEM,ANTHEM POS/HMO,1298.12,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,298.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,ANTHEM,ANTHEM PPO,1298.12,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,298.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1909.00,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,909.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,CENPATICO,ALL MEDICAID CENPATICO,1909.00,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,909.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1622.65,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,622.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,CIGNA,ALL COMMERCIAL CIGNA,1336.30,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,336.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,COFINITY,COFINITY,1909.00,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,909.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1813.55,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,813.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,1603.56,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,603.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1355.39,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,355.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1393.57,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,393.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,927.77,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $927.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1622.65,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,622.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HUMANA,HUMANA CHOICE CARE HMO,1212.22,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,212.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HUMANA,HUMANA CHOICE CARE PPO,1622.65,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,622.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,680.61,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,HUMANA,HUMANA NATIIONAL POS HMO,1212.22,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,212.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1393.57,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,393.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1909.00,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,909.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,680.61,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,680.61,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,954.50,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $954.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1603.56,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,603.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,1531.37,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1431.75,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,431.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1756.28,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,756.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1145.40,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,145.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1145.40,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,145.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,PREVEA HEALTH NETWORK,PREVEA360,1145.40,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,145.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1145.40,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,145.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1218.51,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,218.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,687.42,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1374.48,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,374.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9037 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,1909.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9037 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,1909.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9037 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,680.61,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,1909.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9037 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,UNITY HEALTH PLAN,UNITY HOSPICE,680.61,,,,,,,126.6200,1909.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1374.48,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,374.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1183.58,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,183.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1374.48,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,374.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1374.48,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,374.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHER L/R IRR EA,P9037,HCPCS,390,RC,39000122,CDM,,,,both,,,1909.0000,1259.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1145.40,,,,,,,126.6200,1909.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,909.00 in Billed Charges for Rev 390 Proc P9037 = $1,145.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,AETNA,AETNA HSHS,648.58,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $648.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,AETNA,AETNA MEDICARE,265.41,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,AETNA,ALL COMMERCIAL AETNA,1004.00,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $1,004.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,265.41,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,ANTHEM,ANTHEM POS/HMO,682.72,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $682.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,ANTHEM,ANTHEM PPO,682.72,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $682.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1004.00,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $1,004.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,CENPATICO,ALL MEDICAID CENPATICO,1004.00,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $1,004.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,853.40,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $853.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,CIGNA,ALL COMMERCIAL CIGNA,702.80,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $702.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,COFINITY,COFINITY,1004.00,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $1,004.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,953.80,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $953.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,843.36,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $843.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,712.84,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $712.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,732.92,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $732.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,487.94,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $487.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,853.40,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $853.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HUMANA,HUMANA CHOICE CARE HMO,637.54,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $637.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HUMANA,HUMANA CHOICE CARE PPO,853.40,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $853.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,265.41,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,HUMANA,HUMANA NATIIONAL POS HMO,637.54,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $637.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,732.92,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $732.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1004.00,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $1,004.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,265.41,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,265.41,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,502.00,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,843.36,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $843.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,597.17,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,753.00,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $753.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,923.68,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $923.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,602.40,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $602.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,602.40,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $602.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,PREVEA HEALTH NETWORK,PREVEA360,602.40,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $602.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,602.40,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $602.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,640.85,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $640.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,268.06,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,722.88,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $722.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,57.4200,1004.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9040 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,57.4200,1004.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9040 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,265.41,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,57.4200,1004.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9040 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,UNITY HEALTH PLAN,UNITY HOSPICE,265.41,,,,,,,57.4200,1004.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,722.88,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $722.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,622.48,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $622.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,722.88,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $722.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,722.88,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $722.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
RBC LEUKOREDUCED IRRADIATED,P9040,HCPCS,390,RC,39000124,CDM,,,,both,,,1004.0000,662.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,602.40,,,,,,,57.4200,1004.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,004.00 in Billed Charges for Rev 390 Proc P9040 = $602.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,AETNA,AETNA HSHS,1771.33,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,771.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,AETNA,AETNA MEDICARE,708.06,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,AETNA,ALL COMMERCIAL AETNA,2742.00,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9052 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,708.06,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,ANTHEM,ANTHEM POS/HMO,1864.56,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,864.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,ANTHEM,ANTHEM PPO,1864.56,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,864.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2742.00,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,CENPATICO,ALL MEDICAID CENPATICO,2742.00,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2330.70,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,330.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,CIGNA,ALL COMMERCIAL CIGNA,1919.40,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,919.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,COFINITY,COFINITY,2742.00,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9052 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9052 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2604.90,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,604.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,2303.28,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,303.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1946.82,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,946.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2001.66,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,001.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,1332.61,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,332.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2330.70,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,330.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HUMANA,HUMANA CHOICE CARE HMO,1741.17,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,741.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HUMANA,HUMANA CHOICE CARE PPO,2330.70,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,330.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,708.06,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,HUMANA,HUMANA NATIIONAL POS HMO,1741.17,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,741.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2001.66,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,001.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2742.00,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9052 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,708.06,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9052 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9052 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,708.06,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1371.00,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2303.28,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,303.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,1593.14,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2056.50,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,056.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2522.64,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $2,522.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1645.20,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,645.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1645.20,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,645.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,PREVEA HEALTH NETWORK,PREVEA360,1645.20,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,645.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1645.20,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,645.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1750.22,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,750.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,715.14,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1974.24,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,974.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9052 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,2742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9052 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,2742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9052 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,708.06,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,2742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9052 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,UNITY HEALTH PLAN,UNITY HOSPICE,708.06,,,,,,,126.6200,2742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1974.24,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,974.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1700.04,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,700.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1974.24,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,974.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1974.24,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,974.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLATELETS, HLA-M, L/R, UNIT",P9052,HCPCS,390,RC,39000132,CDM,,,,both,,,2742.0000,1809.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1645.20,,,,,,,126.6200,2742.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,742.00 in Billed Charges for Rev 390 Proc P9052 = $1,645.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,AETNA,AETNA HSHS,1518.10,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,518.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,AETNA,AETNA MEDICARE,503.45,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,AETNA,ALL COMMERCIAL AETNA,2350.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9053 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,503.45,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,ANTHEM,ANTHEM POS/HMO,1598.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,598.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,ANTHEM,ANTHEM PPO,1598.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,598.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2350.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,CENPATICO,ALL MEDICAID CENPATICO,2350.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1997.50,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,CIGNA,ALL COMMERCIAL CIGNA,1645.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,COFINITY,COFINITY,2350.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9053 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9053 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2232.50,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $2,232.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,1974.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,974.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1668.50,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,668.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1715.50,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,715.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,1142.10,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,142.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1997.50,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HUMANA,HUMANA CHOICE CARE HMO,1492.25,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,492.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HUMANA,HUMANA CHOICE CARE PPO,1997.50,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,503.45,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,HUMANA,HUMANA NATIIONAL POS HMO,1492.25,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,492.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1715.50,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,715.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2350.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9053 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,503.45,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9053 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9053 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,503.45,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1175.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1974.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,974.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,1132.76,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1762.50,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,762.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2162.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $2,162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1410.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1410.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,PREVEA HEALTH NETWORK,PREVEA360,1410.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1410.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1500.01,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,500.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,508.48,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1692.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,692.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9053 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,2350.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9053 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,2350.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9053 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,503.45,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,2350.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9053 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,UNITY HEALTH PLAN,UNITY HOSPICE,503.45,,,,,,,126.6200,2350.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1692.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,692.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1457.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,457.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1692.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,692.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1692.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,692.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, PHER, L/R CMV-NEG, IRR",P9053,HCPCS,390,RC,39000134,CDM,,,,both,,,2350.0000,1551.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1410.00,,,,,,,126.6200,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,350.00 in Billed Charges for Rev 390 Proc P9053 = $1,410.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,AETNA,AETNA HSHS,1201.56,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,201.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,AETNA,AETNA MEDICARE,250.49,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,AETNA,ALL COMMERCIAL AETNA,1860.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9055 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,250.49,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,ANTHEM,ANTHEM POS/HMO,1264.80,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,264.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,ANTHEM,ANTHEM PPO,1264.80,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,264.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1860.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,CENPATICO,ALL MEDICAID CENPATICO,1860.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1581.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,581.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,CIGNA,ALL COMMERCIAL CIGNA,1302.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,COFINITY,COFINITY,1860.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9055 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9055 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1767.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,767.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,1562.40,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,562.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1320.60,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,320.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1357.80,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,357.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,903.96,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $903.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1581.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,581.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HUMANA,HUMANA CHOICE CARE HMO,1181.10,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,181.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HUMANA,HUMANA CHOICE CARE PPO,1581.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,581.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,250.49,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,HUMANA,HUMANA NATIIONAL POS HMO,1181.10,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,181.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1357.80,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,357.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1860.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,860.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9055 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,250.49,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9055 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9055 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,250.49,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,930.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $930.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1562.40,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,562.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,563.60,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1395.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,395.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1711.20,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,711.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1116.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,116.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1116.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,116.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,PREVEA HEALTH NETWORK,PREVEA360,1116.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,116.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1116.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,116.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1187.24,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,187.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,252.99,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1339.20,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,339.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9055 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,1860.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9055 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,1860.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9055 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,250.49,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,1860.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9055 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,UNITY HEALTH PLAN,UNITY HOSPICE,250.49,,,,,,,126.6200,1860.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1339.20,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,339.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1153.20,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,153.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1339.20,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,339.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1339.20,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,339.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"PLT, APH/PHER, L/R, CMV-NEG",P9055,HCPCS,390,RC,39000138,CDM,,,,both,,,1860.0000,1227.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1116.00,,,,,,,126.6200,1860.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,860.00 in Billed Charges for Rev 390 Proc P9055 = $1,116.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,AETNA,AETNA HSHS,986.44,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $986.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,AETNA,AETNA MEDICARE,607.43,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,AETNA,ALL COMMERCIAL AETNA,1527.00,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,ANTHEM,ANTEHM MEDICAID,126.62,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9073 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,607.43,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,ANTHEM,ANTHEM POS/HMO,1038.36,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,038.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,ANTHEM,ANTHEM PPO,1038.36,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,038.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1527.00,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,CENPATICO,ALL MEDICAID CENPATICO,1527.00,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1297.95,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,297.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,CIGNA,ALL COMMERCIAL CIGNA,1068.90,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,068.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,COFINITY,COFINITY,1527.00,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.62,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9073 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.62,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9073 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1450.65,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,450.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,1282.68,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,282.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1084.17,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,084.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1114.71,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,114.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,742.12,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $742.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1297.95,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,297.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HUMANA,HUMANA CHOICE CARE HMO,969.65,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $969.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HUMANA,HUMANA CHOICE CARE PPO,1297.95,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,297.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,607.43,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,HUMANA,HUMANA NATIIONAL POS HMO,969.65,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $969.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1114.71,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,114.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1527.00,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,527.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.62,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9073 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,607.43,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.62,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9073 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,134.22,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9073 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 100% = $126.62... $126.62 at 106% = $134.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,607.43,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,763.50,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $763.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1282.68,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,282.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,1366.72,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1145.25,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,145.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1404.84,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,404.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,916.20,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $916.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,916.20,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $916.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,PREVEA HEALTH NETWORK,PREVEA360,916.20,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $916.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,916.20,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $916.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,974.68,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $974.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,613.50,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1099.44,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,099.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,TRIOLOGY,TRILOGY MEDICAID,134.21,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02062 Proc P9073 at $125.60 (Base Rate) * 1.0081 (Relative Weight) = $126.62 (Total Line Payment) at 106% = $134.21. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,126.6200,1527.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9073 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,126.6200,1527.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9073 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,607.43,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,126.6200,1527.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9073 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,UNITY HEALTH PLAN,UNITY HOSPICE,607.43,,,,,,,126.6200,1527.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1099.44,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,099.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,946.74,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $946.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1099.44,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,099.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1099.44,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $1,099.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PLATELETS PHERESIS PATH REDUCED EA UN,P9073,HCPCS,390,RC,39000204,CDM,,,,both,,,1527.0000,1007.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,916.20,,,,,,,126.6200,1527.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,527.00 in Billed Charges for Rev 390 Proc P9073 = $916.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,AETNA,AETNA HSHS,711.89,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $711.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,AETNA,AETNA MEDICARE,265.41,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,AETNA,ALL COMMERCIAL AETNA,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,265.41,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM POS/HMO,749.36,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $749.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,ANTHEM,ANTHEM PPO,749.36,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $749.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,CENPATICO,ALL MEDICAID CENPATICO,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,936.70,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,CIGNA,ALL COMMERCIAL CIGNA,771.40,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $771.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,COFINITY,COFINITY,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1046.90,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $1,046.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,925.68,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $925.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,782.42,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $782.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,804.46,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $804.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,535.57,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $535.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,936.70,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA CHOICE CARE HMO,699.77,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $699.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA CHOICE CARE PPO,936.70,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $936.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,265.41,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,HUMANA,HUMANA NATIIONAL POS HMO,699.77,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $699.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,804.46,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $804.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1102.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $1,102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,265.41,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,265.41,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,551.00,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,925.68,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $925.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,597.17,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,826.50,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $826.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1013.84,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $1,013.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA360,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,703.41,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $703.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,268.06,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,793.44,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9040 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,57.4200,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9040 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,57.4200,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9040 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,265.41,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,57.4200,1102.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9040 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,UNITY HEALTH PLAN,UNITY HOSPICE,265.41,,,,,,,57.4200,1102.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,793.44,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,683.24,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $683.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,793.44,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,793.44,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $793.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC RED CELLS L/R IRR EA SALINE WASH (RC),P9040,HCPCS,390,RC,39000209,CDM,,,,both,,,1102.0000,727.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,661.20,,,,,,,57.4200,1102.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,102.00 in Billed Charges for Rev 390 Proc P9040 = $661.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,AETNA,AETNA HSHS,1200.27,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,200.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,AETNA,AETNA MEDICARE,73.77,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,AETNA,ALL COMMERCIAL AETNA,1858.00,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,ANTHEM,ANTEHM MEDICAID,57.42,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9059 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,73.77,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,ANTHEM,ANTHEM POS/HMO,1263.44,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,263.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,ANTHEM,ANTHEM PPO,1263.44,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,263.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1858.00,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,CENPATICO,ALL MEDICAID CENPATICO,1858.00,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1579.30,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,579.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,CIGNA,ALL COMMERCIAL CIGNA,1300.60,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,300.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,COFINITY,COFINITY,1858.00,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.42,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9059 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.42,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9059 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1765.10,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,765.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,1560.72,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,560.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1319.18,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,319.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1356.34,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,356.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,902.99,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $902.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1579.30,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,579.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HUMANA,HUMANA CHOICE CARE HMO,1179.83,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,179.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HUMANA,HUMANA CHOICE CARE PPO,1579.30,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,579.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,73.77,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,HUMANA,HUMANA NATIIONAL POS HMO,1179.83,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,179.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1356.34,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,356.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1858.00,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,858.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.42,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9059 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,73.77,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.42,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9059 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,60.87,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9059 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 100% = $57.42... $57.42 at 106% = $60.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,73.77,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,929.00,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $929.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1560.72,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,560.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,165.98,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1393.50,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,393.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1709.36,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,709.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1114.80,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,114.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1114.80,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,114.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,PREVEA HEALTH NETWORK,PREVEA360,1114.80,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,114.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1114.80,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,114.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1185.96,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,185.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,74.51,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1337.76,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,337.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,TRIOLOGY,TRILOGY MEDICAID,60.87,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02061 Proc P9059 at $125.60 (Base Rate) * 0.4572 (Relative Weight) = $57.42 (Total Line Payment) at 106% = $60.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,57.4200,1858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9059 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,57.4200,1858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9059 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,73.77,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,57.4200,1858.0000,other,ST VINCENT HOSPITAL (ACU). Rev 390 Proc P9059 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,UNITY HEALTH PLAN,UNITY HOSPICE,73.77,,,,,,,57.4200,1858.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1337.76,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,337.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1151.96,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,151.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1337.76,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,337.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1337.76,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,337.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COVID CONVALESCENT PLASMA,P9059,HCPCS,390,RC,39000211,CDM,,,,both,,,1858.0000,1226.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1114.80,,,,,,,57.4200,1858.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,858.00 in Billed Charges for Rev 390 Proc P9059 = $1,114.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA HSHS,126.62,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $126.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,AETNA,AETNA MEDICARE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,AETNA,ALL COMMERCIAL AETNA,196.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94668 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM POS/HMO,133.28,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $133.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,ANTHEM,ANTHEM PPO,133.28,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $133.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,196.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,CENPATICO,ALL MEDICAID CENPATICO,196.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,166.60,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,CIGNA,ALL COMMERCIAL CIGNA,137.20,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $137.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,COFINITY,COFINITY,196.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94668 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94668 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,186.20,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $186.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,164.64,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.16,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $139.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.08,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,95.26,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $95.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,166.60,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE HMO,124.46,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $124.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA CHOICE CARE PPO,166.60,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $166.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA MEDICARE ADVANTAGE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,HUMANA,HUMANA NATIIONAL POS HMO,124.46,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $124.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.08,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $143.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,196.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94668 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94668 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94668 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE,MOLINA MEDICARE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $98.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,164.64,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $164.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,NAPHCARE,ALL COMMERICAL NAPHCARE,290.78,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.00,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,180.32,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $180.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94668 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94668 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94668 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94668 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.11,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $125.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.52,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.12,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94668 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94668 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94668 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,290.7800,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94668 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,UNITY HEALTH PLAN,UNITY HOSPICE,129.23,,,,,,,26.4300,290.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.12,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,121.52,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $121.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.12,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.12,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $141.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MNPJ CHEST WALL SBSQ,94668,CPT,410,RC,41000060,CDM,,,,both,,,196.0000,129.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,117.60,,,,,,,26.4300,290.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $196.00 in Billed Charges for Rev 410 Proc 94668 = $117.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,AETNA,AETNA HSHS,177.00,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $177.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,AETNA,AETNA MEDICARE,124.98,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,AETNA,ALL COMMERCIAL AETNA,274.00,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $274.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,124.98,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,ANTHEM,ANTHEM POS/HMO,186.32,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $186.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,ANTHEM,ANTHEM PPO,186.32,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $186.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,274.00,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $274.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,CENPATICO,ALL MEDICAID CENPATICO,274.00,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $274.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,232.90,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $232.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,CIGNA,ALL COMMERCIAL CIGNA,191.80,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $191.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,COFINITY,COFINITY,274.00,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $274.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,260.30,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $260.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,230.16,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $230.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,194.54,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $194.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,200.02,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $200.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,133.16,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $133.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,232.90,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $232.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HUMANA,HUMANA CHOICE CARE HMO,173.99,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $173.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HUMANA,HUMANA CHOICE CARE PPO,232.90,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $232.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,124.98,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,HUMANA,HUMANA NATIIONAL POS HMO,173.99,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $173.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,200.02,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $200.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,274.00,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $274.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,124.98,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,124.98,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,137.00,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $137.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,230.16,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $230.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,281.21,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,205.50,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $205.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,252.08,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $252.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,281.2100,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,281.2100,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,281.2100,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,281.2100,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,174.89,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $174.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,126.23,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,197.28,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $197.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,281.2100,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,281.2100,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,124.98,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,281.2100,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,UNITY HEALTH PLAN,UNITY HOSPICE,124.98,,,,,,,26.4300,281.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,197.28,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $197.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,169.88,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $169.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,197.28,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $197.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,197.28,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $197.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,41000065,CDM,,,,both,,,274.0000,180.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,164.40,,,,,,,26.4300,281.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $274.00 in Billed Charges for Rev 410 Proc 94799 = $164.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,AETNA,AETNA HSHS,350.13,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $350.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,AETNA,AETNA MEDICARE,124.98,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,AETNA,ALL COMMERCIAL AETNA,542.00,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,124.98,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,ANTHEM,ANTHEM POS/HMO,368.56,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $368.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,ANTHEM,ANTHEM PPO,368.56,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $368.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,542.00,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,CENPATICO,ALL MEDICAID CENPATICO,542.00,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,460.70,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $460.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,CIGNA,ALL COMMERCIAL CIGNA,379.40,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $379.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,COFINITY,COFINITY,542.00,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,514.90,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $514.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,455.28,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $455.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,384.82,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $384.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,395.66,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $395.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,263.41,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $263.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,460.70,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $460.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HUMANA,HUMANA CHOICE CARE HMO,344.17,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $344.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HUMANA,HUMANA CHOICE CARE PPO,460.70,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $460.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,124.98,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,HUMANA,HUMANA NATIIONAL POS HMO,344.17,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $344.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,395.66,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $395.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,542.00,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $542.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,124.98,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,124.98,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,271.00,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,455.28,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $455.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,281.21,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,406.50,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $406.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,498.64,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $498.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,542.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,542.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,542.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,542.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,345.96,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $345.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,126.23,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,390.24,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $390.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94799 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,542.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,542.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,124.98,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,542.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94799 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,UNITY HEALTH PLAN,UNITY HOSPICE,124.98,,,,,,,26.4300,542.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,390.24,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $390.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,336.04,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $336.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,390.24,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $390.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,390.24,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $390.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PEP THERAPY FLUTTER,94799,CPT,410,RC,41000067,CDM,,,,both,,,542.0000,357.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,325.20,,,,,,,26.4300,542.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $542.00 in Billed Charges for Rev 410 Proc 94799 = $325.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,AETNA,AETNA HSHS,419.25,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $419.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,AETNA,AETNA MEDICARE,212.70,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,AETNA,ALL COMMERCIAL AETNA,649.00,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $649.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,ANTHEM,ANTEHM MEDICAID,60.95,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,ANTHEM,ANTHEM POS/HMO,441.32,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $441.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,ANTHEM,ANTHEM PPO,441.32,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $441.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,649.00,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $649.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,CENPATICO,ALL MEDICAID CENPATICO,649.00,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $649.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,551.65,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $551.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,CIGNA,ALL COMMERCIAL CIGNA,454.30,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $454.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,COFINITY,COFINITY,649.00,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $649.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,60.95,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,60.95,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,616.55,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $616.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,545.16,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $545.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,460.79,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $460.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,473.77,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $473.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,315.41,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $315.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,551.65,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $551.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HUMANA,HUMANA CHOICE CARE HMO,412.12,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $412.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HUMANA,HUMANA CHOICE CARE PPO,551.65,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $551.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,HUMANA,HUMANA NATIIONAL POS HMO,412.12,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $412.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,473.77,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $473.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,649.00,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $649.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,60.95,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,60.95,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,MOLINA HEALTHCARE,MOLINA MEDICAID,64.61,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95... $60.95 at 106% = $64.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,324.50,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $324.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,545.16,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $545.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,486.75,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $486.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,597.08,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $597.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,60.9500,649.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,60.9500,649.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,60.9500,649.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,60.9500,649.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,414.26,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $414.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,467.28,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $467.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,TRIOLOGY,TRILOGY MEDICAID,64.61,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 106% = $64.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,60.9500,649.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,60.9500,649.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,60.9500,649.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,60.9500,649.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,467.28,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $467.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,402.38,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $402.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,467.28,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $467.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,467.28,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $467.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP/BIPAP SUBSQ,94660,CPT,410,RC,41000083,CDM,,,,both,,,649.0000,428.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,389.40,,,,,,,60.9500,649.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $649.00 in Billed Charges for Rev 410 Proc 94660 = $389.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,AETNA,AETNA HSHS,509.05,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $509.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,AETNA,AETNA MEDICARE,212.70,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,AETNA,ALL COMMERCIAL AETNA,788.00,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,ANTHEM,ANTHEM POS/HMO,535.84,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $535.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,ANTHEM,ANTHEM PPO,535.84,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $535.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,788.00,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,CENPATICO,ALL MEDICAID CENPATICO,788.00,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,669.80,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $669.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,CIGNA,ALL COMMERCIAL CIGNA,551.60,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $551.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,COFINITY,COFINITY,788.00,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,748.60,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $748.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,661.92,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $661.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,559.48,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $559.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,575.24,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $575.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,382.97,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $382.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,669.80,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $669.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HUMANA,HUMANA CHOICE CARE HMO,500.38,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $500.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HUMANA,HUMANA CHOICE CARE PPO,669.80,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $669.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,HUMANA,HUMANA NATIIONAL POS HMO,500.38,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $500.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,575.24,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $575.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,788.00,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $788.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,394.00,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $394.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,661.92,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $661.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,591.00,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $591.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,724.96,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $724.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,788.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,788.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,788.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,788.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,502.98,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $502.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,567.36,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $567.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,788.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,788.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,788.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,26.4300,788.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,567.36,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $567.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,488.56,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $488.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,567.36,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $567.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,567.36,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $567.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION INITIAL,94669,CPT,410,RC,41000087,CDM,,,,both,,,788.0000,520.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,472.80,,,,,,,26.4300,788.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $788.00 in Billed Charges for Rev 410 Proc 94669 = $472.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,AETNA,AETNA HSHS,390.18,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $390.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,AETNA,AETNA MEDICARE,212.70,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,AETNA,ALL COMMERCIAL AETNA,604.00,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94610 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,ANTHEM,ANTHEM POS/HMO,410.72,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $410.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,ANTHEM,ANTHEM PPO,410.72,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $410.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,604.00,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,CENPATICO,ALL MEDICAID CENPATICO,604.00,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,513.40,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $513.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,CIGNA,ALL COMMERCIAL CIGNA,422.80,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $422.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,COFINITY,COFINITY,604.00,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94610 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94610 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,573.80,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $573.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,507.36,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $507.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,428.84,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $428.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,440.92,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $440.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,293.54,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $293.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,513.40,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $513.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HUMANA,HUMANA CHOICE CARE HMO,383.54,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $383.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HUMANA,HUMANA CHOICE CARE PPO,513.40,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $513.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,HUMANA,HUMANA NATIIONAL POS HMO,383.54,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $383.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,440.92,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $440.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,604.00,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94610 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94610 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94610 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,302.00,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,507.36,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $507.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,453.00,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $453.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,555.68,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $555.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94610 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94610 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94610 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94610 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,385.53,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $385.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,434.88,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $434.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94610 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94610 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94610 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,604.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94610 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,26.4300,604.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,434.88,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $434.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,374.48,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $374.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,434.88,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $434.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,434.88,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $434.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC INTRAPULM SURFACTANT ADMIN W/ENDOTRACH TUBE,94610,CPT,410,RC,41000095,CDM,,,,both,,,604.0000,398.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,362.40,,,,,,,26.4300,604.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $604.00 in Billed Charges for Rev 410 Proc 94610 = $362.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,AETNA,AETNA HSHS,3095.63,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,095.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,AETNA,ALL COMMERCIAL AETNA,4792.00,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,ANTHEM,ANTHEM POS/HMO,3258.56,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,258.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,ANTHEM,ANTHEM PPO,3258.56,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,258.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4792.00,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,CENPATICO,ALL MEDICAID CENPATICO,4792.00,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4073.20,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,073.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,CIGNA,ALL COMMERCIAL CIGNA,3354.40,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,354.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,COFINITY,COFINITY,4792.00,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4552.40,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,552.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,4025.28,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,025.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3402.32,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,402.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3498.16,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,498.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,2328.91,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $2,328.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4073.20,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,073.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,HUMANA,HUMANA CHOICE CARE HMO,3042.92,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,042.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,HUMANA,HUMANA CHOICE CARE PPO,4073.20,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,073.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,HUMANA,HUMANA NATIIONAL POS HMO,3042.92,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,042.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3498.16,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,498.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,4792.00,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2396.00,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $2,396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4025.28,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,025.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3594.00,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,594.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4408.64,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $4,408.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2875.20,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $2,875.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2875.20,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $2,875.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,PREVEA HEALTH NETWORK,PREVEA360,2875.20,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $2,875.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2875.20,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $2,875.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3058.73,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,058.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3450.24,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,450.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3442.00,,,,,,,2328.9100,4792.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 413 Proc 99183 1 Visit at $3,442.00 per Visit = $3,442.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,3442.00,,,,,,,2328.9100,4792.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 413 Proc 99183 1 Visit at $3,442.00 per Visit = $3,442.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,3442.00,,,,,,,2328.9100,4792.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 413 Proc 99183 1 Visit at $3,442.00 per Visit = $3,442.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3450.24,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,450.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2971.04,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $2,971.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3450.24,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,450.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3450.24,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $3,450.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HYPERBARIC OXYGEN THERAPY,99183,CPT,413,RC,41300000,CDM,,,,both,,,4792.0000,3162.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2875.20,,,,,,,2328.9100,4792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $4,792.00 in Billed Charges for Rev 413 Proc 99183 = $2,875.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,AETNA,AETNA HSHS,532.30,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $532.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,AETNA,AETNA MEDICARE,133.66,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,AETNA,ALL COMMERCIAL AETNA,824.00,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTEHM MEDICAID,174.99,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00017 Proc G0277 at $125.60 (Base Rate) * 1.3932 (Relative Weight) = $174.99 (Total Line Payment) at 100% = $174.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,133.66,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTHEM POS/HMO,560.32,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $560.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,ANTHEM,ANTHEM PPO,560.32,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $560.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,824.00,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,CENPATICO,ALL MEDICAID CENPATICO,824.00,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,700.40,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,CIGNA,ALL COMMERCIAL CIGNA,576.80,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $576.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,COFINITY,COFINITY,824.00,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,174.99,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00017 Proc G0277 at $125.60 (Base Rate) * 1.3932 (Relative Weight) = $174.99 (Total Line Payment) at 100% = $174.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,174.99,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00017 Proc G0277 at $125.60 (Base Rate) * 1.3932 (Relative Weight) = $174.99 (Total Line Payment) at 100% = $174.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,782.80,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $782.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,692.16,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $692.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,585.04,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $585.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,601.52,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $601.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,400.46,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $400.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,700.40,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA CHOICE CARE HMO,523.24,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $523.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA CHOICE CARE PPO,700.40,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $700.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,133.66,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,HUMANA,HUMANA NATIIONAL POS HMO,523.24,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $523.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,601.52,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $601.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,824.00,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $824.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,174.99,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00017 Proc G0277 at $125.60 (Base Rate) * 1.3932 (Relative Weight) = $174.99 (Total Line Payment) at 100% = $174.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,133.66,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,174.99,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00017 Proc G0277 at $125.60 (Base Rate) * 1.3932 (Relative Weight) = $174.99 (Total Line Payment) at 100% = $174.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,185.49,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00017 Proc G0277 at $125.60 (Base Rate) * 1.3932 (Relative Weight) = $174.99 (Total Line Payment) at 100% = $174.99... $174.99 at 106% = $185.49 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,133.66,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,412.00,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $412.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,692.16,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $692.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,300.75,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,618.00,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $618.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,758.08,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $758.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,494.40,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $494.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,494.40,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $494.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA360,494.40,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $494.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,494.40,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $494.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,525.96,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $525.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,135.00,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,593.28,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,TRIOLOGY,TRILOGY MEDICAID,185.49,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00017 Proc G0277 at $125.60 (Base Rate) * 1.3932 (Relative Weight) = $174.99 (Total Line Payment) at 106% = $185.49. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,824.00,,,,,,,133.6600,824.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 413 Proc G0277 1 Visit at $3,442.00 per Visit = $3,442.00 (Service Line reduced to $824.00, claim capped at $824.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,824.00,,,,,,,133.6600,824.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 413 Proc G0277 1 Visit at $3,442.00 per Visit = $3,442.00 (Service Line reduced to $824.00, claim capped at $824.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,133.66,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,824.00,,,,,,,133.6600,824.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 413 Proc G0277 1 Visit at $3,442.00 per Visit = $3,442.00 (Service Line reduced to $824.00, claim capped at $824.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,UNITY HEALTH PLAN,UNITY HOSPICE,133.66,,,,,,,133.6600,824.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,593.28,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,510.88,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $510.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,593.28,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,593.28,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $593.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HYPERBARIC O2 PER 30 MIN,G0277,HCPCS,413,RC,41300003,CDM,,,,both,,,824.0000,543.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,494.40,,,,,,,133.6600,824.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $824.00 in Billed Charges for Rev 413 Proc G0277 = $494.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA HSHS,75.58,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $75.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA MEDICARE,15.06,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,AETNA,ALL COMMERCIAL AETNA,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTEHM MEDICAID,27.07,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.07 from Fee Schedule WIMCD_THX for Rev 420 Proc 97022 * Qty 1 = $27.07 at 100% = $27.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,15.06,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM POS/HMO,117.00,,,,,,,14.7100,117.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $331.00 per Visit = $331.00 (Limited to $117.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM PPO,117.00,,,,,,,14.7100,117.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $331.00 per Visit = $331.00 (Limited to $117.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,CENPATICO,ALL MEDICAID CENPATICO,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,99.45,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,CIGNA,ALL COMMERCIAL CIGNA,81.90,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $81.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,COFINITY,COFINITY,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,27.07,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.07 from Fee Schedule WIMCD_THX for Rev 420 Proc 97022 * Qty 1 = $27.07 at 100% = $27.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,27.07,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.07 from Fee Schedule WIMCD_THX for Rev 420 Proc 97022 * Qty 1 = $27.07 at 100% = $27.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,111.15,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $111.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,98.28,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.07,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $83.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,85.41,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,56.86,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $56.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,99.45,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE HMO,74.30,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE PPO,99.45,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,15.06,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA NATIIONAL POS HMO,74.30,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,85.41,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,27.07,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.07 from Fee Schedule WIMCD_THX for Rev 420 Proc 97022 * Qty 1 = $27.07 at 100% = $27.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.06,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,27.07,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.07 from Fee Schedule WIMCD_THX for Rev 420 Proc 97022 * Qty 1 = $27.07 at 100% = $27.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,28.69,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $27.07 from Fee Schedule WIMCD_THX for Rev 420 Proc 97022 * Qty 1 = $27.07 at 100% = $27.07... $27.07 at 106% = $28.69 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,15.06,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,58.50,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,98.28,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,33.89,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,87.75,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $87.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,107.64,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $107.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,74.68,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $74.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,15.21,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.24,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97022 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,15.06,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97022 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,UNITY HEALTH PLAN,UNITY HOSPICE,15.06,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.24,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,72.54,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $72.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.24,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.24,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
WHIRLPOOL THERAPY,97022,CPT,420,RC,42000015,CDM,,,,both,,,117.0000,77.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.20,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $117.00 in Billed Charges for Rev 420 Proc 97022 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,AETNA,AETNA HSHS,91.73,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $91.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,AETNA,AETNA MEDICARE,31.84,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,AETNA,ALL COMMERCIAL AETNA,142.00,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $142.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,ANTHEM,ANTEHM MEDICAID,30.86,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.86 from Fee Schedule WIMCD_THX for Rev 420 Proc 97112 * Qty 1 = $30.86 at 100% = $30.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,31.84,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,ANTHEM,ANTHEM POS/HMO,142.00,,,,,,,17.5100,142.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $331.00 per Visit = $331.00 (Limited to $142.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,ANTHEM,ANTHEM PPO,142.00,,,,,,,17.5100,142.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $331.00 per Visit = $331.00 (Limited to $142.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,142.00,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $142.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,CENPATICO,ALL MEDICAID CENPATICO,142.00,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $142.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,120.70,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $120.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,CIGNA,ALL COMMERCIAL CIGNA,99.40,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $99.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,COFINITY,COFINITY,142.00,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $142.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,30.86,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.86 from Fee Schedule WIMCD_THX for Rev 420 Proc 97112 * Qty 1 = $30.86 at 100% = $30.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,30.86,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.86 from Fee Schedule WIMCD_THX for Rev 420 Proc 97112 * Qty 1 = $30.86 at 100% = $30.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,134.90,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $134.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,119.28,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $119.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,100.82,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $100.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,103.66,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $103.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,69.01,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $69.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,120.70,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $120.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HUMANA,HUMANA CHOICE CARE HMO,90.17,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $90.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HUMANA,HUMANA CHOICE CARE PPO,120.70,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $120.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,31.84,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,HUMANA,HUMANA NATIIONAL POS HMO,90.17,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $90.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,103.66,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $103.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,142.00,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $142.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,30.86,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.86 from Fee Schedule WIMCD_THX for Rev 420 Proc 97112 * Qty 1 = $30.86 at 100% = $30.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,31.84,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,30.86,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.86 from Fee Schedule WIMCD_THX for Rev 420 Proc 97112 * Qty 1 = $30.86 at 100% = $30.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,32.71,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.86 from Fee Schedule WIMCD_THX for Rev 420 Proc 97112 * Qty 1 = $30.86 at 100% = $30.86... $30.86 at 106% = $32.71 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,31.84,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,71.00,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,119.28,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $119.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,71.64,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,106.50,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $106.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,130.64,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $130.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,142.00,,,,,,,17.5100,142.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $142.00, claim capped at $142.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,142.00,,,,,,,17.5100,142.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $142.00, claim capped at $142.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,PREVEA HEALTH NETWORK,PREVEA360,142.00,,,,,,,17.5100,142.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $142.00, claim capped at $142.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,142.00,,,,,,,17.5100,142.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $142.00, claim capped at $142.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,90.64,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $90.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,32.16,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,102.24,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $102.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,TRIOLOGY,TRILOGY MEDICAID,17.51,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00269 Proc 97112 at $125.60 (Base Rate) * 0.1315 (Relative Weight) = $16.52 (Total Line Payment) at 106% = $17.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,142.00,,,,,,,17.5100,142.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $142.00, claim capped at $142.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,142.00,,,,,,,17.5100,142.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $142.00, claim capped at $142.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,31.84,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,142.00,,,,,,,17.5100,142.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97112 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $142.00, claim capped at $142.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,UNITY HEALTH PLAN,UNITY HOSPICE,31.84,,,,,,,17.5100,142.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,102.24,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $102.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,88.04,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $88.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,102.24,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $102.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,102.24,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $102.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEUROMUSCULAR RE ED EA 15 MIN,97112,CPT,420,RC,42000045,CDM,,,,both,,,142.0000,93.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,85.20,,,,,,,17.5100,142.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $142.00 in Billed Charges for Rev 420 Proc 97112 = $85.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,AETNA,AETNA HSHS,78.81,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $78.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,AETNA,AETNA MEDICARE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,AETNA,ALL COMMERCIAL AETNA,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTEHM MEDICAID,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM POS/HMO,122.00,,,,,,,14.7100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM PPO,122.00,,,,,,,14.7100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,CENPATICO,ALL MEDICAID CENPATICO,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,103.70,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,CIGNA,ALL COMMERCIAL CIGNA,85.40,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $85.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,COFINITY,COFINITY,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,115.90,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $115.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,102.48,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,86.62,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $86.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.06,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,59.29,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $59.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,103.70,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE HMO,77.47,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE PPO,103.70,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA NATIIONAL POS HMO,77.47,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.06,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,32.41,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 * Qty 1 = $30.58 at 100% = $30.58... $30.58 at 106% = $32.41 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,102.48,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,63.56,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,91.50,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $91.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,112.24,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $112.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.87,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $77.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,28.53,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.84,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97116 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,UNITY HEALTH PLAN,UNITY HOSPICE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.84,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.64,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $75.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.84,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.84,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN,97116,CPT,420,RC,42000049,CDM,,,,both,,,122.0000,80.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.20,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $122.00 in Billed Charges for Rev 420 Proc 97116 = $73.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,AETNA,AETNA HSHS,78.81,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $78.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,AETNA,AETNA MEDICARE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,AETNA,ALL COMMERCIAL AETNA,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,ANTHEM,ANTEHM MEDICAID,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 Mod GP * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,ANTHEM,ANTHEM POS/HMO,122.00,,,,,,,14.7100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,ANTHEM,ANTHEM PPO,122.00,,,,,,,14.7100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,CENPATICO,ALL MEDICAID CENPATICO,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,103.70,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,CIGNA,ALL COMMERCIAL CIGNA,85.40,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $85.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,COFINITY,COFINITY,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 Mod GP * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 Mod GP * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,115.90,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $115.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,102.48,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,86.62,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $86.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.06,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,59.29,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $59.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,103.70,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE HMO,77.47,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE PPO,103.70,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,HUMANA NATIIONAL POS HMO,77.47,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.06,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,122.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 Mod GP * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,30.58,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 Mod GP * Qty 1 = $30.58 at 100% = $30.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,32.41,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $30.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97116 Mod GP * Qty 1 = $30.58 at 100% = $30.58... $30.58 at 106% = $32.41 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.00,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,102.48,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,63.56,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,91.50,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $91.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,112.24,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $112.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.87,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $77.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,28.53,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.84,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97116 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,122.00,,,,,,,14.7100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97116 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,UNITY HEALTH PLAN,UNITY HOSPICE,28.25,,,,,,,14.7100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.84,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.64,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $75.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.84,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.84,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AMBULATION GAIT TRAIN EA 15 MIN PRO,97116,CPT,420,RC,42000052,CDM,,,GP,both,,,122.0000,80.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.20,,,,,,,14.7100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $122.00 in Billed Charges for Rev 420 Proc 97116 Mod GP = $73.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA MEDICARE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTEHM MEDICAID,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,106.00,,,,,,,14.7100,106.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $331.00 per Visit = $331.00 (Limited to $106.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM PPO,106.00,,,,,,,14.7100,106.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $331.00 per Visit = $331.00 (Limited to $106.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,67.31,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,67.31,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,26.05,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 * Qty 1 = $24.58 at 100% = $24.58... $24.58 at 106% = $26.05 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,64.69,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,29.04,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97124 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,UNITY HEALTH PLAN,UNITY HOSPICE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN,97124,CPT,420,RC,42000053,CDM,,,,both,,,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 420 Proc 97124 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,AETNA,AETNA MEDICARE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,ANTHEM,ANTEHM MEDICAID,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 Mod GP * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,106.00,,,,,,,14.7100,106.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $331.00 per Visit = $331.00 (Limited to $106.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,ANTHEM,ANTHEM PPO,106.00,,,,,,,14.7100,106.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $331.00 per Visit = $331.00 (Limited to $106.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 Mod GP * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 Mod GP * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,67.31,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,67.31,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 Mod GP * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,24.58,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 Mod GP * Qty 1 = $24.58 at 100% = $24.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,26.05,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $24.58 from Fee Schedule WIMCD_THX for Rev 420 Proc 97124 Mod GP * Qty 1 = $24.58 at 100% = $24.58... $24.58 at 106% = $26.05 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,64.69,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,29.04,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97124 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,106.00,,,,,,,14.7100,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97124 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,UNITY HEALTH PLAN,UNITY HOSPICE,28.75,,,,,,,14.7100,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC MASSAGE EA 15 MIN PRO,97124,CPT,420,RC,42000055,CDM,,,GP,both,,,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,14.7100,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 420 Proc 97124 Mod GP = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,AETNA,AETNA HSHS,78.81,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $78.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,AETNA,AETNA MEDICARE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,AETNA,ALL COMMERCIAL AETNA,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTEHM MEDICAID,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM POS/HMO,122.00,,,,,,,17.5100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM PPO,122.00,,,,,,,17.5100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,CENPATICO,ALL MEDICAID CENPATICO,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,CIGNA,ALL COMMERCIAL CIGNA,85.40,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $85.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,COFINITY,COFINITY,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,115.90,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $115.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,102.48,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,86.62,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $86.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.06,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,59.29,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $59.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE HMO,77.47,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE PPO,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA NATIIONAL POS HMO,77.47,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.06,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,27.06,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 * Qty 1 = $25.53 at 100% = $25.53... $25.53 at 106% = $27.06 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,102.48,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,60.62,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,91.50,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $91.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,112.24,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $112.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.87,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $77.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,27.21,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,TRIOLOGY,TRILOGY MEDICAID,17.51,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00269 Proc 97140 at $125.60 (Base Rate) * 0.1315 (Relative Weight) = $16.52 (Total Line Payment) at 106% = $17.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,UNITY HEALTH PLAN,UNITY HOSPICE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.64,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $75.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,42000056,CDM,,,,both,,,122.0000,80.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.20,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $122.00 in Billed Charges for Rev 420 Proc 97140 = $73.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,AETNA,AETNA HSHS,78.81,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $78.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,AETNA,AETNA MEDICARE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,AETNA,ALL COMMERCIAL AETNA,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,ANTHEM,ANTEHM MEDICAID,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 Mod GP * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,ANTHEM,ANTHEM POS/HMO,122.00,,,,,,,17.5100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,ANTHEM,ANTHEM PPO,122.00,,,,,,,17.5100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,CENPATICO,ALL MEDICAID CENPATICO,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,CIGNA,ALL COMMERCIAL CIGNA,85.40,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $85.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,COFINITY,COFINITY,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 Mod GP * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 Mod GP * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,115.90,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $115.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,102.48,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,86.62,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $86.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.06,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,59.29,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $59.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE HMO,77.47,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE PPO,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,HUMANA,HUMANA NATIIONAL POS HMO,77.47,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.06,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 Mod GP * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,25.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 Mod GP * Qty 1 = $25.53 at 100% = $25.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,27.06,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.53 from Fee Schedule WIMCD_THX for Rev 420 Proc 97140 Mod GP * Qty 1 = $25.53 at 100% = $25.53... $25.53 at 106% = $27.06 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,102.48,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,60.62,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,91.50,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $91.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,112.24,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $112.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.87,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $77.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,27.21,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,TRIOLOGY,TRILOGY MEDICAID,17.51,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00269 Proc 97140 at $125.60 (Base Rate) * 0.1315 (Relative Weight) = $16.52 (Total Line Payment) at 106% = $17.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97140 Mod GP 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,UNITY HEALTH PLAN,UNITY HOSPICE,26.94,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.64,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $75.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MANUAL THERAPY EA 15 MIN PRO,97140,CPT,420,RC,42000061,CDM,,,GP,both,,,122.0000,80.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.20,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $122.00 in Billed Charges for Rev 420 Proc 97140 Mod GP = $73.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,AETNA,AETNA HSHS,93.67,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $93.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,AETNA,AETNA MEDICARE,34.00,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,AETNA,ALL COMMERCIAL AETNA,145.00,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTEHM MEDICAID,32.94,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.94 from Fee Schedule WIMCD_THX for Rev 420 Proc 97530 * Qty 1 = $32.94 at 100% = $32.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,34.00,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM POS/HMO,145.00,,,,,,,17.5100,145.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $331.00 per Visit = $331.00 (Limited to $145.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,ANTHEM,ANTHEM PPO,145.00,,,,,,,17.5100,145.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $331.00 per Visit = $331.00 (Limited to $145.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,145.00,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,CENPATICO,ALL MEDICAID CENPATICO,145.00,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,123.25,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,CIGNA,ALL COMMERCIAL CIGNA,101.50,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $101.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,COFINITY,COFINITY,145.00,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,32.94,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.94 from Fee Schedule WIMCD_THX for Rev 420 Proc 97530 * Qty 1 = $32.94 at 100% = $32.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,32.94,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.94 from Fee Schedule WIMCD_THX for Rev 420 Proc 97530 * Qty 1 = $32.94 at 100% = $32.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,137.75,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $137.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,121.80,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,102.95,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $102.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,105.85,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $105.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,70.47,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $70.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,123.25,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA CHOICE CARE HMO,92.08,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $92.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA CHOICE CARE PPO,123.25,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $123.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,34.00,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,HUMANA,HUMANA NATIIONAL POS HMO,92.08,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $92.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,105.85,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $105.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,145.00,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $145.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,32.94,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.94 from Fee Schedule WIMCD_THX for Rev 420 Proc 97530 * Qty 1 = $32.94 at 100% = $32.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,34.00,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,32.94,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.94 from Fee Schedule WIMCD_THX for Rev 420 Proc 97530 * Qty 1 = $32.94 at 100% = $32.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,34.92,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $32.94 from Fee Schedule WIMCD_THX for Rev 420 Proc 97530 * Qty 1 = $32.94 at 100% = $32.94... $32.94 at 106% = $34.92 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,34.00,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,72.50,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $72.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,121.80,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $121.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,76.50,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,108.75,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $108.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,133.40,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $133.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,145.00,,,,,,,17.5100,145.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $145.00, claim capped at $145.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,145.00,,,,,,,17.5100,145.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $145.00, claim capped at $145.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA360,145.00,,,,,,,17.5100,145.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $145.00, claim capped at $145.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,145.00,,,,,,,17.5100,145.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $145.00, claim capped at $145.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,92.55,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $92.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,34.34,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,104.40,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,TRIOLOGY,TRILOGY MEDICAID,17.51,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00269 Proc 97530 at $125.60 (Base Rate) * 0.1315 (Relative Weight) = $16.52 (Total Line Payment) at 106% = $17.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,145.00,,,,,,,17.5100,145.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $145.00, claim capped at $145.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,145.00,,,,,,,17.5100,145.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $145.00, claim capped at $145.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,34.00,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,145.00,,,,,,,17.5100,145.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97530 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $145.00, claim capped at $145.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,UNITY HEALTH PLAN,UNITY HOSPICE,34.00,,,,,,,17.5100,145.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,104.40,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,89.90,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $89.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,104.40,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,104.40,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $104.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC ACTIVITIES EA 15 MIN,97530,CPT,420,RC,42000065,CDM,,,,both,,,145.0000,95.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.00,,,,,,,17.5100,145.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.00 in Billed Charges for Rev 420 Proc 97530 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,AETNA,AETNA HSHS,7.95,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $7.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,AETNA,AETNA MEDICARE,4.05,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,AETNA,ALL COMMERCIAL AETNA,12.31,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,ANTHEM,ANTEHM MEDICAID,12.31,,,,,,,4.0500,13.0500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7197 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $12.31, claim capped at $12.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,4.05,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,ANTHEM,ANTHEM POS/HMO,6.89,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7197 * Qty 1 = $4.05 at 170% = $6.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,ANTHEM,ANTHEM PPO,8.51,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7197 * Qty 1 = $4.05 at 210% = $8.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.31,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,CENPATICO,ALL MEDICAID CENPATICO,12.31,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.46,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $10.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,CIGNA,ALL COMMERCIAL CIGNA,8.62,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $8.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,COFINITY,COFINITY,12.31,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,12.31,,,,,,,4.0500,13.0500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7197 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $12.31, claim capped at $12.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,12.31,,,,,,,4.0500,13.0500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7197 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $12.31, claim capped at $12.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.69,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,10.34,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $10.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.74,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.99,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $8.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,5.98,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $5.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.46,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $10.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HUMANA,HUMANA CHOICE CARE HMO,6.61,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.61 from Fee Schedule 005543_170 for Rev 636 Proc J7197 * Qty 1 = $6.61 at 100% = $6.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HUMANA,HUMANA CHOICE CARE PPO,10.46,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $10.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,4.05,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,HUMANA,HUMANA NATIIONAL POS HMO,6.61,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.61 from Fee Schedule 005543_170 for Rev 636 Proc J7197 * Qty 1 = $6.61 at 100% = $6.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.99,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $8.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.31,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,12.31,,,,,,,4.0500,13.0500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7197 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $12.31, claim capped at $12.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,4.05,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,12.31,,,,,,,4.0500,13.0500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7197 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $12.31, claim capped at $12.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,MOLINA HEALTHCARE,MOLINA MEDICAID,13.05,,,,,,,4.0500,13.0500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7197 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $12.31, claim capped at $12.31 in billed charges)... $12.31 at 106% = $13.05 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,4.05,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.16,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $6.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.34,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $10.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,9.12,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.23,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $9.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.33,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $11.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.25,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7197 * Qty 1 = $4.05 at 179% = $7.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.25,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7197 * Qty 1 = $4.05 at 179% = $7.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,PREVEA HEALTH NETWORK,PREVEA360,7.25,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7197 * Qty 1 = $4.05 at 179% = $7.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.25,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7197 * Qty 1 = $4.05 at 179% = $7.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.86,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $7.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,4.09,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.86,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,TRIOLOGY,TRILOGY MEDICAID,12.31,,,,,,,4.0500,13.0500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7197 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 106% = $2,153.99 (Service Line reduced to $12.31, claim capped at $12.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.68,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.68 from Fee Schedule UHC_31190C for Rev 636 Proc J7197 * Qty 1 = $6.68 at 100% = $6.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,6.68,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.68 from Fee Schedule UHC_31190C for Rev 636 Proc J7197 * Qty 1 = $6.68 at 100% = $6.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,4.05,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,6.68,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.68 from Fee Schedule UHC_31190C for Rev 636 Proc J7197 * Qty 1 = $6.68 at 100% = $6.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,UNITY HEALTH PLAN,UNITY HOSPICE,4.05,,,,,,,4.0500,13.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.86,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.63,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $7.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.86,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.86,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTITHROMBIN III (HUMAN) 500 UNITS SOLR per 1 Units,J7197,HCPCS,636,RC,13533-606-12,CDM,,,,both,1.000000,UN,12.3100,8.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.39,,,,,,,4.0500,13.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.31 in Billed Charges for Rev 636 Proc J7197 = $7.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,AETNA,AETNA HSHS,348.56,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $348.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,AETNA,AETNA MEDICARE,230.80,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,AETNA,ALL COMMERCIAL AETNA,539.56,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $539.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,ANTHEM,ANTEHM MEDICAID,539.56,,,,,,,230.8000,571.9300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9043 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $539.56, claim capped at $539.56 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,230.80,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,ANTHEM,ANTHEM POS/HMO,392.36,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $230.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9043 * Qty 1 = $230.80 at 170% = $392.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,ANTHEM,ANTHEM PPO,484.68,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $230.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9043 * Qty 1 = $230.80 at 210% = $484.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,539.56,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $539.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,CENPATICO,ALL MEDICAID CENPATICO,539.56,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $539.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,458.63,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $458.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,CIGNA,ALL COMMERCIAL CIGNA,377.69,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $377.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,COFINITY,COFINITY,539.56,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $539.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,539.56,,,,,,,230.8000,571.9300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9043 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $539.56, claim capped at $539.56 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,539.56,,,,,,,230.8000,571.9300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9043 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $539.56, claim capped at $539.56 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,512.58,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $512.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,453.23,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $453.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,383.09,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $383.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,393.88,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $393.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,262.23,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $262.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,458.63,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $458.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HUMANA,HUMANA CHOICE CARE HMO,366.35,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $366.35 from Fee Schedule 005543_170 for Rev 636 Proc J9043 * Qty 1 = $366.35 at 100% = $366.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HUMANA,HUMANA CHOICE CARE PPO,458.63,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $458.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HUMANA,HUMANA MEDICARE ADVANTAGE,230.80,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,HUMANA,HUMANA NATIIONAL POS HMO,366.35,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $366.35 from Fee Schedule 005543_170 for Rev 636 Proc J9043 * Qty 1 = $366.35 at 100% = $366.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,393.88,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $393.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,539.56,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $539.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,539.56,,,,,,,230.8000,571.9300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9043 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $539.56, claim capped at $539.56 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,230.80,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,539.56,,,,,,,230.8000,571.9300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9043 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $539.56, claim capped at $539.56 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,MOLINA HEALTHCARE,MOLINA MEDICAID,571.93,,,,,,,230.8000,571.9300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9043 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $539.56, claim capped at $539.56 in billed charges)... $539.56 at 106% = $571.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,MOLINA HEALTHCARE,MOLINA MEDICARE,230.80,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,269.78,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $269.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,453.23,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $453.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,NAPHCARE,ALL COMMERICAL NAPHCARE,519.29,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,404.67,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $404.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,496.40,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $496.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,413.13,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $230.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9043 * Qty 1 = $230.80 at 179% = $413.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,413.13,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $230.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9043 * Qty 1 = $230.80 at 179% = $413.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,PREVEA HEALTH NETWORK,PREVEA360,413.13,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $230.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9043 * Qty 1 = $230.80 at 179% = $413.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,413.13,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $230.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9043 * Qty 1 = $230.80 at 179% = $413.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,344.40,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $344.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,233.11,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,388.48,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $388.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,TRIOLOGY,TRILOGY MEDICAID,539.56,,,,,,,230.8000,571.9300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9043 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 106% = $2,153.99 (Service Line reduced to $539.56, claim capped at $539.56 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,380.82,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $380.82 from Fee Schedule UHC_31190C for Rev 636 Proc J9043 * Qty 1 = $380.82 at 100% = $380.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,UNITED HEALTHCARE,UHC ONEIDA NATION,380.82,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $380.82 from Fee Schedule UHC_31190C for Rev 636 Proc J9043 * Qty 1 = $380.82 at 100% = $380.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,230.80,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,UNITED HEALTHCARE,UNITED HEALTHCARE,380.82,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $380.82 from Fee Schedule UHC_31190C for Rev 636 Proc J9043 * Qty 1 = $380.82 at 100% = $380.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,UNITY HEALTH PLAN,UNITY HOSPICE,230.80,,,,,,,230.8000,571.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,388.48,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $388.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,334.53,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $334.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,388.48,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $388.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,388.48,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $388.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CABAZITAXEL 10 MG/ML SOLN 6 ML VIAL per 1 mg,J9043,HCPCS,636,RC,0024-5824-11,CDM,,,,both,1.000000,ME,539.5600,356.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,323.74,,,,,,,230.8000,571.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $539.56 in Billed Charges for Rev 636 Proc J9043 = $323.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,AETNA,AETNA HSHS,4.77,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $4.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,AETNA,ALL COMMERCIAL AETNA,7.38,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,ANTHEM,ANTHEM POS/HMO,5.02,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $7.38 in Billed Charges at 68% = $5.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,ANTHEM,ANTHEM PPO,5.02,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $7.38 in Billed Charges at 68% = $5.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7.38,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,CENPATICO,ALL MEDICAID CENPATICO,7.38,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.27,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $6.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,CIGNA,ALL COMMERCIAL CIGNA,5.17,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,COFINITY,COFINITY,7.38,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.01,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,6.20,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $6.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.24,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.39,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,3.59,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $3.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.27,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $6.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,HUMANA,HUMANA CHOICE CARE HMO,1.24,,,,,,,1.2400,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.24 from Fee Schedule 005543_170 for Rev 636 Proc J0706 * Qty 1 = $1.24 at 100% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,HUMANA,HUMANA CHOICE CARE PPO,6.27,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $6.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,HUMANA,HUMANA NATIIONAL POS HMO,1.24,,,,,,,1.2400,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.24 from Fee Schedule 005543_170 for Rev 636 Proc J0706 * Qty 1 = $1.24 at 100% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.39,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,7.38,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.69,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $3.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.20,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $6.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5.54,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6.79,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $6.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.43,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $7.38 in Billed Charges at 60% = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.43,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $7.38 in Billed Charges at 60% = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,PREVEA HEALTH NETWORK,PREVEA360,4.43,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $7.38 in Billed Charges at 60% = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.43,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $7.38 in Billed Charges at 60% = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.71,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.31,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.35,,,,,,,1.2400,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $3.35 from Fee Schedule UHC_31190C for Rev 636 Proc J0706 * Qty 1 = $3.35 at 100% = $3.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,UNITED HEALTHCARE,UHC ONEIDA NATION,3.35,,,,,,,1.2400,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $3.35 from Fee Schedule UHC_31190C for Rev 636 Proc J0706 * Qty 1 = $3.35 at 100% = $3.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,UNITED HEALTHCARE,UNITED HEALTHCARE,3.35,,,,,,,1.2400,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $3.35 from Fee Schedule UHC_31190C for Rev 636 Proc J0706 * Qty 1 = $3.35 at 100% = $3.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.31,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.58,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.31,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.31,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,51754-0500-1,CDM,,,,both,5.000000,ME,7.3800,4.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.43,,,,,,,1.2400,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $7.38 in Billed Charges for Rev 636 Proc J0706 = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,AETNA,AETNA HSHS,3.97,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $3.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,AETNA,ALL COMMERCIAL AETNA,6.15,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $6.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,ANTHEM,ANTHEM POS/HMO,4.18,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $6.15 in Billed Charges at 68% = $4.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,ANTHEM,ANTHEM PPO,4.18,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $6.15 in Billed Charges at 68% = $4.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6.15,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $6.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,CENPATICO,ALL MEDICAID CENPATICO,6.15,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $6.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.23,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $5.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,CIGNA,ALL COMMERCIAL CIGNA,4.31,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,COFINITY,COFINITY,6.15,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $6.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.84,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,5.17,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.37,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.49,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,2.99,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $2.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.23,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $5.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,HUMANA,HUMANA CHOICE CARE HMO,1.24,,,,,,,1.2400,6.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.24 from Fee Schedule 005543_170 for Rev 636 Proc J0706 * Qty 1 = $1.24 at 100% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,HUMANA,HUMANA CHOICE CARE PPO,5.23,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $5.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,HUMANA,HUMANA NATIIONAL POS HMO,1.24,,,,,,,1.2400,6.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.24 from Fee Schedule 005543_170 for Rev 636 Proc J0706 * Qty 1 = $1.24 at 100% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.49,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,6.15,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $6.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.08,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $3.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.17,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.61,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.66,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $5.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.69,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $6.15 in Billed Charges at 60% = $3.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.69,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $6.15 in Billed Charges at 60% = $3.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,PREVEA HEALTH NETWORK,PREVEA360,3.69,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $6.15 in Billed Charges at 60% = $3.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.69,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0706 $6.15 in Billed Charges at 60% = $3.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.93,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $3.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.43,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.35,,,,,,,1.2400,6.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.35 from Fee Schedule UHC_31190C for Rev 636 Proc J0706 * Qty 1 = $3.35 at 100% = $3.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,3.35,,,,,,,1.2400,6.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.35 from Fee Schedule UHC_31190C for Rev 636 Proc J0706 * Qty 1 = $3.35 at 100% = $3.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,3.35,,,,,,,1.2400,6.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.35 from Fee Schedule UHC_31190C for Rev 636 Proc J0706 * Qty 1 = $3.35 at 100% = $3.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.43,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.81,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $3.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.43,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.43,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE 60 MG/3ML SOLN per 5 mg,J0706,HCPCS,636,RC,72485-104-01,CDM,,,,both,5.000000,ME,6.1500,4.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.69,,,,,,,1.2400,6.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $6.15 in Billed Charges for Rev 636 Proc J0706 = $3.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,AETNA,AETNA HSHS,1.58,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,AETNA,ALL COMMERCIAL AETNA,2.45,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2.45,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,CENPATICO,ALL MEDICAID CENPATICO,2.45,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2.08,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,CIGNA,ALL COMMERCIAL CIGNA,1.72,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,COFINITY,COFINITY,2.45,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2.33,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,2.06,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1.74,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1.79,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,1.19,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2.08,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,HUMANA,HUMANA CHOICE CARE PPO,2.08,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1.79,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2.45,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.23,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2.06,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1.84,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2.25,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $2.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.56,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1.76,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,2.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1.76,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.52,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1.76,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1.76,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0143-9333-01,CDM,,,,both,0.500000,ME,2.4500,1.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1.47,,,,,,,0.0200,2.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $2.45 in Billed Charges for Rev 636 Proc J0665 = $1.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,AETNA,AETNA HSHS,6.33,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $6.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,AETNA,ALL COMMERCIAL AETNA,9.80,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.80,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,CENPATICO,ALL MEDICAID CENPATICO,9.80,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8.33,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,CIGNA,ALL COMMERCIAL CIGNA,6.86,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,COFINITY,COFINITY,9.80,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9.31,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,8.23,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $8.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.96,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $6.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.15,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $7.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,4.76,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $4.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8.33,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,HUMANA,HUMANA CHOICE CARE PPO,8.33,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.15,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $7.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.80,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.90,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8.23,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $8.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.35,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.02,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $9.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.26,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $6.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.06,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.06,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.08,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $6.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.06,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.06,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-18,CDM,,,,both,0.500000,ME,9.8000,6.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.88,,,,,,,0.0200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.80 in Billed Charges for Rev 636 Proc J0665 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,AETNA,AETNA HSHS,0.35,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,AETNA,ALL COMMERCIAL AETNA,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,CENPATICO,ALL MEDICAID CENPATICO,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.46,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,CIGNA,ALL COMMERCIAL CIGNA,0.38,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,COFINITY,COFINITY,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.51,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,0.45,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.38,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,0.26,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.46,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,HUMANA,HUMANA CHOICE CARE PPO,0.46,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.27,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.45,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.41,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.50,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.34,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.33,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9334-01,CDM,,,,both,0.500000,ME,0.5400,0.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.32,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.54 in Billed Charges for Rev 636 Proc J0665 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,AETNA,AETNA HSHS,0.10,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,AETNA,ALL COMMERCIAL AETNA,0.16,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.16,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,CENPATICO,ALL MEDICAID CENPATICO,0.16,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.14,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,CIGNA,ALL COMMERCIAL CIGNA,0.11,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,COFINITY,COFINITY,0.16,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.15,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,0.13,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.11,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.12,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,0.08,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.14,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,HUMANA,HUMANA CHOICE CARE PPO,0.14,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.12,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.16,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.08,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.13,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.12,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.15,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.10,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.12,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.12,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.10,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.12,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.12,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.5 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1162-02,CDM,,,,both,0.500000,ME,0.1600,0.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.10,,,,,,,0.0200,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.16 in Billed Charges for Rev 636 Proc J0665 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,AETNA,AETNA HSHS,0.42,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,AETNA,ALL COMMERCIAL AETNA,0.65,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.65,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,CENPATICO,ALL MEDICAID CENPATICO,0.65,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.55,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,CIGNA,ALL COMMERCIAL CIGNA,0.46,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,COFINITY,COFINITY,0.65,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.62,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,0.55,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.46,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.47,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,0.32,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.55,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,HUMANA,HUMANA CHOICE CARE PPO,0.55,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.47,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.65,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.33,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.55,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.49,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.60,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.41,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.47,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.47,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.40,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.47,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.47,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0143-9335-01,CDM,,,,both,0.500000,ME,0.6500,0.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.39,,,,,,,0.0200,0.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.65 in Billed Charges for Rev 636 Proc J0665 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,AETNA,AETNA HSHS,1.51,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,AETNA,ALL COMMERCIAL AETNA,2.33,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $2.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2.33,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $2.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,CENPATICO,ALL MEDICAID CENPATICO,2.33,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $2.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1.98,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,CIGNA,ALL COMMERCIAL CIGNA,1.63,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,COFINITY,COFINITY,2.33,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $2.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2.21,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $2.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,1.96,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1.65,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1.70,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,1.13,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1.98,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,HUMANA,HUMANA CHOICE CARE PPO,1.98,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1.70,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2.33,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $2.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.17,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1.96,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1.75,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2.14,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $2.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.49,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1.68,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,2.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1.68,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.44,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1.68,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1.68,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0264-9379-88,CDM,,,,both,0.500000,ME,2.3300,1.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1.40,,,,,,,0.0200,2.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $2.33 in Billed Charges for Rev 636 Proc J0665 = $1.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,AETNA,AETNA HSHS,7.14,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $7.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,AETNA,AETNA MEDICARE,1.44,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,AETNA,ALL COMMERCIAL AETNA,11.06,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $11.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1.44,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,ANTHEM,ANTHEM POS/HMO,2.45,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0666 * Qty 1 = $1.44 at 170% = $2.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,ANTHEM,ANTHEM PPO,3.02,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0666 * Qty 1 = $1.44 at 210% = $3.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11.06,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $11.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,CENPATICO,ALL MEDICAID CENPATICO,11.06,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $11.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.40,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $9.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,CIGNA,ALL COMMERCIAL CIGNA,7.74,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $7.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,COFINITY,COFINITY,11.06,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $11.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.51,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $10.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,9.29,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $9.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.85,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.07,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,5.38,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $5.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.40,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $9.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HUMANA,HUMANA CHOICE CARE HMO,7.02,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0666 $11.06 in Billed Charges at 63.5% = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HUMANA,HUMANA CHOICE CARE PPO,9.40,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $9.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HUMANA,HUMANA MEDICARE ADVANTAGE,1.44,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,HUMANA,HUMANA NATIIONAL POS HMO,7.02,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0666 $11.06 in Billed Charges at 63.5% = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.07,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,11.06,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $11.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1.44,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,MOLINA HEALTHCARE,MOLINA MEDICARE,1.44,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.53,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $5.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.29,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $9.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,NAPHCARE,ALL COMMERICAL NAPHCARE,3.24,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.30,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $8.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.18,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $10.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.58,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0666 * Qty 1 = $1.44 at 179% = $2.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.58,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0666 * Qty 1 = $1.44 at 179% = $2.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,PREVEA HEALTH NETWORK,PREVEA360,2.58,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0666 * Qty 1 = $1.44 at 179% = $2.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.58,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0666 * Qty 1 = $1.44 at 179% = $2.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.06,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1.45,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.96,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.38,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.38 from Fee Schedule UHC_31190C for Rev 636 Proc J0666 * Qty 1 = $2.38 at 100% = $2.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,2.38,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.38 from Fee Schedule UHC_31190C for Rev 636 Proc J0666 * Qty 1 = $2.38 at 100% = $2.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1.44,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,2.38,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.38 from Fee Schedule UHC_31190C for Rev 636 Proc J0666 * Qty 1 = $2.38 at 100% = $2.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,UNITY HEALTH PLAN,UNITY HOSPICE,1.44,,,,,,,1.4400,11.0600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.96,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.86,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.96,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.96,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE LIPOSOME 1.3 % SUSP per 1 mg,J0666,HCPCS,636,RC,65250-266-09,CDM,,,,both,1.000000,ME,11.0600,7.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.64,,,,,,,1.4400,11.0600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.06 in Billed Charges for Rev 636 Proc J0666 = $6.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,AETNA,AETNA HSHS,3.60,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $3.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,AETNA,AETNA MEDICARE,0.83,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,AETNA,ALL COMMERCIAL AETNA,5.58,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $5.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,0.83,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,ANTHEM,ANTHEM POS/HMO,3.79,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.58 in Billed Charges at 68% = $3.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,ANTHEM,ANTHEM PPO,3.79,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.58 in Billed Charges at 68% = $3.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.58,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $5.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,CENPATICO,ALL MEDICAID CENPATICO,5.58,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $5.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.74,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,CIGNA,ALL COMMERCIAL CIGNA,3.91,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $3.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,COFINITY,COFINITY,5.58,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $5.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.30,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $5.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,4.69,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.96,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $3.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.07,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,2.71,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $2.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.74,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HUMANA,HUMANA CHOICE CARE HMO,3.54,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.58 in Billed Charges at 63.5% = $3.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HUMANA,HUMANA CHOICE CARE PPO,4.74,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HUMANA,HUMANA MEDICARE ADVANTAGE,0.83,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,HUMANA,HUMANA NATIIONAL POS HMO,3.54,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.58 in Billed Charges at 63.5% = $3.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.07,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.58,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $5.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,0.83,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,MOLINA HEALTHCARE,MOLINA MEDICARE,0.83,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.79,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $2.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.69,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,NAPHCARE,ALL COMMERICAL NAPHCARE,1.86,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.19,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.13,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $5.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.35,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.58 in Billed Charges at 60% = $3.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.35,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.58 in Billed Charges at 60% = $3.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,PREVEA HEALTH NETWORK,PREVEA360,3.35,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.58 in Billed Charges at 60% = $3.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.35,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.58 in Billed Charges at 60% = $3.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.56,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $3.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,0.84,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.02,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.37,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0668 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,1.37,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0668 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,0.83,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,1.37,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0668 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,UNITY HEALTH PLAN,UNITY HOSPICE,0.83,,,,,,,0.8300,5.5800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.02,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.46,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $3.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.02,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.02,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-301-02,CDM,,,,both,1.000000,ME,5.5800,3.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.35,,,,,,,0.8300,5.5800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.58 in Billed Charges for Rev 636 Proc J0668 = $3.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,AETNA,AETNA HSHS,129.93,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $129.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,AETNA,ALL COMMERCIAL AETNA,201.13,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $201.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,ANTHEM,ANTEHM MEDICAID,56.96,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9017 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,ANTHEM,ANTHEM POS/HMO,12.56,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.39 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9017 * Qty 1 = $7.39 at 170% = $12.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,ANTHEM,ANTHEM PPO,15.52,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.39 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9017 * Qty 1 = $7.39 at 210% = $15.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,201.13,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $201.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,CENPATICO,ALL MEDICAID CENPATICO,201.13,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $201.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,170.96,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $170.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,CIGNA,ALL COMMERCIAL CIGNA,140.79,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $140.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,COFINITY,COFINITY,201.13,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $201.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,56.96,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9017 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,56.96,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9017 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,191.07,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $191.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,168.95,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $168.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,142.80,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $142.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,146.82,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $146.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,97.75,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $97.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,170.96,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $170.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,HUMANA,HUMANA CHOICE CARE HMO,18.17,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $18.17 from Fee Schedule 005543_170 for Rev 636 Proc J9017 * Qty 1 = $18.17 at 100% = $18.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,HUMANA,HUMANA CHOICE CARE PPO,170.96,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $170.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,HUMANA,HUMANA NATIIONAL POS HMO,18.17,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $18.17 from Fee Schedule 005543_170 for Rev 636 Proc J9017 * Qty 1 = $18.17 at 100% = $18.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,146.82,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $146.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,201.13,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $201.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,56.96,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9017 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,56.96,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9017 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,MOLINA HEALTHCARE,MOLINA MEDICAID,60.38,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9017 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96... $56.96 at 106% = $60.38 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,100.57,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $100.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,168.95,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $168.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,150.85,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $150.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,185.04,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $185.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.23,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.39 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9017 * Qty 1 = $7.39 at 179% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.23,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.39 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9017 * Qty 1 = $7.39 at 179% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,PREVEA HEALTH NETWORK,PREVEA360,13.23,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.39 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9017 * Qty 1 = $7.39 at 179% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.23,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.39 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9017 * Qty 1 = $7.39 at 179% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,128.38,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $128.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,144.81,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $144.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,TRIOLOGY,TRILOGY MEDICAID,60.38,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9017 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 106% = $60.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.19,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $12.19 from Fee Schedule UHC_31190C for Rev 636 Proc J9017 * Qty 1 = $12.19 at 100% = $12.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,UNITED HEALTHCARE,UHC ONEIDA NATION,12.19,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $12.19 from Fee Schedule UHC_31190C for Rev 636 Proc J9017 * Qty 1 = $12.19 at 100% = $12.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,UNITED HEALTHCARE,UNITED HEALTHCARE,12.19,,,,,,,12.1900,201.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $12.19 from Fee Schedule UHC_31190C for Rev 636 Proc J9017 * Qty 1 = $12.19 at 100% = $12.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,144.81,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $144.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,124.70,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $124.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,144.81,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $144.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,144.81,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $144.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARSENIC TRIOXIDE 12 MG/6ML SOLN 6 ML VIAL per 1 mg,J9017,HCPCS,636,RC,25021-227-06,CDM,,,,both,1.000000,ME,201.1300,132.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,120.68,,,,,,,12.1900,201.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $201.13 in Billed Charges for Rev 636 Proc J9017 = $120.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,AETNA,AETNA HSHS,52.49,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $52.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,AETNA,ALL COMMERCIAL AETNA,81.25,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $81.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,ANTHEM,ANTHEM POS/HMO,11.75,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0702 * Qty 1 = $6.91 at 170% = $11.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,ANTHEM,ANTHEM PPO,14.51,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0702 * Qty 1 = $6.91 at 210% = $14.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,81.25,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $81.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,CENPATICO,ALL MEDICAID CENPATICO,81.25,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $81.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.06,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $69.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,CIGNA,ALL COMMERCIAL CIGNA,56.88,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $56.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,COFINITY,COFINITY,81.25,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $81.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.19,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $77.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,HEALTH CARE ALLIANCE,THE ALLIANCE,68.25,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $68.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,57.69,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $57.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.31,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $59.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,HSHS EMPLOYEES,HSHS EMPLOYEES,39.49,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $39.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.06,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $69.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,HUMANA,HUMANA CHOICE CARE HMO,12.38,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $12.38 from Fee Schedule 005543_170 for Rev 636 Proc J0702 * Qty 1 = $12.38 at 100% = $12.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,HUMANA,HUMANA CHOICE CARE PPO,69.06,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $69.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,HUMANA,HUMANA NATIIONAL POS HMO,12.38,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $12.38 from Fee Schedule 005543_170 for Rev 636 Proc J0702 * Qty 1 = $12.38 at 100% = $12.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.31,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $59.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,LIVE360,LIVE360 HSHS HEALTHY PLAN,81.25,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $81.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,40.63,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $40.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.25,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $68.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,60.94,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $60.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,74.75,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $74.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.37,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0702 * Qty 1 = $6.91 at 179% = $12.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.37,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0702 * Qty 1 = $6.91 at 179% = $12.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,PREVEA HEALTH NETWORK,PREVEA360,12.37,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0702 * Qty 1 = $6.91 at 179% = $12.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.37,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0702 * Qty 1 = $6.91 at 179% = $12.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,51.86,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $51.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,58.50,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.40,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $11.40 from Fee Schedule UHC_31190C for Rev 636 Proc J0702 * Qty 1 = $11.40 at 100% = $11.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,UNITED HEALTHCARE,UHC ONEIDA NATION,11.40,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $11.40 from Fee Schedule UHC_31190C for Rev 636 Proc J0702 * Qty 1 = $11.40 at 100% = $11.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,UNITED HEALTHCARE,UNITED HEALTHCARE,11.40,,,,,,,11.4000,81.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $11.40 from Fee Schedule UHC_31190C for Rev 636 Proc J0702 * Qty 1 = $11.40 at 100% = $11.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,58.50,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.38,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $50.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,58.50,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,58.50,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE ACET/SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP per 6 mg,J0702,HCPCS,636,RC,0517-0720-01,CDM,,,,both,6.000000,ME,81.2500,53.6300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,48.75,,,,,,,11.4000,81.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.25 in Billed Charges for Rev 636 Proc J0702 = $48.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,AETNA,AETNA HSHS,3.53,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,AETNA,ALL COMMERCIAL AETNA,5.47,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $5.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,ANTHEM,ANTHEM POS/HMO,0.61,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 170% = $0.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,ANTHEM,ANTHEM PPO,0.76,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 210% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.47,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $5.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,CENPATICO,ALL MEDICAID CENPATICO,5.47,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $5.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.65,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $4.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,CIGNA,ALL COMMERCIAL CIGNA,3.83,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,COFINITY,COFINITY,5.47,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $5.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.20,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $5.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,4.59,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $4.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.88,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.99,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,2.66,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $2.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.65,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $4.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,HUMANA,HUMANA CHOICE CARE HMO,1.05,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.05 from Fee Schedule 005543_170 for Rev 636 Proc J1939 * Qty 1 = $1.05 at 100% = $1.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,HUMANA,HUMANA CHOICE CARE PPO,4.65,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $4.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,HUMANA,HUMANA NATIIONAL POS HMO,1.05,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.05 from Fee Schedule 005543_170 for Rev 636 Proc J1939 * Qty 1 = $1.05 at 100% = $1.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.99,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.47,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $5.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.74,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $2.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.59,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $4.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.10,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.03,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $5.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.64,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.64,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,PREVEA HEALTH NETWORK,PREVEA360,0.64,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.64,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.49,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.94,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.59,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,0.59,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,0.59,,,,,,,0.5900,5.4700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.94,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.39,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.94,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.94,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-01,CDM,,,,both,0.500000,ME,5.4700,3.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.28,,,,,,,0.5900,5.4700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.47 in Billed Charges for Rev 636 Proc J1939 = $3.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,AETNA,AETNA HSHS,3.52,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,AETNA,ALL COMMERCIAL AETNA,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,ANTHEM,ANTHEM POS/HMO,0.61,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 170% = $0.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,ANTHEM,ANTHEM PPO,0.76,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 210% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,CENPATICO,ALL MEDICAID CENPATICO,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.63,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,CIGNA,ALL COMMERCIAL CIGNA,3.82,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,COFINITY,COFINITY,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.18,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,4.58,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.87,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.98,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,2.65,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $2.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.63,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,HUMANA,HUMANA CHOICE CARE HMO,1.05,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.05 from Fee Schedule 005543_170 for Rev 636 Proc J1939 * Qty 1 = $1.05 at 100% = $1.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,HUMANA,HUMANA CHOICE CARE PPO,4.63,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,HUMANA,HUMANA NATIIONAL POS HMO,1.05,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.05 from Fee Schedule 005543_170 for Rev 636 Proc J1939 * Qty 1 = $1.05 at 100% = $1.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.98,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.73,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $2.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.58,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.09,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $4.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.01,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $5.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.64,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.64,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,PREVEA HEALTH NETWORK,PREVEA360,0.64,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.64,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.48,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.92,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.92,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.38,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.92,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.92,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,0641-6007-10,CDM,,,,both,0.500000,ME,5.4500,3.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.27,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.45 in Billed Charges for Rev 636 Proc J1939 = $3.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,AETNA,AETNA HSHS,15.83,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,AETNA,ALL COMMERCIAL AETNA,24.50,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,ANTHEM,ANTHEM POS/HMO,0.61,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 170% = $0.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,ANTHEM,ANTHEM PPO,0.76,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 210% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.50,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,CENPATICO,ALL MEDICAID CENPATICO,24.50,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.83,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,CIGNA,ALL COMMERCIAL CIGNA,17.15,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,COFINITY,COFINITY,24.50,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.28,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $23.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,20.58,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.40,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.89,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,11.91,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $11.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.83,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE HMO,1.05,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.05 from Fee Schedule 005543_170 for Rev 636 Proc J1939 * Qty 1 = $1.05 at 100% = $1.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE PPO,20.83,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,HUMANA,HUMANA NATIIONAL POS HMO,1.05,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.05 from Fee Schedule 005543_170 for Rev 636 Proc J1939 * Qty 1 = $1.05 at 100% = $1.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.89,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.50,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.25,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.58,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.38,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $18.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.54,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $22.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.64,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.64,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360,0.64,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.64,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.64,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.64,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.59,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.59,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.59,,,,,,,0.5900,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.64,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.19,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $15.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.64,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.64,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUMETANIDE, 0.5 MG",J1939,HCPCS,636,RC,72205-101-01,CDM,,,,both,0.500000,ME,24.5000,16.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.70,,,,,,,0.5900,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.50 in Billed Charges for Rev 636 Proc J1939 = $14.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,AETNA,AETNA HSHS,22.49,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $22.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,AETNA,ALL COMMERCIAL AETNA,34.81,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $34.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,ANTHEM,ANTHEM POS/HMO,4.98,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 170% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,ANTHEM,ANTHEM PPO,6.15,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 210% = $6.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,34.81,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $34.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,CENPATICO,ALL MEDICAID CENPATICO,34.81,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $34.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,29.59,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $29.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,CIGNA,ALL COMMERCIAL CIGNA,24.37,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $24.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,COFINITY,COFINITY,34.81,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $34.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,33.07,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $33.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,29.24,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $29.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,24.72,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $24.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,25.41,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $25.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,16.92,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $16.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,29.59,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $29.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,HUMANA,HUMANA CHOICE CARE HMO,6.27,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $6.27 from Fee Schedule 005543_170 for Rev 636 Proc J9045 * Qty 1 = $6.27 at 100% = $6.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,HUMANA,HUMANA CHOICE CARE PPO,29.59,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $29.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,HUMANA,HUMANA NATIIONAL POS HMO,6.27,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $6.27 from Fee Schedule 005543_170 for Rev 636 Proc J9045 * Qty 1 = $6.27 at 100% = $6.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,25.41,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $25.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,34.81,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $34.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,17.41,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $17.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,29.24,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $29.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,26.11,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $26.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,32.03,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $32.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.24,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.24,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,PREVEA HEALTH NETWORK,PREVEA360,5.24,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.24,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,22.22,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $22.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,25.06,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $25.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.83,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,UNITED HEALTHCARE,UHC ONEIDA NATION,4.83,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,UNITED HEALTHCARE,UNITED HEALTHCARE,4.83,,,,,,,4.8300,34.8100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,25.06,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $25.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,21.58,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $21.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,25.06,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $25.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,25.06,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $25.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 600 MG/60ML SOLN 60 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-56,CDM,,,,both,50.000000,ME,34.8100,22.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,20.89,,,,,,,4.8300,34.8100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $34.81 in Billed Charges for Rev 636 Proc J9045 = $20.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,AETNA,AETNA HSHS,150.13,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $150.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,AETNA,AETNA MEDICARE,13.70,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,AETNA,ALL COMMERCIAL AETNA,232.40,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $232.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.70,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,ANTHEM,ANTHEM POS/HMO,158.03,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $232.40 in Billed Charges at 68% = $158.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,ANTHEM,ANTHEM PPO,158.03,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $232.40 in Billed Charges at 68% = $158.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,232.40,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $232.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,CENPATICO,ALL MEDICAID CENPATICO,232.40,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $232.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,197.54,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $197.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,CIGNA,ALL COMMERCIAL CIGNA,162.68,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $162.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,COFINITY,COFINITY,232.40,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $232.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,220.78,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $220.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,195.22,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $195.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,165.00,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $165.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,169.65,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $169.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,112.95,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $112.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,197.54,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $197.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HUMANA,HUMANA CHOICE CARE HMO,147.57,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $232.40 in Billed Charges at 63.5% = $147.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HUMANA,HUMANA CHOICE CARE PPO,197.54,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $197.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HUMANA,HUMANA MEDICARE ADVANTAGE,13.70,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,HUMANA,HUMANA NATIIONAL POS HMO,147.57,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $232.40 in Billed Charges at 63.5% = $147.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,169.65,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $169.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,232.40,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $232.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.70,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,MOLINA HEALTHCARE,MOLINA MEDICARE,13.70,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,116.20,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $116.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,195.22,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $195.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,NAPHCARE,ALL COMMERICAL NAPHCARE,30.83,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,174.30,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $174.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,213.81,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $213.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,139.44,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $232.40 in Billed Charges at 60% = $139.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,139.44,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $232.40 in Billed Charges at 60% = $139.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,PREVEA HEALTH NETWORK,PREVEA360,139.44,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $232.40 in Billed Charges at 60% = $139.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,139.44,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $232.40 in Billed Charges at 60% = $139.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,148.34,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $148.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.84,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,167.33,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $167.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,22.61,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0675 * Qty 1 = $22.61 at 100% = $22.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,UNITED HEALTHCARE,UHC ONEIDA NATION,22.61,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0675 * Qty 1 = $22.61 at 100% = $22.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.70,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,UNITED HEALTHCARE,UNITED HEALTHCARE,22.61,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $22.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0675 * Qty 1 = $22.61 at 100% = $22.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,UNITY HEALTH PLAN,UNITY HOSPICE,13.70,,,,,,,13.7000,232.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,167.33,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $167.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,144.09,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $144.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,167.33,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $167.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,167.33,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $167.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,0009-0856-05,CDM,,,,both,0.100000,ME,232.4000,153.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,139.44,,,,,,,13.7000,232.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $232.40 in Billed Charges for Rev 636 Proc J0675 = $139.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,AETNA,AETNA HSHS,108.54,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $108.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,AETNA,AETNA MEDICARE,55.61,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,AETNA,ALL COMMERCIAL AETNA,168.02,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $168.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,ANTHEM,ANTEHM MEDICAID,168.02,,,,,,,55.6100,178.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.02, claim capped at $168.02 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,55.61,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,ANTHEM,ANTHEM POS/HMO,94.54,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 170% = $94.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,ANTHEM,ANTHEM PPO,116.78,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 210% = $116.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,168.02,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $168.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,CENPATICO,ALL MEDICAID CENPATICO,168.02,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $168.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,142.82,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $142.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,CIGNA,ALL COMMERCIAL CIGNA,117.61,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $117.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,COFINITY,COFINITY,168.02,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $168.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,168.02,,,,,,,55.6100,178.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.02, claim capped at $168.02 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,168.02,,,,,,,55.6100,178.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.02, claim capped at $168.02 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,159.62,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $159.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HEALTH CARE ALLIANCE,THE ALLIANCE,141.14,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $141.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,119.29,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $119.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,122.65,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $122.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HSHS EMPLOYEES,HSHS EMPLOYEES,81.66,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $81.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,142.82,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $142.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HUMANA,HUMANA CHOICE CARE HMO,84.37,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.37 from Fee Schedule 005543_170 for Rev 636 Proc J9047 * Qty 1 = $84.37 at 100% = $84.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HUMANA,HUMANA CHOICE CARE PPO,142.82,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $142.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HUMANA,HUMANA MEDICARE ADVANTAGE,55.61,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,HUMANA,HUMANA NATIIONAL POS HMO,84.37,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $84.37 from Fee Schedule 005543_170 for Rev 636 Proc J9047 * Qty 1 = $84.37 at 100% = $84.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,122.65,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $122.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,LIVE360,LIVE360 HSHS HEALTHY PLAN,168.02,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $168.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,168.02,,,,,,,55.6100,178.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.02, claim capped at $168.02 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,55.61,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,168.02,,,,,,,55.6100,178.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.02, claim capped at $168.02 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,MOLINA HEALTHCARE,MOLINA MEDICAID,178.10,,,,,,,55.6100,178.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.02, claim capped at $168.02 in billed charges)... $168.02 at 106% = $178.10 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,MOLINA HEALTHCARE,MOLINA MEDICARE,55.61,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,84.01,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $84.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,141.14,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $141.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,NAPHCARE,ALL COMMERICAL NAPHCARE,125.12,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,126.02,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $126.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,154.58,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $154.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,99.54,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 179% = $99.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,99.54,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 179% = $99.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,PREVEA HEALTH NETWORK,PREVEA360,99.54,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 179% = $99.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,99.54,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 179% = $99.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,107.25,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $107.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,56.17,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,120.97,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $120.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,TRIOLOGY,TRILOGY MEDICAID,168.02,,,,,,,55.6100,178.1000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 106% = $612.69 (Service Line reduced to $168.02, claim capped at $168.02 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,91.76,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $91.76 from Fee Schedule UHC_31190C for Rev 636 Proc J9047 * Qty 1 = $91.76 at 100% = $91.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,UNITED HEALTHCARE,UHC ONEIDA NATION,91.76,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $91.76 from Fee Schedule UHC_31190C for Rev 636 Proc J9047 * Qty 1 = $91.76 at 100% = $91.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,55.61,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,UNITED HEALTHCARE,UNITED HEALTHCARE,91.76,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $91.76 from Fee Schedule UHC_31190C for Rev 636 Proc J9047 * Qty 1 = $91.76 at 100% = $91.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,UNITY HEALTH PLAN,UNITY HOSPICE,55.61,,,,,,,55.6100,178.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,120.97,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $120.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,104.17,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $104.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,120.97,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $120.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,120.97,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $120.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 30 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-102-01,CDM,,,,both,1.000000,ME,168.0200,110.8900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,100.81,,,,,,,55.6100,178.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $168.02 in Billed Charges for Rev 636 Proc J9047 = $100.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,AETNA,AETNA HSHS,1.14,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,AETNA,ALL COMMERCIAL AETNA,1.77,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,ANTHEM,ANTHEM POS/HMO,0.15,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 170% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,ANTHEM,ANTHEM PPO,0.19,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 210% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1.77,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,CENPATICO,ALL MEDICAID CENPATICO,1.77,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1.50,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,CIGNA,ALL COMMERCIAL CIGNA,1.24,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,COFINITY,COFINITY,1.77,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1.68,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,1.49,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1.26,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1.29,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,0.86,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $0.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1.50,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,HUMANA,HUMANA CHOICE CARE HMO,0.15,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule 005543_170 for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,HUMANA,HUMANA CHOICE CARE PPO,1.50,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,HUMANA,HUMANA NATIIONAL POS HMO,0.15,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule 005543_170 for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1.29,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1.77,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.89,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $0.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1.49,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1.33,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1.63,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.16,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 179% = $0.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.16,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 179% = $0.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,PREVEA HEALTH NETWORK,PREVEA360,0.16,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 179% = $0.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.16,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 179% = $0.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.13,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1.27,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.15,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.15,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.15,,,,,,,0.1500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1.27,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.10,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1.27,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1.27,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-620-01,CDM,,,,both,10.000000,ME,1.7700,1.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1.06,,,,,,,0.1500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $1.77 in Billed Charges for Rev 636 Proc J0613 = $1.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,AETNA,AETNA HSHS,0.26,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,AETNA,ALL COMMERCIAL AETNA,0.40,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.40,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,CENPATICO,ALL MEDICAID CENPATICO,0.40,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.34,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,CIGNA,ALL COMMERCIAL CIGNA,0.28,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,COFINITY,COFINITY,0.40,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.38,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,0.34,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.28,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.29,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,0.19,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.34,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,HUMANA,HUMANA CHOICE CARE HMO,0.07,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,HUMANA,HUMANA CHOICE CARE PPO,0.34,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,HUMANA,HUMANA NATIIONAL POS HMO,0.07,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.29,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.40,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.20,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.34,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.30,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.37,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.26,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.29,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.29,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.25,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.29,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.29,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-03,CDM,,,,both,10.000000,ME,0.4000,0.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.24,,,,,,,0.0500,0.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.40 in Billed Charges for Rev 636 Proc J0612 = $0.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,AETNA,AETNA HSHS,1.04,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,AETNA,ALL COMMERCIAL AETNA,1.61,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1.61,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,CENPATICO,ALL MEDICAID CENPATICO,1.61,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1.37,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,CIGNA,ALL COMMERCIAL CIGNA,1.13,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,COFINITY,COFINITY,1.61,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1.53,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,1.35,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1.14,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1.18,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,0.78,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $0.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1.37,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,HUMANA,HUMANA CHOICE CARE HMO,0.07,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,HUMANA,HUMANA CHOICE CARE PPO,1.37,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,HUMANA,HUMANA NATIIONAL POS HMO,0.07,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1.18,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1.61,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.81,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $0.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1.35,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1.21,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1.48,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.03,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1.16,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1.16,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.00,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1.16,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1.16,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $1.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2363-1,CDM,,,,both,10.000000,ME,1.6100,1.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.97,,,,,,,0.0500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $1.61 in Billed Charges for Rev 636 Proc J0612 = $0.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,AETNA,AETNA HSHS,7.91,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,AETNA,ALL COMMERCIAL AETNA,12.25,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM POS/HMO,1.41,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 170% = $1.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM PPO,1.74,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 210% = $1.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.25,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,CENPATICO,ALL MEDICAID CENPATICO,12.25,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.41,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,CIGNA,ALL COMMERCIAL CIGNA,8.58,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,COFINITY,COFINITY,12.25,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.64,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $11.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,10.29,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.70,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.94,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.95,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.41,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE HMO,1.39,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule 005543_170 for Rev 636 Proc J0690 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE PPO,10.41,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,HUMANA,HUMANA NATIIONAL POS HMO,1.39,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule 005543_170 for Rev 636 Proc J0690 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.94,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.25,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.13,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.29,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.19,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $9.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.27,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.49,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 179% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.49,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 179% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360,1.49,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 179% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.49,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 179% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.82,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.82,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.37,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0690 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,1.37,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0690 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,1.37,,,,,,,1.3700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0690 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.82,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.60,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.82,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.82,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN SODIUM INJECTION,J0690,HCPCS,636,RC,60505-6231-5,CDM,,,,both,500.000000,ME,12.2500,8.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.35,,,,,,,1.3700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 636 Proc J0690 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,AETNA,AETNA HSHS,15.83,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,AETNA,ALL COMMERCIAL AETNA,24.50,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM POS/HMO,1.41,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 170% = $1.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM PPO,1.74,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 210% = $1.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.50,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,CENPATICO,ALL MEDICAID CENPATICO,24.50,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.83,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,CIGNA,ALL COMMERCIAL CIGNA,17.15,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,COFINITY,COFINITY,24.50,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.28,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $23.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,20.58,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.40,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.89,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,11.91,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $11.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.83,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE HMO,1.39,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule 005543_170 for Rev 636 Proc J0690 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE PPO,20.83,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA NATIIONAL POS HMO,1.39,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule 005543_170 for Rev 636 Proc J0690 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.89,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.50,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.25,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.58,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.38,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $18.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.54,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $22.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.49,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 179% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.49,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 179% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360,1.49,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 179% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.49,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.83 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0690 * Qty 1 = $0.83 at 179% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.64,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.64,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.37,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0690 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,1.37,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0690 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,1.37,,,,,,,1.3700,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0690 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.64,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.19,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $15.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.64,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.64,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 2 GM/20 ML SOSY per 500 mg,J0690,HCPCS,636,RC,44567-707-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.70,,,,,,,1.3700,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.50 in Billed Charges for Rev 636 Proc J0690 = $14.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,AETNA,AETNA HSHS,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,AETNA,ALL COMMERCIAL AETNA,0.11,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,ANTHEM,ANTHEM POS/HMO,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.11 in Billed Charges at 68% = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,ANTHEM,ANTHEM PPO,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.11 in Billed Charges at 68% = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.11,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,CENPATICO,ALL MEDICAID CENPATICO,0.11,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.09,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,CIGNA,ALL COMMERCIAL CIGNA,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,COFINITY,COFINITY,0.11,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.10,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,0.09,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,0.05,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.09,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,HUMANA,HUMANA CHOICE CARE HMO,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.11 in Billed Charges at 63.5% = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,HUMANA,HUMANA CHOICE CARE PPO,0.09,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,HUMANA,HUMANA NATIIONAL POS HMO,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.11 in Billed Charges at 63.5% = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.11,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.06,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.09,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.10,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.11 in Billed Charges at 60% = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.11 in Billed Charges at 60% = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,PREVEA HEALTH NETWORK,PREVEA360,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.11 in Billed Charges at 60% = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.11 in Billed Charges at 60% = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0618 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,0.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0618 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0618 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.08,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN 10 ML SYRINGE per 2 mg,J0618,HCPCS,636,RC,64253-900-30,CDM,,,,both,2.000000,ME,0.1100,0.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.07,,,,,,,0.0500,0.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.11 in Billed Charges for Rev 636 Proc J0618 = $0.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,AETNA,AETNA HSHS,11.98,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $11.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,AETNA,ALL COMMERCIAL AETNA,18.55,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $18.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,ANTHEM,ANTHEM POS/HMO,1.48,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 170% = $1.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,ANTHEM,ANTHEM PPO,1.83,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 210% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,18.55,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $18.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,CENPATICO,ALL MEDICAID CENPATICO,18.55,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $18.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15.77,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $15.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,CIGNA,ALL COMMERCIAL CIGNA,12.99,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $12.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,COFINITY,COFINITY,18.55,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $18.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17.62,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $17.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,15.58,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $15.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.17,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $13.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13.54,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $13.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,9.02,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $9.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15.77,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $15.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,HUMANA,HUMANA CHOICE CARE HMO,2.18,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.18 from Fee Schedule 005543_170 for Rev 636 Proc J0692 * Qty 1 = $2.18 at 100% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,HUMANA,HUMANA CHOICE CARE PPO,15.77,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $15.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,HUMANA,HUMANA NATIIONAL POS HMO,2.18,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.18 from Fee Schedule 005543_170 for Rev 636 Proc J0692 * Qty 1 = $2.18 at 100% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13.54,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $13.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,18.55,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $18.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.28,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $9.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15.58,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $15.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13.91,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,17.07,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $17.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.56,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.56,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,PREVEA HEALTH NETWORK,PREVEA360,1.56,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.56,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.84,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $11.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.36,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $13.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.44,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,1.44,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,1.44,,,,,,,1.4400,18.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.36,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $13.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.50,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $11.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.36,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $13.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.36,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $13.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,0409-9735-01,CDM,,,,both,500.000000,ME,18.5500,12.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.13,,,,,,,1.4400,18.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.55 in Billed Charges for Rev 636 Proc J0692 = $11.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,AETNA,AETNA HSHS,55.75,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $55.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,AETNA,ALL COMMERCIAL AETNA,86.30,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $86.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,ANTHEM,ANTHEM POS/HMO,10.15,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.97 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0701 * Qty 1 = $5.97 at 170% = $10.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,ANTHEM,ANTHEM PPO,12.54,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.97 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0701 * Qty 1 = $5.97 at 210% = $12.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,86.30,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $86.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,CENPATICO,ALL MEDICAID CENPATICO,86.30,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $86.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,73.36,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $73.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,CIGNA,ALL COMMERCIAL CIGNA,60.41,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $60.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,COFINITY,COFINITY,86.30,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $86.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,81.99,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $81.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,72.49,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $72.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,61.27,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $61.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,63.00,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,41.94,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $41.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,73.36,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $73.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,HUMANA,HUMANA CHOICE CARE HMO,9.67,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.67 from Fee Schedule 005543_170 for Rev 636 Proc J0701 * Qty 1 = $9.67 at 100% = $9.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,HUMANA,HUMANA CHOICE CARE PPO,73.36,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $73.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,HUMANA,HUMANA NATIIONAL POS HMO,9.67,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.67 from Fee Schedule 005543_170 for Rev 636 Proc J0701 * Qty 1 = $9.67 at 100% = $9.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,63.00,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $63.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,86.30,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $86.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,43.15,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $43.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,72.49,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $72.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,64.73,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $64.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,79.40,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $79.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.69,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.97 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0701 * Qty 1 = $5.97 at 179% = $10.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.69,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.97 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0701 * Qty 1 = $5.97 at 179% = $10.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,PREVEA HEALTH NETWORK,PREVEA360,10.69,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.97 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0701 * Qty 1 = $5.97 at 179% = $10.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.69,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.97 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0701 * Qty 1 = $5.97 at 179% = $10.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,55.09,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $55.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,62.14,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $62.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.85,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.85 from Fee Schedule UHC_31190C for Rev 636 Proc J0701 * Qty 1 = $9.85 at 100% = $9.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,9.85,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.85 from Fee Schedule UHC_31190C for Rev 636 Proc J0701 * Qty 1 = $9.85 at 100% = $9.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,9.85,,,,,,,9.6700,86.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.85 from Fee Schedule UHC_31190C for Rev 636 Proc J0701 * Qty 1 = $9.85 at 100% = $9.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,62.14,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $62.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,53.51,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $53.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,62.14,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $62.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,62.14,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $62.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 GM/100ML SOLN per 500 mg,J0701,HCPCS,636,RC,0338-1301-48,CDM,,,,both,500.000000,ME,86.3000,56.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,51.78,,,,,,,9.6700,86.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $86.30 in Billed Charges for Rev 636 Proc J0701 = $51.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,AETNA,AETNA HSHS,6.14,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,AETNA,AETNA MEDICARE,2.42,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,AETNA,ALL COMMERCIAL AETNA,9.50,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $9.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,ANTHEM,ANTEHM MEDICAID,9.50,,,,,,,2.4200,10.0700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0699 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $9.50, claim capped at $9.50 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.42,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,ANTHEM,ANTHEM POS/HMO,4.11,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0699 * Qty 1 = $2.42 at 170% = $4.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,ANTHEM,ANTHEM PPO,5.08,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0699 * Qty 1 = $2.42 at 210% = $5.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.50,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $9.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,CENPATICO,ALL MEDICAID CENPATICO,9.50,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $9.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8.08,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $8.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,CIGNA,ALL COMMERCIAL CIGNA,6.65,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,COFINITY,COFINITY,9.50,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $9.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,9.50,,,,,,,2.4200,10.0700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0699 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $9.50, claim capped at $9.50 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,9.50,,,,,,,2.4200,10.0700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0699 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $9.50, claim capped at $9.50 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9.03,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $9.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,7.98,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $7.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.75,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.94,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,4.62,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $4.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8.08,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $8.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HUMANA,HUMANA CHOICE CARE HMO,3.86,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $3.86 from Fee Schedule 005543_170 for Rev 636 Proc J0699 * Qty 1 = $3.86 at 100% = $3.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HUMANA,HUMANA CHOICE CARE PPO,8.08,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $8.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HUMANA,HUMANA MEDICARE ADVANTAGE,2.42,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,HUMANA,HUMANA NATIIONAL POS HMO,3.86,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $3.86 from Fee Schedule 005543_170 for Rev 636 Proc J0699 * Qty 1 = $3.86 at 100% = $3.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.94,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.50,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $9.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,9.50,,,,,,,2.4200,10.0700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0699 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $9.50, claim capped at $9.50 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.42,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,9.50,,,,,,,2.4200,10.0700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0699 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $9.50, claim capped at $9.50 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,MOLINA HEALTHCARE,MOLINA MEDICAID,10.07,,,,,,,2.4200,10.0700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0699 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $9.50, claim capped at $9.50 in billed charges)... $9.50 at 106% = $10.07 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,MOLINA HEALTHCARE,MOLINA MEDICARE,2.42,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.75,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $4.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.98,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $7.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,NAPHCARE,ALL COMMERICAL NAPHCARE,5.44,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.13,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $7.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.74,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.33,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0699 * Qty 1 = $2.42 at 179% = $4.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.33,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0699 * Qty 1 = $2.42 at 179% = $4.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,PREVEA HEALTH NETWORK,PREVEA360,4.33,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0699 * Qty 1 = $2.42 at 179% = $4.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.33,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0699 * Qty 1 = $2.42 at 179% = $4.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.06,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.44,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.84,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,TRIOLOGY,TRILOGY MEDICAID,9.50,,,,,,,2.4200,10.0700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0699 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 106% = $56.29 (Service Line reduced to $9.50, claim capped at $9.50 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.99,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $3.99 from Fee Schedule UHC_31190C for Rev 636 Proc J0699 * Qty 1 = $3.99 at 100% = $3.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,UNITED HEALTHCARE,UHC ONEIDA NATION,3.99,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $3.99 from Fee Schedule UHC_31190C for Rev 636 Proc J0699 * Qty 1 = $3.99 at 100% = $3.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.42,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,UNITED HEALTHCARE,UNITED HEALTHCARE,3.99,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $3.99 from Fee Schedule UHC_31190C for Rev 636 Proc J0699 * Qty 1 = $3.99 at 100% = $3.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,UNITY HEALTH PLAN,UNITY HOSPICE,2.42,,,,,,,2.4200,10.0700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.84,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.89,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $5.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.84,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.84,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIDEROCOL 1 G SOLR 1 EACH VIAL per 10 mg,J0699,HCPCS,636,RC,59630-266-01,CDM,,,,both,10.000000,ME,9.5000,6.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.70,,,,,,,2.4200,10.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.50 in Billed Charges for Rev 636 Proc J0699 = $5.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,AETNA,AETNA HSHS,11.39,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $11.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,AETNA,ALL COMMERCIAL AETNA,17.63,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $17.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,ANTHEM,ANTHEM POS/HMO,2.50,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 170% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,ANTHEM,ANTHEM PPO,3.09,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 210% = $3.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17.63,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $17.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,CENPATICO,ALL MEDICAID CENPATICO,17.63,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $17.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.99,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $14.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,CIGNA,ALL COMMERCIAL CIGNA,12.34,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $12.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,COFINITY,COFINITY,17.63,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $17.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16.75,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,14.81,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $14.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12.52,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $12.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.87,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $12.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,8.57,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $8.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.99,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $14.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,HUMANA,HUMANA CHOICE CARE HMO,2.75,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $2.75 from Fee Schedule 005543_170 for Rev 636 Proc J0713 * Qty 1 = $2.75 at 100% = $2.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,HUMANA,HUMANA CHOICE CARE PPO,14.99,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $14.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,HUMANA,HUMANA NATIIONAL POS HMO,2.75,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $2.75 from Fee Schedule 005543_170 for Rev 636 Proc J0713 * Qty 1 = $2.75 at 100% = $2.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.87,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $12.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,17.63,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $17.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.82,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.81,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $14.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13.22,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $13.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,16.22,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $16.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.63,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.63,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,PREVEA HEALTH NETWORK,PREVEA360,2.63,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.63,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.25,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $11.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.69,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $12.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.43,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,2.43,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,2.43,,,,,,,2.4300,17.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.69,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $12.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.93,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $10.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.69,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $12.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.69,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $12.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ CEFTAZIDIME PER 500 MG,J0713,HCPCS,636,RC,0409-5084-11,CDM,,,,both,500.000000,ME,17.6300,11.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.58,,,,,,,2.4300,17.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.63 in Billed Charges for Rev 636 Proc J0713 = $10.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,AETNA,AETNA HSHS,13.11,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $13.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,AETNA,ALL COMMERCIAL AETNA,20.30,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $20.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,ANTHEM,ANTHEM POS/HMO,2.50,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 170% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,ANTHEM,ANTHEM PPO,3.09,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 210% = $3.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.30,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $20.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,CENPATICO,ALL MEDICAID CENPATICO,20.30,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $20.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.26,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $17.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,CIGNA,ALL COMMERCIAL CIGNA,14.21,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $14.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,COFINITY,COFINITY,20.30,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $20.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.29,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $19.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,17.05,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $17.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.41,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $14.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.82,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $14.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,9.87,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $9.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.26,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $17.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,HUMANA,HUMANA CHOICE CARE HMO,2.75,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.75 from Fee Schedule 005543_170 for Rev 636 Proc J0713 * Qty 1 = $2.75 at 100% = $2.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,HUMANA,HUMANA CHOICE CARE PPO,17.26,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $17.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,HUMANA,HUMANA NATIIONAL POS HMO,2.75,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.75 from Fee Schedule 005543_170 for Rev 636 Proc J0713 * Qty 1 = $2.75 at 100% = $2.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.82,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $14.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.30,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $20.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.15,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $10.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.05,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $17.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.23,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $15.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.68,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $18.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.63,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.63,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,PREVEA HEALTH NETWORK,PREVEA360,2.63,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.63,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.96,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $12.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.62,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $14.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.43,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,2.43,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,2.43,,,,,,,2.4300,20.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.62,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $14.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.59,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $12.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.62,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $14.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.62,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $14.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2 G SOLR 1 EACH VIAL per 500 mg,J0713,HCPCS,636,RC,25021-128-50,CDM,,,,both,500.000000,ME,20.3000,13.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.18,,,,,,,2.4300,20.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.30 in Billed Charges for Rev 636 Proc J0713 = $12.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,AETNA,AETNA HSHS,15.83,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,AETNA,ALL COMMERCIAL AETNA,24.50,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM POS/HMO,2.50,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 170% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM PPO,3.09,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 210% = $3.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.50,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,CENPATICO,ALL MEDICAID CENPATICO,24.50,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.83,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,CIGNA,ALL COMMERCIAL CIGNA,17.15,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,COFINITY,COFINITY,24.50,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.28,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $23.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,20.58,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.40,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.89,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,11.91,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $11.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.83,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE HMO,2.75,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.75 from Fee Schedule 005543_170 for Rev 636 Proc J0713 * Qty 1 = $2.75 at 100% = $2.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE PPO,20.83,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA NATIIONAL POS HMO,2.75,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.75 from Fee Schedule 005543_170 for Rev 636 Proc J0713 * Qty 1 = $2.75 at 100% = $2.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.89,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.50,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.25,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.58,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.38,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $18.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.54,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $22.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.63,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.63,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360,2.63,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.63,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.47 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0713 * Qty 1 = $1.47 at 179% = $2.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.64,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.64,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.43,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,2.43,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,2.43,,,,,,,2.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0713 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.64,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.19,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $15.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.64,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.64,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME 2.25 MG/0.1 ML SOLN per 500 mg,J0713,HCPCS,636,RC,44567-235-25,CDM,,,,both,500.000000,ME,24.5000,16.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.70,,,,,,,2.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.50 in Billed Charges for Rev 636 Proc J0713 = $14.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,AETNA,AETNA HSHS,28.05,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,AETNA,AETNA MEDICARE,8.95,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,AETNA,ALL COMMERCIAL AETNA,43.42,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $43.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,ANTHEM,ANTEHM MEDICAID,43.42,,,,,,,8.9500,46.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0695 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $43.42, claim capped at $43.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,8.95,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,ANTHEM,ANTHEM POS/HMO,15.22,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $8.95 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0695 * Qty 1 = $8.95 at 170% = $15.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,ANTHEM,ANTHEM PPO,18.80,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $8.95 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0695 * Qty 1 = $8.95 at 210% = $18.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,43.42,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $43.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,CENPATICO,ALL MEDICAID CENPATICO,43.42,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $43.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,36.91,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $36.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,CIGNA,ALL COMMERCIAL CIGNA,30.39,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $30.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,COFINITY,COFINITY,43.42,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $43.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,43.42,,,,,,,8.9500,46.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0695 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $43.42, claim capped at $43.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,43.42,,,,,,,8.9500,46.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0695 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $43.42, claim capped at $43.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,41.25,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $41.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,36.47,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $36.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,30.83,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $30.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,31.70,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $31.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,21.10,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $21.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,36.91,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $36.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HUMANA,HUMANA CHOICE CARE HMO,14.01,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $14.01 from Fee Schedule 005543_170 for Rev 636 Proc J0695 * Qty 1 = $14.01 at 100% = $14.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HUMANA,HUMANA CHOICE CARE PPO,36.91,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $36.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,8.95,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,HUMANA,HUMANA NATIIONAL POS HMO,14.01,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $14.01 from Fee Schedule 005543_170 for Rev 636 Proc J0695 * Qty 1 = $14.01 at 100% = $14.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,31.70,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $31.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,43.42,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $43.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,43.42,,,,,,,8.9500,46.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0695 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $43.42, claim capped at $43.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.95,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,43.42,,,,,,,8.9500,46.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0695 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $43.42, claim capped at $43.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,46.03,,,,,,,8.9500,46.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0695 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $43.42, claim capped at $43.42 in billed charges)... $43.42 at 106% = $46.03 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,8.95,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,21.71,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $21.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,36.47,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $36.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,20.13,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,32.57,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $32.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,39.95,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $39.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.02,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $8.95 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0695 * Qty 1 = $8.95 at 179% = $16.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.02,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $8.95 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0695 * Qty 1 = $8.95 at 179% = $16.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,PREVEA HEALTH NETWORK,PREVEA360,16.02,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $8.95 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0695 * Qty 1 = $8.95 at 179% = $16.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.02,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $8.95 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0695 * Qty 1 = $8.95 at 179% = $16.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,27.72,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $27.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,9.04,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,31.26,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $31.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,TRIOLOGY,TRILOGY MEDICAID,43.42,,,,,,,8.9500,46.0300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0695 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 106% = $56.29 (Service Line reduced to $43.42, claim capped at $43.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.77,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $14.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0695 * Qty 1 = $14.77 at 100% = $14.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,14.77,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $14.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0695 * Qty 1 = $14.77 at 100% = $14.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,8.95,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,14.77,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $14.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0695 * Qty 1 = $14.77 at 100% = $14.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,UNITY HEALTH PLAN,UNITY HOSPICE,8.95,,,,,,,8.9500,46.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,31.26,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $31.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,26.92,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $26.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,31.26,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $31.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,31.26,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $31.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL per 75 mg,J0695,HCPCS,636,RC,67919-030-01,CDM,,,,both,75.000000,ME,43.4200,28.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,26.05,,,,,,,8.9500,46.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $43.42 in Billed Charges for Rev 636 Proc J0695 = $26.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,AETNA,AETNA HSHS,7.91,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,AETNA,ALL COMMERCIAL AETNA,12.25,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM POS/HMO,0.78,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 170% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM PPO,0.97,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 210% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.25,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,CENPATICO,ALL MEDICAID CENPATICO,12.25,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.41,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,CIGNA,ALL COMMERCIAL CIGNA,8.58,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,COFINITY,COFINITY,12.25,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.64,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $11.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,10.29,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.70,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.94,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.95,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.41,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE HMO,0.78,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE PPO,10.41,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,HUMANA,HUMANA NATIIONAL POS HMO,0.78,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.94,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.25,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.13,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.29,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.19,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $9.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.27,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.82,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.82,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360,0.82,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.82,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.82,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.82,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.76,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.76,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.76,,,,,,,0.7600,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.82,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.60,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.82,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.82,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,44567-701-25,CDM,,,,both,250.000000,ME,12.2500,8.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.35,,,,,,,0.7600,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 636 Proc J0696 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,AETNA,AETNA HSHS,45.34,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $45.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,AETNA,ALL COMMERCIAL AETNA,70.19,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $70.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,ANTHEM,ANTHEM POS/HMO,0.78,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 170% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,ANTHEM,ANTHEM PPO,0.97,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 210% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,70.19,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $70.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,CENPATICO,ALL MEDICAID CENPATICO,70.19,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $70.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,59.66,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $59.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,CIGNA,ALL COMMERCIAL CIGNA,49.13,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $49.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,COFINITY,COFINITY,70.19,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $70.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,66.68,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $66.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,58.96,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $58.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,49.83,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $49.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,51.24,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $51.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,34.11,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $34.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,59.66,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $59.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,HUMANA,HUMANA CHOICE CARE HMO,0.78,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,HUMANA,HUMANA CHOICE CARE PPO,59.66,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $59.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,HUMANA,HUMANA NATIIONAL POS HMO,0.78,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,51.24,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $51.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,70.19,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $70.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35.10,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $35.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,58.96,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $58.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,52.64,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $52.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,64.57,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $64.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.82,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.82,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,PREVEA HEALTH NETWORK,PREVEA360,0.82,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.82,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44.80,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $44.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,50.54,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.76,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.76,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.76,,,,,,,0.7600,70.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,50.54,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,43.52,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $43.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,50.54,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,50.54,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-4,CDM,,,,both,250.000000,ME,70.1900,46.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42.11,,,,,,,0.7600,70.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.19 in Billed Charges for Rev 636 Proc J0696 = $42.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,AETNA,AETNA HSHS,55.61,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $55.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,AETNA,ALL COMMERCIAL AETNA,86.08,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $86.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,ANTHEM,ANTHEM POS/HMO,0.78,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 170% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,ANTHEM,ANTHEM PPO,0.97,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 210% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,86.08,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $86.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,CENPATICO,ALL MEDICAID CENPATICO,86.08,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $86.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,73.17,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $73.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,CIGNA,ALL COMMERCIAL CIGNA,60.26,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $60.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,COFINITY,COFINITY,86.08,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $86.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,81.78,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $81.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,72.31,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $72.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,61.12,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $61.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,62.84,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $62.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,41.83,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $41.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,73.17,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $73.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,HUMANA,HUMANA CHOICE CARE HMO,0.78,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,HUMANA,HUMANA CHOICE CARE PPO,73.17,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $73.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,HUMANA,HUMANA NATIIONAL POS HMO,0.78,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,62.84,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $62.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,86.08,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $86.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,43.04,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $43.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,72.31,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $72.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,64.56,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $64.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,79.19,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $79.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.82,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.82,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,PREVEA HEALTH NETWORK,PREVEA360,0.82,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.82,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,54.94,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $54.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,61.98,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $61.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.76,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,UNITED HEALTHCARE,UHC ONEIDA NATION,0.76,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,UNITED HEALTHCARE,UNITED HEALTHCARE,0.76,,,,,,,0.7600,86.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,61.98,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $61.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,53.37,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $53.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,61.98,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $61.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,61.98,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $61.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 500 MG SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6152-4,CDM,,,,both,250.000000,ME,86.0800,56.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,51.65,,,,,,,0.7600,86.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $86.08 in Billed Charges for Rev 636 Proc J0696 = $51.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,AETNA,AETNA HSHS,864.99,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $864.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,AETNA,AETNA MEDICARE,428.53,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,AETNA,ALL COMMERCIAL AETNA,1339.00,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,339.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,ANTHEM,ANTEHM MEDICAID,185.11,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 36430 at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,428.53,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,ANTHEM,ANTHEM POS/HMO,910.52,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $910.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,ANTHEM,ANTHEM PPO,910.52,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $910.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1339.00,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,339.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,CENPATICO,ALL MEDICAID CENPATICO,1339.00,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,339.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1138.15,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,138.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,CIGNA,ALL COMMERCIAL CIGNA,937.30,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $937.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,COFINITY,COFINITY,1339.00,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,339.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,185.11,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 36430 at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,185.11,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 36430 at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1272.05,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,272.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,1124.76,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,124.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,950.69,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $950.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,977.47,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $977.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,650.75,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $650.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1138.15,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,138.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HUMANA,HUMANA CHOICE CARE HMO,850.27,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $850.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HUMANA,HUMANA CHOICE CARE PPO,1138.15,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,138.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,428.53,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,HUMANA,HUMANA NATIIONAL POS HMO,850.27,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.5% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $850.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,977.47,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $977.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1339.00,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,339.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,185.11,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 36430 at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,428.53,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,185.11,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 36430 at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,196.22,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 36430 at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 100% = $185.11... $185.11 at 106% = $196.22 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,428.53,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,669.50,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $669.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1124.76,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,124.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,964.19,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1004.25,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,004.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1231.88,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $1,231.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,803.40,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $803.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,803.40,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $803.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,PREVEA HEALTH NETWORK,PREVEA360,803.40,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $803.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,803.40,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $803.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,854.68,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $854.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,432.82,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,964.08,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $964.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,TRIOLOGY,TRILOGY MEDICAID,196.22,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00113 Proc 36430 at $125.60 (Base Rate) * 1.4738 (Relative Weight) = $185.11 (Total Line Payment) at 106% = $196.22. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,505.20,,,,,,,185.1100,1339.0000,other,ST VINCENT HOSPITAL (ACU). Rev 391 Proc 36430 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,505.20,,,,,,,185.1100,1339.0000,other,ST VINCENT HOSPITAL (ACU). Rev 391 Proc 36430 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,428.53,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,505.20,,,,,,,185.1100,1339.0000,other,ST VINCENT HOSPITAL (ACU). Rev 391 Proc 36430 1 Visit at $505.20 per Visit = $505.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,UNITY HEALTH PLAN,UNITY HOSPICE,428.53,,,,,,,185.1100,1339.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,964.08,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $964.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,830.18,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $830.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,964.08,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $964.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,964.08,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $964.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,39100001,CDM,,,,both,,,1339.0000,883.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,803.40,,,,,,,185.1100,1339.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,339.00 in Billed Charges for Rev 391 Proc 36430 = $803.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,AETNA,AETNA HSHS,361.76,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $361.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,AETNA,AETNA MEDICARE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,AETNA,ALL COMMERCIAL AETNA,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,ANTHEM,ANTEHM MEDICAID,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,ANTHEM,ANTHEM POS/HMO,350.00,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 Mod GG 1 Visit at $350.00 per Visit = $350.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,ANTHEM,ANTHEM PPO,350.00,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 Mod GG 1 Visit at $350.00 per Visit = $350.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,CENPATICO,ALL MEDICAID CENPATICO,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,476.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,CIGNA,ALL COMMERCIAL CIGNA,392.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,COFINITY,COFINITY,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,532.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $532.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,470.40,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $470.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,397.60,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $397.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,408.80,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $408.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,272.16,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $272.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,476.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HUMANA,HUMANA CHOICE CARE HMO,218.57,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.57 from Fee Schedule 005543_205 for Rev 401 Proc 77066 Mod TC (GG) * Qty 1 = $218.57 at 100% = $218.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HUMANA,HUMANA CHOICE CARE PPO,476.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $476.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,HUMANA,HUMANA NATIIONAL POS HMO,218.57,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.57 from Fee Schedule 005543_205 for Rev 401 Proc 77066 Mod TC (GG) * Qty 1 = $218.57 at 100% = $218.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,408.80,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $408.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,560.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $560.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,21.87,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,23.18,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87... $21.87 at 106% = $23.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,280.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $280.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,470.40,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $470.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,237.33,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,420.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $420.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,515.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $515.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA360,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,357.45,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $357.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,106.53,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,403.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,TRIOLOGY,TRILOGY MEDICAID,23.18,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77066 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 106% = $23.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,193.80,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 Mod GG 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,193.80,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 Mod GG 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,193.80,,,,,,,21.8700,560.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77066 Mod GG 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,UNITY HEALTH PLAN,UNITY HOSPICE,105.48,,,,,,,21.8700,560.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,403.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,347.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $347.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,403.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,403.20,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $403.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MAMMOGRAM DIAG W/CAD UPGRADE BIL,77066,CPT,401,RC,40100006,CDM,,,GG,both,,,560.0000,369.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,336.00,,,,,,,21.8700,560.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $560.00 in Billed Charges for Rev 401 Proc 77066 Mod GG = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,AETNA,AETNA HSHS,303.62,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $303.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,AETNA,AETNA MEDICARE,82.34,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,AETNA,ALL COMMERCIAL AETNA,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,ANTHEM,ANTEHM MEDICAID,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77065 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,82.34,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,ANTHEM,ANTHEM POS/HMO,350.00,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77065 1 Visit at $350.00 per Visit = $350.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,ANTHEM,ANTHEM PPO,350.00,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77065 1 Visit at $350.00 per Visit = $350.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,CENPATICO,ALL MEDICAID CENPATICO,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,399.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $399.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,CIGNA,ALL COMMERCIAL CIGNA,329.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $329.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,COFINITY,COFINITY,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77065 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77065 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,446.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $446.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,394.80,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $394.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,333.70,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $333.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,343.10,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $343.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,228.42,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $228.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,399.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $399.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HUMANA,HUMANA CHOICE CARE HMO,170.68,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $170.68 from Fee Schedule 005543_205 for Rev 401 Proc 77065 Mod TC * Qty 1 = $170.68 at 100% = $170.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HUMANA,HUMANA CHOICE CARE PPO,399.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $399.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,82.34,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,HUMANA,HUMANA NATIIONAL POS HMO,170.68,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $170.68 from Fee Schedule 005543_205 for Rev 401 Proc 77065 Mod TC * Qty 1 = $170.68 at 100% = $170.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,343.10,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $343.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,470.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $470.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77065 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,82.34,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,21.87,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77065 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,23.18,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77065 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 100% = $21.87... $21.87 at 106% = $23.18 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,82.34,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,235.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,394.80,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $394.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,185.27,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,352.50,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $352.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,432.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $432.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,PREVEA HEALTH NETWORK,PREVEA360,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,300.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,83.16,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,338.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,TRIOLOGY,TRILOGY MEDICAID,23.18,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00286 Proc 77065 at $125.60 (Base Rate) * 0.1741 (Relative Weight) = $21.87 (Total Line Payment) at 106% = $23.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,193.80,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77065 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,193.80,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77065 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,82.34,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,193.80,,,,,,,21.8700,470.0000,other,ST VINCENT HOSPITAL (ACU). Rev 401 Proc 77065 1 Visit at $193.80 per Visit = $193.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,UNITY HEALTH PLAN,UNITY HOSPICE,82.34,,,,,,,21.8700,470.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,338.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,291.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $291.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,338.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,338.40,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $338.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DX MAMMO INCL CAD UNI,77065,CPT,401,RC,40100007,CDM,,,,both,,,470.0000,310.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,282.00,,,,,,,21.8700,470.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $470.00 in Billed Charges for Rev 401 Proc 77065 = $282.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,AETNA,AETNA HSHS,3483.23,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,483.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,AETNA,AETNA MEDICARE,1604.25,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,AETNA,ALL COMMERCIAL AETNA,5392.00,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $5,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,ANTHEM,ANTEHM MEDICAID,820.29,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 21925 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1604.25,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,ANTHEM,ANTHEM PPO,500.00,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5392.00,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $5,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,CENPATICO,ALL MEDICAID CENPATICO,5392.00,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $5,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4583.20,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $4,583.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,CIGNA,ALL COMMERCIAL CIGNA,3774.40,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,774.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,COFINITY,COFINITY,5392.00,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $5,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,820.29,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 21925 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,820.29,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 21925 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5122.40,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $5,122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,4529.28,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $4,529.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3828.32,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,828.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3936.16,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,936.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,2620.51,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $2,620.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4583.20,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $4,583.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HUMANA,HUMANA CHOICE CARE HMO,721.70,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $721.70 from Fee Schedule 005543_205 for Rev 402 Proc 21925 Mod TC * Qty 1 = $721.70 at 100% = $721.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HUMANA,HUMANA CHOICE CARE PPO,4583.20,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $4,583.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,1604.25,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,HUMANA,HUMANA NATIIONAL POS HMO,721.70,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $721.70 from Fee Schedule 005543_205 for Rev 402 Proc 21925 Mod TC * Qty 1 = $721.70 at 100% = $721.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3936.16,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,936.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,5392.00,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $5,392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,820.29,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 21925 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1604.25,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,820.29,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 21925 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,869.51,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 21925 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 100% = $820.29... $820.29 at 106% = $869.51 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,1604.25,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2696.00,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $2,696.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4529.28,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $4,529.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,3609.56,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4044.00,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $4,044.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4960.64,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $4,960.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3441.71,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,441.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1620.29,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3882.24,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,882.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,TRIOLOGY,TRILOGY MEDICAID,869.51,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00051 Proc 21925 at $125.60 (Base Rate) * 6.531 (Relative Weight) = $820.29 (Total Line Payment) at 106% = $869.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1604.25,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,500.0000,5392.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 21925 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,UNITY HEALTH PLAN,UNITY HOSPICE,1604.25,,,,,,,500.0000,5392.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3882.24,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,882.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3343.04,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,343.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3882.24,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,882.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3882.24,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,882.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC BX SOFT TISSUE BACK/FLANK DEEP,21925,CPT,402,RC,40200005,CDM,,,,both,,,5392.0000,3558.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3235.20,,,,,,,500.0000,5392.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,392.00 in Billed Charges for Rev 402 Proc 21925 = $3,235.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,AETNA,AETNA HSHS,175.07,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $175.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,AETNA,AETNA MEDICARE,57.30,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,AETNA,ALL COMMERCIAL AETNA,271.00,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,ANTHEM,ANTEHM MEDICAID,39.48,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00159 Proc 51798 at $125.60 (Base Rate) * 0.3143 (Relative Weight) = $39.48 (Total Line Payment) at 100% = $39.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,57.30,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,ANTHEM,ANTHEM POS/HMO,271.00,,,,,,,21.7700,271.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 Qty 1 * $500.00 = $500.00 (Limited to $271.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,ANTHEM,ANTHEM PPO,271.00,,,,,,,21.7700,271.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 Qty 1 * $500.00 = $500.00 (Limited to $271.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,271.00,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,CENPATICO,ALL MEDICAID CENPATICO,271.00,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,230.35,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $230.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,CIGNA,ALL COMMERCIAL CIGNA,189.70,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $189.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,COFINITY,COFINITY,271.00,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,39.48,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00159 Proc 51798 at $125.60 (Base Rate) * 0.3143 (Relative Weight) = $39.48 (Total Line Payment) at 100% = $39.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,39.48,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00159 Proc 51798 at $125.60 (Base Rate) * 0.3143 (Relative Weight) = $39.48 (Total Line Payment) at 100% = $39.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,257.45,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $257.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,227.64,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $227.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,192.41,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $192.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,197.83,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $197.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,131.71,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $131.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,230.35,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $230.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HUMANA,HUMANA CHOICE CARE HMO,21.77,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.77 from Fee Schedule 005543_205 for Rev 402 Proc 51798 Mod TC * Qty 1 = $21.77 at 100% = $21.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HUMANA,HUMANA CHOICE CARE PPO,230.35,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $230.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,57.30,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,HUMANA,HUMANA NATIIONAL POS HMO,21.77,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $21.77 from Fee Schedule 005543_205 for Rev 402 Proc 51798 Mod TC * Qty 1 = $21.77 at 100% = $21.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,197.83,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $197.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,271.00,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $271.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,39.48,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00159 Proc 51798 at $125.60 (Base Rate) * 0.3143 (Relative Weight) = $39.48 (Total Line Payment) at 100% = $39.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,57.30,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,39.48,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00159 Proc 51798 at $125.60 (Base Rate) * 0.3143 (Relative Weight) = $39.48 (Total Line Payment) at 100% = $39.48. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,41.85,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00159 Proc 51798 at $125.60 (Base Rate) * 0.3143 (Relative Weight) = $39.48 (Total Line Payment) at 100% = $39.48... $39.48 at 106% = $41.85 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,57.30,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,135.50,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $135.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,227.64,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $227.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,128.93,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,203.25,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $203.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,249.32,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $249.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,271.00,,,,,,,21.7700,271.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $271.00, claim capped at $271.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,271.00,,,,,,,21.7700,271.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $271.00, claim capped at $271.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,PREVEA HEALTH NETWORK,PREVEA360,271.00,,,,,,,21.7700,271.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $271.00, claim capped at $271.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,271.00,,,,,,,21.7700,271.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $271.00, claim capped at $271.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,172.98,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $172.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,57.87,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,195.12,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $195.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,TRIOLOGY,TRILOGY MEDICAID,41.84,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00159 Proc 51798 at $125.60 (Base Rate) * 0.3143 (Relative Weight) = $39.48 (Total Line Payment) at 106% = $41.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,271.00,,,,,,,21.7700,271.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $271.00, claim capped at $271.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,271.00,,,,,,,21.7700,271.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $271.00, claim capped at $271.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,57.30,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,271.00,,,,,,,21.7700,271.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 51798 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $271.00, claim capped at $271.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,UNITY HEALTH PLAN,UNITY HOSPICE,57.30,,,,,,,21.7700,271.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,195.12,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $195.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,168.02,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $168.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,195.12,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $195.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,195.12,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $195.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BLADDER SCAN,51798,CPT,402,RC,40200007,CDM,,,,both,,,271.0000,178.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,162.60,,,,,,,21.7700,271.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $271.00 in Billed Charges for Rev 402 Proc 51798 = $162.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,AETNA,AETNA HSHS,2173.14,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,173.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,AETNA,AETNA MEDICARE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,AETNA,ALL COMMERCIAL AETNA,3364.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $3,364.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,ANTHEM,ANTEHM MEDICAID,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49407 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,ANTHEM,ANTHEM PPO,500.00,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3364.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $3,364.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,CENPATICO,ALL MEDICAID CENPATICO,3364.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $3,364.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2859.40,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,859.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,CIGNA,ALL COMMERCIAL CIGNA,2354.80,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,354.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,COFINITY,COFINITY,3364.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $3,364.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49407 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49407 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3195.80,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $3,195.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,2825.76,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,825.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2388.44,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,388.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2455.72,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,455.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,1634.90,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $1,634.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2859.40,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,859.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HUMANA,HUMANA CHOICE CARE HMO,384.46,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $384.46 from Fee Schedule 005543_205 for Rev 402 Proc 49407 Mod TC * Qty 1 = $384.46 at 100% = $384.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HUMANA,HUMANA CHOICE CARE PPO,2859.40,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,859.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HUMANA,HUMANA MEDICARE ADVANTAGE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,HUMANA,HUMANA NATIIONAL POS HMO,384.46,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $384.46 from Fee Schedule 005543_205 for Rev 402 Proc 49407 Mod TC * Qty 1 = $384.46 at 100% = $384.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2455.72,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,455.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3364.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $3,364.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49407 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,330.73,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49407 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,MOLINA HEALTHCARE,MOLINA MEDICAID,350.57,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49407 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 100% = $330.73... $330.73 at 106% = $350.57 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,MOLINA HEALTHCARE,MOLINA MEDICARE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1682.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $1,682.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2825.76,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,825.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,NAPHCARE,ALL COMMERICAL NAPHCARE,3609.56,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2523.00,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,523.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3094.88,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $3,094.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2147.24,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,147.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1620.29,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2422.08,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,422.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,TRIOLOGY,TRILOGY MEDICAID,350.57,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00150 Proc 49407 at $125.60 (Base Rate) * 2.6332 (Relative Weight) = $330.73 (Total Line Payment) at 106% = $350.57. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,330.7300,3609.5600,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 49407 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,UNITY HEALTH PLAN,UNITY HOSPICE,1604.25,,,,,,,330.7300,3609.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2422.08,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,422.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2085.68,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,085.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2422.08,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,422.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2422.08,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,422.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DRAIN ABSC PELVIC TRNSVAG PERC,49407,CPT,402,RC,40200009,CDM,,,,both,,,3364.0000,2220.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2018.40,,,,,,,330.7300,3609.5600,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,364.00 in Billed Charges for Rev 402 Proc 49407 = $2,018.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,AETNA,AETNA HSHS,984.50,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $984.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,AETNA,AETNA MEDICARE,894.65,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,AETNA,ALL COMMERCIAL AETNA,1524.00,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,ANTHEM,ANTEHM MEDICAID,264.45,,,,,,,145.4300,2012.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00178 Proc 59000 at $125.60 (Base Rate) * 2.1055 (Relative Weight) = $264.45 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $264.45 at 100% = $264.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,894.65,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,ANTHEM,ANTHEM PPO,500.00,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1524.00,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,CENPATICO,ALL MEDICAID CENPATICO,1524.00,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1295.40,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,295.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,CIGNA,ALL COMMERCIAL CIGNA,1066.80,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,066.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,COFINITY,COFINITY,1524.00,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,264.45,,,,,,,145.4300,2012.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00178 Proc 59000 at $125.60 (Base Rate) * 2.1055 (Relative Weight) = $264.45 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $264.45 at 100% = $264.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,264.45,,,,,,,145.4300,2012.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00178 Proc 59000 at $125.60 (Base Rate) * 2.1055 (Relative Weight) = $264.45 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $264.45 at 100% = $264.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1447.80,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,447.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,1280.16,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,280.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1082.04,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,082.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1112.52,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,112.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,740.66,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $740.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1295.40,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,295.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HUMANA,HUMANA CHOICE CARE HMO,145.43,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $145.43 from Fee Schedule 005543_205 for Rev 402 Proc 59000 Mod TC * Qty 1 = $145.43 at 100% = $145.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HUMANA,HUMANA CHOICE CARE PPO,1295.40,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,295.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HUMANA,HUMANA MEDICARE ADVANTAGE,894.65,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,HUMANA,HUMANA NATIIONAL POS HMO,145.43,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $145.43 from Fee Schedule 005543_205 for Rev 402 Proc 59000 Mod TC * Qty 1 = $145.43 at 100% = $145.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1112.52,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,112.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1524.00,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,524.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,264.45,,,,,,,145.4300,2012.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00178 Proc 59000 at $125.60 (Base Rate) * 2.1055 (Relative Weight) = $264.45 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $264.45 at 100% = $264.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,894.65,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,264.45,,,,,,,145.4300,2012.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00178 Proc 59000 at $125.60 (Base Rate) * 2.1055 (Relative Weight) = $264.45 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $264.45 at 100% = $264.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,MOLINA HEALTHCARE,MOLINA MEDICAID,280.32,,,,,,,145.4300,2012.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00178 Proc 59000 at $125.60 (Base Rate) * 2.1055 (Relative Weight) = $264.45 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $264.45 at 100% = $264.45... $264.45 at 106% = $280.32 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,MOLINA HEALTHCARE,MOLINA MEDICARE,894.65,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,762.00,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $762.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1280.16,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,280.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,NAPHCARE,ALL COMMERICAL NAPHCARE,2012.95,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1143.00,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,143.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1402.08,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,402.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,972.77,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $972.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,903.60,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1097.28,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,097.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,TRIOLOGY,TRILOGY MEDICAID,280.32,,,,,,,145.4300,2012.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00178 Proc 59000 at $125.60 (Base Rate) * 2.1055 (Relative Weight) = $264.45 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $264.45 at 106% = $280.32. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,894.65,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,145.4300,2012.9500,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 59000 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,UNITY HEALTH PLAN,UNITY HOSPICE,894.65,,,,,,,145.4300,2012.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1097.28,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,097.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,944.88,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $944.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1097.28,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,097.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1097.28,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $1,097.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC AMNIOCENTESIS DIAGNOSTIC,59000,CPT,402,RC,40200010,CDM,,,,both,,,1524.0000,1005.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,914.40,,,,,,,145.4300,2012.9500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,524.00 in Billed Charges for Rev 402 Proc 59000 = $914.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,AETNA,AETNA HSHS,795.23,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $795.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,AETNA,AETNA MEDICARE,687.83,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,AETNA,ALL COMMERCIAL AETNA,1231.00,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,ANTHEM,ANTEHM MEDICAID,313.03,,,,,,,91.9600,1547.6200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 60300 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,687.83,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,ANTHEM,ANTHEM PPO,500.00,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1231.00,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,CENPATICO,ALL MEDICAID CENPATICO,1231.00,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1046.35,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,046.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,CIGNA,ALL COMMERCIAL CIGNA,861.70,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $861.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,COFINITY,COFINITY,1231.00,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,313.03,,,,,,,91.9600,1547.6200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 60300 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,313.03,,,,,,,91.9600,1547.6200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 60300 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1169.45,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,169.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,1034.04,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,034.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,874.01,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $874.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,898.63,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $898.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,598.27,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $598.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1046.35,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,046.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HUMANA,HUMANA CHOICE CARE HMO,91.96,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). $91.96 from Fee Schedule 005543_205 for Rev 402 Proc 60300 Mod TC * Qty 1 = $91.96 at 100% = $91.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HUMANA,HUMANA CHOICE CARE PPO,1046.35,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,046.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,687.83,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,HUMANA,HUMANA NATIIONAL POS HMO,91.96,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). $91.96 from Fee Schedule 005543_205 for Rev 402 Proc 60300 Mod TC * Qty 1 = $91.96 at 100% = $91.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,898.63,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $898.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1231.00,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,313.03,,,,,,,91.9600,1547.6200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 60300 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,687.83,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,313.03,,,,,,,91.9600,1547.6200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 60300 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,331.81,,,,,,,91.9600,1547.6200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 60300 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 100% = $313.03... $313.03 at 106% = $331.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,687.83,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,615.50,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $615.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1034.04,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,034.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,1547.62,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,923.25,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $923.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1132.52,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $1,132.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,785.75,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $785.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,694.71,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,886.32,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $886.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,TRIOLOGY,TRILOGY MEDICAID,331.81,,,,,,,91.9600,1547.6200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00002 Proc 60300 at $125.60 (Base Rate) * 2.4923 (Relative Weight) = $313.03 (Total Line Payment), Adjusted by ((1 + (0.5 * (1 - 1))) / 1) = $313.03 at 106% = $331.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,687.83,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,91.9600,1547.6200,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 60300 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,UNITY HEALTH PLAN,UNITY HOSPICE,687.83,,,,,,,91.9600,1547.6200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,886.32,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $886.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,763.22,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $763.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,886.32,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $886.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,886.32,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $886.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ASP/INJ CYST THYROID,60300,CPT,402,RC,40200011,CDM,,,,both,,,1231.0000,812.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,738.60,,,,,,,91.9600,1547.6200,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,231.00 in Billed Charges for Rev 402 Proc 60300 = $738.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,AETNA,AETNA HSHS,616.28,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $616.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,AETNA,ALL COMMERCIAL AETNA,954.00,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76506 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,954.00,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,CENPATICO,ALL MEDICAID CENPATICO,954.00,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,810.90,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,CIGNA,ALL COMMERCIAL CIGNA,667.80,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $667.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,COFINITY,COFINITY,954.00,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76506 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76506 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,906.30,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $906.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,801.36,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $801.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,677.34,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $677.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,696.42,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $696.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,463.64,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $463.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,810.90,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HUMANA,HUMANA CHOICE CARE HMO,160.88,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $160.88 from Fee Schedule 005543_205 for Rev 402 Proc 76506 Mod TC * Qty 1 = $160.88 at 100% = $160.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HUMANA,HUMANA CHOICE CARE PPO,810.90,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,HUMANA,HUMANA NATIIONAL POS HMO,160.88,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $160.88 from Fee Schedule 005543_205 for Rev 402 Proc 76506 Mod TC * Qty 1 = $160.88 at 100% = $160.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,696.42,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $696.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,954.00,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $954.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76506 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76506 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76506 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,477.00,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $477.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,801.36,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $801.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,715.50,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $715.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,877.68,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $877.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,608.94,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $608.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,686.88,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $686.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76506 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,954.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76506 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,954.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,686.88,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $686.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,591.48,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $591.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,686.88,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $686.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,686.88,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $686.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ENCEPHALOGRAM,76506,CPT,402,RC,40200012,CDM,,,,both,,,954.0000,629.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,572.40,,,,,,,50.1000,954.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $954.00 in Billed Charges for Rev 402 Proc 76506 = $572.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,AETNA,AETNA HSHS,540.70,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $540.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,AETNA,ALL COMMERCIAL AETNA,837.00,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76536 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,837.00,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,CENPATICO,ALL MEDICAID CENPATICO,837.00,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,711.45,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $711.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,CIGNA,ALL COMMERCIAL CIGNA,585.90,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $585.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,COFINITY,COFINITY,837.00,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76536 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76536 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,795.15,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $795.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,703.08,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $703.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,594.27,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $594.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,611.01,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $611.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,406.78,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $406.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,711.45,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $711.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HUMANA,HUMANA CHOICE CARE HMO,164.14,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.14 from Fee Schedule 005543_205 for Rev 402 Proc 76536 Mod TC * Qty 1 = $164.14 at 100% = $164.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HUMANA,HUMANA CHOICE CARE PPO,711.45,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $711.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,HUMANA,HUMANA NATIIONAL POS HMO,164.14,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $164.14 from Fee Schedule 005543_205 for Rev 402 Proc 76536 Mod TC * Qty 1 = $164.14 at 100% = $164.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,611.01,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $611.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,837.00,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76536 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76536 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76536 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,418.50,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $418.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,703.08,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $703.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,627.75,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $627.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,770.04,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $770.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,534.26,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $534.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,602.64,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76536 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76536 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,602.64,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,518.94,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $518.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,602.64,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,602.64,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SOFT TISSUE HEAD/NECK,76536,CPT,402,RC,40200013,CDM,,,,both,,,837.0000,552.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,502.20,,,,,,,50.1000,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $837.00 in Billed Charges for Rev 402 Proc 76536 = $502.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,AETNA,AETNA HSHS,534.89,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $534.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,AETNA,ALL COMMERCIAL AETNA,828.00,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76641 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,828.00,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,CENPATICO,ALL MEDICAID CENPATICO,828.00,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,703.80,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $703.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,CIGNA,ALL COMMERCIAL CIGNA,579.60,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $579.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,COFINITY,COFINITY,828.00,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76641 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76641 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,786.60,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $786.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,695.52,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $695.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,587.88,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $587.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,604.44,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $604.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,402.41,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $402.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,703.80,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $703.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HUMANA,HUMANA CHOICE CARE HMO,133.46,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $133.46 from Fee Schedule 005543_205 for Rev 402 Proc 76641 Mod TC * Qty 1 = $133.46 at 100% = $133.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HUMANA,HUMANA CHOICE CARE PPO,703.80,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $703.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,HUMANA,HUMANA NATIIONAL POS HMO,133.46,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $133.46 from Fee Schedule 005543_205 for Rev 402 Proc 76641 Mod TC * Qty 1 = $133.46 at 100% = $133.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,604.44,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $604.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,828.00,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $828.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76641 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76641 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76641 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,414.00,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $414.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,695.52,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $695.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,621.00,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $621.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,761.76,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $761.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,528.51,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $528.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,596.16,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $596.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76641 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,828.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76641 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,828.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,596.16,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $596.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,513.36,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $513.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,596.16,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $596.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,596.16,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $596.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US BREAST COMPLETE,76641,CPT,402,RC,40200015,CDM,,,,both,,,828.0000,546.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,496.80,,,,,,,50.1000,828.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $828.00 in Billed Charges for Rev 402 Proc 76641 = $496.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,AETNA,AETNA HSHS,753.24,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $753.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,AETNA,AETNA MEDICARE,101.55,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,AETNA,ALL COMMERCIAL AETNA,1166.00,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $1,166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,ANTHEM,ANTEHM MEDICAID,77.18,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76700 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,ANTHEM,ANTHEM PPO,500.00,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1166.00,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $1,166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,CENPATICO,ALL MEDICAID CENPATICO,1166.00,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $1,166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,991.10,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $991.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,CIGNA,ALL COMMERCIAL CIGNA,816.20,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $816.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,COFINITY,COFINITY,1166.00,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $1,166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.18,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76700 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.18,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76700 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1107.70,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $1,107.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,979.44,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $979.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,827.86,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $827.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,851.18,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $851.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,566.68,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $566.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,991.10,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $991.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HUMANA,HUMANA CHOICE CARE HMO,153.28,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $153.28 from Fee Schedule 005543_205 for Rev 402 Proc 76700 Mod TC * Qty 1 = $153.28 at 100% = $153.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HUMANA,HUMANA CHOICE CARE PPO,991.10,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $991.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,HUMANA,HUMANA NATIIONAL POS HMO,153.28,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $153.28 from Fee Schedule 005543_205 for Rev 402 Proc 76700 Mod TC * Qty 1 = $153.28 at 100% = $153.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,851.18,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $851.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1166.00,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $1,166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.18,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76700 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.18,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76700 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,MOLINA HEALTHCARE,MOLINA MEDICAID,81.81,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76700 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18... $77.18 at 106% = $81.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,583.00,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,979.44,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $979.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,874.50,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $874.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1072.72,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $1,072.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,744.26,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $744.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,839.52,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $839.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,TRIOLOGY,TRILOGY MEDICAID,81.81,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76700 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 106% = $81.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,77.1800,1166.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76700 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,77.1800,1166.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,839.52,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $839.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,722.92,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $722.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,839.52,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $839.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,839.52,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $839.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN CMPL,76700,CPT,402,RC,40200017,CDM,,,,both,,,1166.0000,769.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,699.60,,,,,,,77.1800,1166.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,166.00 in Billed Charges for Rev 402 Proc 76700 = $699.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,AETNA,AETNA HSHS,565.90,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $565.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,AETNA,ALL COMMERCIAL AETNA,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76705 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,CENPATICO,ALL MEDICAID CENPATICO,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,744.60,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $744.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,CIGNA,ALL COMMERCIAL CIGNA,613.20,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $613.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,COFINITY,COFINITY,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76705 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76705 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,832.20,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $832.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,735.84,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $735.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,621.96,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $621.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,639.48,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $639.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,425.74,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $425.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,744.60,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $744.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HUMANA,HUMANA CHOICE CARE HMO,116.48,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $116.48 from Fee Schedule 005543_205 for Rev 402 Proc 76705 Mod TC * Qty 1 = $116.48 at 100% = $116.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HUMANA,HUMANA CHOICE CARE PPO,744.60,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $744.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,HUMANA,HUMANA NATIIONAL POS HMO,116.48,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $116.48 from Fee Schedule 005543_205 for Rev 402 Proc 76705 Mod TC * Qty 1 = $116.48 at 100% = $116.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,639.48,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $639.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76705 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76705 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76705 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,438.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,735.84,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $735.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,657.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $657.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,805.92,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $805.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,559.15,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $559.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,630.72,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $630.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76705 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76705 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,630.72,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $630.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,543.12,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $543.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,630.72,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $630.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,630.72,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $630.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US ABDOMEN LTD,76705,CPT,402,RC,40200018,CDM,,,,both,,,876.0000,578.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,525.60,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $876.00 in Billed Charges for Rev 402 Proc 76705 = $525.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,AETNA,AETNA HSHS,506.46,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $506.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,AETNA,ALL COMMERCIAL AETNA,784.00,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76775 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,784.00,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,CENPATICO,ALL MEDICAID CENPATICO,784.00,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,666.40,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $666.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,CIGNA,ALL COMMERCIAL CIGNA,548.80,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $548.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,COFINITY,COFINITY,784.00,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76775 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76775 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,744.80,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $744.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,658.56,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $658.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,556.64,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $556.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,572.32,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $572.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,381.02,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $381.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,666.40,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $666.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HUMANA,HUMANA CHOICE CARE HMO,63.57,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $63.57 from Fee Schedule 005543_205 for Rev 402 Proc 76775 Mod TC * Qty 1 = $63.57 at 100% = $63.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HUMANA,HUMANA CHOICE CARE PPO,666.40,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $666.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,HUMANA,HUMANA NATIIONAL POS HMO,63.57,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $63.57 from Fee Schedule 005543_205 for Rev 402 Proc 76775 Mod TC * Qty 1 = $63.57 at 100% = $63.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,572.32,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $572.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,784.00,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $784.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76775 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76775 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76775 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,392.00,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,658.56,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $658.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,588.00,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $588.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,721.28,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $721.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,500.43,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $500.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,564.48,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $564.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76775 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,784.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76775 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,784.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,564.48,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $564.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,486.08,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $486.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,564.48,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $564.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,564.48,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $564.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US RETROPERITONEAL LTD,76775,CPT,402,RC,40200020,CDM,,,,both,,,784.0000,517.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,470.40,,,,,,,50.1000,784.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $784.00 in Billed Charges for Rev 402 Proc 76775 = $470.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,AETNA,AETNA HSHS,561.37,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $561.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,AETNA,ALL COMMERCIAL AETNA,869.00,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76776 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,869.00,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,CENPATICO,ALL MEDICAID CENPATICO,869.00,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,738.65,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $738.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,CIGNA,ALL COMMERCIAL CIGNA,608.30,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $608.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,COFINITY,COFINITY,869.00,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76776 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76776 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,825.55,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $825.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,729.96,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $729.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,616.99,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $616.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,634.37,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $634.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,422.33,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $422.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,738.65,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $738.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HUMANA,HUMANA CHOICE CARE HMO,218.57,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.57 from Fee Schedule 005543_205 for Rev 402 Proc 76776 Mod TC * Qty 1 = $218.57 at 100% = $218.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HUMANA,HUMANA CHOICE CARE PPO,738.65,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $738.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,HUMANA,HUMANA NATIIONAL POS HMO,218.57,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.57 from Fee Schedule 005543_205 for Rev 402 Proc 76776 Mod TC * Qty 1 = $218.57 at 100% = $218.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,634.37,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $634.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,869.00,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76776 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76776 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76776 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,434.50,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $434.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,729.96,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $729.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,651.75,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $651.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,799.48,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $799.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,554.68,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $554.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,625.68,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $625.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76776 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76776 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,625.68,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $625.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,538.78,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $538.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,625.68,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $625.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,625.68,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $625.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US KIDNEY TRANSPLANT W/DOPPLER,76776,CPT,402,RC,40200021,CDM,,,,both,,,869.0000,573.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,521.40,,,,,,,50.1000,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $869.00 in Billed Charges for Rev 402 Proc 76776 = $521.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,AETNA,AETNA HSHS,342.38,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $342.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,AETNA,ALL COMMERCIAL AETNA,530.00,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $530.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76800 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,530.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,530.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,530.00,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $530.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,CENPATICO,ALL MEDICAID CENPATICO,530.00,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $530.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,450.50,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $450.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,CIGNA,ALL COMMERCIAL CIGNA,371.00,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,COFINITY,COFINITY,530.00,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $530.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76800 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76800 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,503.50,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $503.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,445.20,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,376.30,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $376.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,386.90,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $386.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,257.58,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $257.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,450.50,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $450.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HUMANA,HUMANA CHOICE CARE HMO,218.35,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.35 from Fee Schedule 005543_205 for Rev 402 Proc 76800 Mod TC * Qty 1 = $218.35 at 100% = $218.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HUMANA,HUMANA CHOICE CARE PPO,450.50,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $450.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,HUMANA,HUMANA NATIIONAL POS HMO,218.35,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $218.35 from Fee Schedule 005543_205 for Rev 402 Proc 76800 Mod TC * Qty 1 = $218.35 at 100% = $218.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,386.90,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $386.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,530.00,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $530.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76800 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76800 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76800 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,265.00,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $265.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,445.20,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,397.50,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $397.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,487.60,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $487.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,530.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,530.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,530.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,530.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,338.30,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $338.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,381.60,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $381.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76800 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,530.00,,,,,,,50.1000,530.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $530.00, claim capped at $530.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,530.00,,,,,,,50.1000,530.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $530.00, claim capped at $530.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,530.00,,,,,,,50.1000,530.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76800 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $530.00, claim capped at $530.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,530.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,381.60,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $381.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,328.60,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $328.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,381.60,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $381.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,381.60,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $381.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SPINAL CANAL & CONTENTS,76800,CPT,402,RC,40200022,CDM,,,,both,,,530.0000,349.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,318.00,,,,,,,50.1000,530.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $530.00 in Billed Charges for Rev 402 Proc 76800 = $318.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,AETNA,AETNA HSHS,246.13,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $246.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,AETNA,ALL COMMERCIAL AETNA,381.00,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76802 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,ANTHEM,ANTHEM POS/HMO,381.00,,,,,,,41.1400,381.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 Qty 1 * $500.00 = $500.00 (Limited to $381.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,ANTHEM,ANTHEM PPO,381.00,,,,,,,41.1400,381.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 Qty 1 * $500.00 = $500.00 (Limited to $381.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,381.00,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,CENPATICO,ALL MEDICAID CENPATICO,381.00,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,323.85,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $323.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,CIGNA,ALL COMMERCIAL CIGNA,266.70,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $266.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,COFINITY,COFINITY,381.00,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76802 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76802 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,361.95,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $361.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,320.04,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $320.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,270.51,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $270.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,278.13,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $278.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,185.17,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $185.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,323.85,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $323.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,HUMANA,HUMANA CHOICE CARE HMO,41.14,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.14 from Fee Schedule 005543_205 for Rev 402 Proc 76802 Mod TC * Qty 1 = $41.14 at 100% = $41.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,HUMANA,HUMANA CHOICE CARE PPO,323.85,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $323.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,HUMANA,HUMANA NATIIONAL POS HMO,41.14,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $41.14 from Fee Schedule 005543_205 for Rev 402 Proc 76802 Mod TC * Qty 1 = $41.14 at 100% = $41.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,278.13,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $278.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,381.00,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76802 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76802 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76802 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,190.50,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $190.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,320.04,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $320.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,285.75,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $285.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,350.52,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $350.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,381.00,,,,,,,41.1400,381.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $381.00, claim capped at $381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,381.00,,,,,,,41.1400,381.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $381.00, claim capped at $381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,PREVEA HEALTH NETWORK,PREVEA360,381.00,,,,,,,41.1400,381.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $381.00, claim capped at $381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,381.00,,,,,,,41.1400,381.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $381.00, claim capped at $381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,243.19,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $243.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,274.32,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $274.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,41.1400,381.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76802 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,381.00,,,,,,,41.1400,381.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $381.00, claim capped at $381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,381.00,,,,,,,41.1400,381.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $381.00, claim capped at $381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,381.00,,,,,,,41.1400,381.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76802 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $381.00, claim capped at $381.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,274.32,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $274.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,236.22,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $236.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,274.32,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $274.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,274.32,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $274.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY <14 WEEKS ADDL,76802,CPT,402,RC,40200024,CDM,,,,both,,,381.0000,251.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,228.60,,,,,,,41.1400,381.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $381.00 in Billed Charges for Rev 402 Proc 76802 = $228.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,AETNA,AETNA HSHS,561.37,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $561.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,AETNA,AETNA MEDICARE,101.55,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,AETNA,ALL COMMERCIAL AETNA,869.00,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76805 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,ANTHEM,ANTHEM PPO,500.00,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,869.00,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,CENPATICO,ALL MEDICAID CENPATICO,869.00,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,738.65,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $738.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,CIGNA,ALL COMMERCIAL CIGNA,608.30,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $608.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,COFINITY,COFINITY,869.00,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76805 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76805 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,825.55,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $825.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,729.96,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $729.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,616.99,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $616.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,634.37,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $634.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,422.33,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $422.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,738.65,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $738.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HUMANA,HUMANA CHOICE CARE HMO,173.51,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.51 from Fee Schedule 005543_205 for Rev 402 Proc 76805 Mod TC * Qty 1 = $173.51 at 100% = $173.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HUMANA,HUMANA CHOICE CARE PPO,738.65,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $738.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,HUMANA,HUMANA NATIIONAL POS HMO,173.51,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $173.51 from Fee Schedule 005543_205 for Rev 402 Proc 76805 Mod TC * Qty 1 = $173.51 at 100% = $173.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,634.37,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $634.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,869.00,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $869.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76805 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76805 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76805 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,434.50,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $434.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,729.96,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $729.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,651.75,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $651.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,799.48,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $799.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,554.68,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $554.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,625.68,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $625.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76805 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,46.1600,869.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76805 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,46.1600,869.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,625.68,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $625.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,538.78,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $538.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,625.68,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $625.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,625.68,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $625.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY >14 WEEKS SGL,76805,CPT,402,RC,40200025,CDM,,,,both,,,869.0000,573.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,521.40,,,,,,,46.1600,869.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $869.00 in Billed Charges for Rev 402 Proc 76805 = $521.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,AETNA,AETNA HSHS,328.17,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $328.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,AETNA,AETNA MEDICARE,101.55,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,AETNA,ALL COMMERCIAL AETNA,508.00,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76815 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,46.1600,508.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,ANTHEM,ANTHEM PPO,500.00,,,,,,,46.1600,508.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,508.00,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,CENPATICO,ALL MEDICAID CENPATICO,508.00,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,431.80,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $431.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,CIGNA,ALL COMMERCIAL CIGNA,355.60,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $355.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,COFINITY,COFINITY,508.00,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76815 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76815 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,482.60,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $482.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,426.72,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $426.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,360.68,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $360.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,370.84,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $370.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,246.89,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $246.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,431.80,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $431.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HUMANA,HUMANA CHOICE CARE HMO,98.85,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $98.85 from Fee Schedule 005543_205 for Rev 402 Proc 76815 Mod TC * Qty 1 = $98.85 at 100% = $98.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HUMANA,HUMANA CHOICE CARE PPO,431.80,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $431.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,HUMANA,HUMANA NATIIONAL POS HMO,98.85,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $98.85 from Fee Schedule 005543_205 for Rev 402 Proc 76815 Mod TC * Qty 1 = $98.85 at 100% = $98.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,370.84,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $370.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,508.00,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $508.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76815 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76815 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76815 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,254.00,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,426.72,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $426.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,381.00,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $381.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,467.36,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $467.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,508.00,,,,,,,46.1600,508.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $508.00, claim capped at $508.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,508.00,,,,,,,46.1600,508.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $508.00, claim capped at $508.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,PREVEA HEALTH NETWORK,PREVEA360,508.00,,,,,,,46.1600,508.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $508.00, claim capped at $508.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,508.00,,,,,,,46.1600,508.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $508.00, claim capped at $508.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,324.26,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $324.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,365.76,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $365.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76815 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,508.00,,,,,,,46.1600,508.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $508.00, claim capped at $508.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,508.00,,,,,,,46.1600,508.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $508.00, claim capped at $508.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,508.00,,,,,,,46.1600,508.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76815 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $508.00, claim capped at $508.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,46.1600,508.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,365.76,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $365.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,314.96,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $314.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,365.76,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $365.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,365.76,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $365.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL HEART BEAT,76815,CPT,402,RC,40200031,CDM,,,,both,,,508.0000,335.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,304.80,,,,,,,46.1600,508.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $508.00 in Billed Charges for Rev 402 Proc 76815 = $304.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,AETNA,AETNA HSHS,430.88,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $430.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,AETNA,AETNA MEDICARE,101.55,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,AETNA,ALL COMMERCIAL AETNA,667.00,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $667.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76817 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,ANTHEM,ANTHEM PPO,500.00,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,667.00,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $667.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,CENPATICO,ALL MEDICAID CENPATICO,667.00,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $667.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,566.95,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $566.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,CIGNA,ALL COMMERCIAL CIGNA,466.90,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $466.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,COFINITY,COFINITY,667.00,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $667.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76817 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76817 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,633.65,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $633.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,560.28,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $560.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,473.57,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $473.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,486.91,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $486.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,324.16,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $324.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,566.95,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $566.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HUMANA,HUMANA CHOICE CARE HMO,111.89,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.89 from Fee Schedule 005543_205 for Rev 402 Proc 76817 Mod TC * Qty 1 = $111.89 at 100% = $111.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HUMANA,HUMANA CHOICE CARE PPO,566.95,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $566.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,HUMANA,HUMANA NATIIONAL POS HMO,111.89,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $111.89 from Fee Schedule 005543_205 for Rev 402 Proc 76817 Mod TC * Qty 1 = $111.89 at 100% = $111.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,486.91,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $486.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,667.00,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $667.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76817 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76817 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76817 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,333.50,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $333.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,560.28,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $560.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,500.25,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $500.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,613.64,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $613.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,425.75,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $425.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,480.24,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $480.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76817 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,46.1600,667.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76817 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,46.1600,667.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,480.24,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $480.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,413.54,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $413.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,480.24,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $480.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,480.24,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $480.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US PREGNANCY TRANSVAGINAL,76817,CPT,402,RC,40200032,CDM,,,,both,,,667.0000,440.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,400.20,,,,,,,46.1600,667.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $667.00 in Billed Charges for Rev 402 Proc 76817 = $400.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,AETNA,AETNA HSHS,479.33,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $479.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,AETNA,AETNA MEDICARE,101.55,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,AETNA,ALL COMMERCIAL AETNA,742.00,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76818 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,ANTHEM,ANTHEM PPO,500.00,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,742.00,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,CENPATICO,ALL MEDICAID CENPATICO,742.00,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,630.70,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $630.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,CIGNA,ALL COMMERCIAL CIGNA,519.40,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $519.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,COFINITY,COFINITY,742.00,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76818 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76818 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,704.90,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $704.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,623.28,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $623.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,526.82,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $526.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,541.66,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $541.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,360.61,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $360.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,630.70,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $630.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HUMANA,HUMANA CHOICE CARE HMO,134.56,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $134.56 from Fee Schedule 005543_205 for Rev 402 Proc 76818 Mod TC * Qty 1 = $134.56 at 100% = $134.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HUMANA,HUMANA CHOICE CARE PPO,630.70,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $630.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,HUMANA,HUMANA NATIIONAL POS HMO,134.56,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $134.56 from Fee Schedule 005543_205 for Rev 402 Proc 76818 Mod TC * Qty 1 = $134.56 at 100% = $134.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,541.66,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $541.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,742.00,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $742.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76818 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76818 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76818 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,371.00,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,623.28,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $623.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,556.50,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $556.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,682.64,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $682.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,473.62,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $473.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,534.24,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76818 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,46.1600,742.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76818 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,46.1600,742.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,534.24,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,460.04,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $460.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,534.24,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,534.24,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $534.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL BIO PROFILE W/NST,76818,CPT,402,RC,40200033,CDM,,,,both,,,742.0000,489.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,445.20,,,,,,,46.1600,742.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $742.00 in Billed Charges for Rev 402 Proc 76818 = $445.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,AETNA,AETNA HSHS,565.90,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $565.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,AETNA,ALL COMMERCIAL AETNA,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76870 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,CENPATICO,ALL MEDICAID CENPATICO,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,744.60,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $744.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,CIGNA,ALL COMMERCIAL CIGNA,613.20,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $613.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,COFINITY,COFINITY,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76870 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76870 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,832.20,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $832.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,735.84,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $735.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,621.96,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $621.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,639.48,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $639.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,425.74,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $425.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,744.60,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $744.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HUMANA,HUMANA CHOICE CARE HMO,137.37,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $137.37 from Fee Schedule 005543_205 for Rev 402 Proc 76870 Mod TC * Qty 1 = $137.37 at 100% = $137.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HUMANA,HUMANA CHOICE CARE PPO,744.60,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $744.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,HUMANA,HUMANA NATIIONAL POS HMO,137.37,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $137.37 from Fee Schedule 005543_205 for Rev 402 Proc 76870 Mod TC * Qty 1 = $137.37 at 100% = $137.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,639.48,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $639.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,876.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $876.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76870 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76870 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76870 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,438.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $438.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,735.84,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $735.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,657.00,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $657.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,805.92,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $805.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,559.15,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $559.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,630.72,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $630.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76870 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,876.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76870 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,876.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,630.72,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $630.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,543.12,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $543.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,630.72,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $630.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,630.72,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $630.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US SCROTUM,76870,CPT,402,RC,40200042,CDM,,,,both,,,876.0000,578.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,525.60,,,,,,,50.1000,876.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $876.00 in Billed Charges for Rev 402 Proc 76870 = $525.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,AETNA,AETNA HSHS,472.23,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $472.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,AETNA,AETNA MEDICARE,101.55,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,AETNA,ALL COMMERCIAL AETNA,731.00,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTEHM MEDICAID,77.18,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76873 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,ANTHEM,ANTHEM PPO,500.00,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,731.00,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,CENPATICO,ALL MEDICAID CENPATICO,731.00,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,621.35,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,CIGNA,ALL COMMERCIAL CIGNA,511.70,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $511.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,COFINITY,COFINITY,731.00,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.18,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76873 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.18,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76873 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,694.45,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $694.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,614.04,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $614.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,519.01,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $519.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,533.63,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,355.27,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $355.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,621.35,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA CHOICE CARE HMO,195.71,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $195.71 from Fee Schedule 005543_205 for Rev 402 Proc 76873 Mod TC * Qty 1 = $195.71 at 100% = $195.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA CHOICE CARE PPO,621.35,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $621.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,HUMANA,HUMANA NATIIONAL POS HMO,195.71,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $195.71 from Fee Schedule 005543_205 for Rev 402 Proc 76873 Mod TC * Qty 1 = $195.71 at 100% = $195.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,533.63,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $533.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,731.00,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $731.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.18,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76873 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.18,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76873 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,81.81,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76873 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18... $77.18 at 106% = $81.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,365.50,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $365.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,614.04,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $614.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,548.25,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $548.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,672.52,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $672.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,466.60,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $466.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,526.32,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,TRIOLOGY,TRILOGY MEDICAID,81.81,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 76873 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 106% = $81.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,77.1800,731.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76873 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,77.1800,731.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,526.32,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,453.22,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $453.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,526.32,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,526.32,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $526.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US TRANSRECTAL PROSTATE VOLUME,76873,CPT,402,RC,40200044,CDM,,,,both,,,731.0000,482.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,438.60,,,,,,,77.1800,731.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $731.00 in Billed Charges for Rev 402 Proc 76873 = $438.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,AETNA,AETNA HSHS,376.62,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $376.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,AETNA,ALL COMMERCIAL AETNA,583.00,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76882 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,583.00,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,CENPATICO,ALL MEDICAID CENPATICO,583.00,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,495.55,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $495.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,CIGNA,ALL COMMERCIAL CIGNA,408.10,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $408.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,COFINITY,COFINITY,583.00,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76882 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76882 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,553.85,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $553.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,489.72,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $489.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,413.93,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $413.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,425.59,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $425.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,283.34,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $283.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,495.55,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $495.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HUMANA,HUMANA CHOICE CARE HMO,60.31,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.31 from Fee Schedule 005543_205 for Rev 402 Proc 76882 Mod TC * Qty 1 = $60.31 at 100% = $60.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HUMANA,HUMANA CHOICE CARE PPO,495.55,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $495.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,HUMANA,HUMANA NATIIONAL POS HMO,60.31,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $60.31 from Fee Schedule 005543_205 for Rev 402 Proc 76882 Mod TC * Qty 1 = $60.31 at 100% = $60.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,425.59,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $425.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,583.00,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $583.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76882 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76882 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76882 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,291.50,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $291.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,489.72,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $489.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,437.25,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $437.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,536.36,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $536.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,372.13,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $372.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,419.76,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $419.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76882 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,583.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76882 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,583.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,419.76,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $419.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,361.46,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $361.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,419.76,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $419.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,419.76,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $419.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US EXTREMITY NON VASCULAR LMTD,76882,CPT,402,RC,40200046,CDM,,,,both,,,583.0000,384.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,349.80,,,,,,,50.1000,583.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $583.00 in Billed Charges for Rev 402 Proc 76882 = $349.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,AETNA,AETNA HSHS,369.51,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $369.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,AETNA,AETNA MEDICARE,84.53,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,AETNA,ALL COMMERCIAL AETNA,572.00,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76885 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,84.53,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,572.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,572.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,572.00,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,CENPATICO,ALL MEDICAID CENPATICO,572.00,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,486.20,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,CIGNA,ALL COMMERCIAL CIGNA,400.40,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $400.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,COFINITY,COFINITY,572.00,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76885 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76885 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,543.40,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $543.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,480.48,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $480.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,406.12,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $406.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,417.56,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $417.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,277.99,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $277.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,486.20,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HUMANA,HUMANA CHOICE CARE HMO,197.01,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $197.01 from Fee Schedule 005543_205 for Rev 402 Proc 76885 Mod TC * Qty 1 = $197.01 at 100% = $197.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HUMANA,HUMANA CHOICE CARE PPO,486.20,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $486.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,84.53,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,HUMANA,HUMANA NATIIONAL POS HMO,197.01,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $197.01 from Fee Schedule 005543_205 for Rev 402 Proc 76885 Mod TC * Qty 1 = $197.01 at 100% = $197.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,417.56,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $417.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,572.00,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $572.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76885 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,84.53,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76885 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76885 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,84.53,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,286.00,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $286.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,480.48,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $480.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,190.19,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,429.00,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $429.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,526.24,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $526.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,572.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,572.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,572.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,572.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,365.11,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $365.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,85.38,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,411.84,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $411.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76885 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,572.00,,,,,,,50.1000,572.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $572.00, claim capped at $572.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,572.00,,,,,,,50.1000,572.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $572.00, claim capped at $572.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,84.53,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,572.00,,,,,,,50.1000,572.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76885 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $572.00, claim capped at $572.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,UNITY HEALTH PLAN,UNITY HOSPICE,84.53,,,,,,,50.1000,572.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,411.84,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $411.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,354.64,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $354.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,411.84,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $411.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,411.84,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $411.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US HIPS INFANT DYNAMIC,76885,CPT,402,RC,40200048,CDM,,,,both,,,572.0000,377.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,343.20,,,,,,,50.1000,572.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $572.00 in Billed Charges for Rev 402 Proc 76885 = $343.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,AETNA,AETNA HSHS,861.76,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $861.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,AETNA,AETNA MEDICARE,209.73,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,AETNA,ALL COMMERCIAL AETNA,1334.00,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,ANTHEM,ANTEHM MEDICAID,92.68,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00474 Proc 76936 at $125.60 (Base Rate) * 0.7379 (Relative Weight) = $92.68 (Total Line Payment) at 100% = $92.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,209.73,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,ANTHEM,ANTHEM PPO,500.00,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1334.00,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,CENPATICO,ALL MEDICAID CENPATICO,1334.00,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1133.90,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,133.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,CIGNA,ALL COMMERCIAL CIGNA,933.80,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $933.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,COFINITY,COFINITY,1334.00,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,92.68,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00474 Proc 76936 at $125.60 (Base Rate) * 0.7379 (Relative Weight) = $92.68 (Total Line Payment) at 100% = $92.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,92.68,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00474 Proc 76936 at $125.60 (Base Rate) * 0.7379 (Relative Weight) = $92.68 (Total Line Payment) at 100% = $92.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1267.30,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,267.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,1120.56,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,120.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,947.14,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $947.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,973.82,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $973.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,648.32,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $648.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1133.90,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,133.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HUMANA,HUMANA CHOICE CARE HMO,328.49,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $328.49 from Fee Schedule 005543_205 for Rev 402 Proc 76936 Mod TC * Qty 1 = $328.49 at 100% = $328.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HUMANA,HUMANA CHOICE CARE PPO,1133.90,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,133.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,209.73,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,HUMANA,HUMANA NATIIONAL POS HMO,328.49,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $328.49 from Fee Schedule 005543_205 for Rev 402 Proc 76936 Mod TC * Qty 1 = $328.49 at 100% = $328.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,973.82,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $973.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1334.00,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,334.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,92.68,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00474 Proc 76936 at $125.60 (Base Rate) * 0.7379 (Relative Weight) = $92.68 (Total Line Payment) at 100% = $92.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,209.73,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,92.68,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00474 Proc 76936 at $125.60 (Base Rate) * 0.7379 (Relative Weight) = $92.68 (Total Line Payment) at 100% = $92.68. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,98.24,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00474 Proc 76936 at $125.60 (Base Rate) * 0.7379 (Relative Weight) = $92.68 (Total Line Payment) at 100% = $92.68... $92.68 at 106% = $98.24 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,209.73,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,667.00,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $667.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1120.56,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,120.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,471.90,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1000.50,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,000.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1227.28,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $1,227.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,851.49,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $851.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,211.83,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,960.48,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $960.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,TRIOLOGY,TRILOGY MEDICAID,98.24,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00474 Proc 76936 at $125.60 (Base Rate) * 0.7379 (Relative Weight) = $92.68 (Total Line Payment) at 106% = $98.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,209.73,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,92.6800,1334.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76936 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,UNITY HEALTH PLAN,UNITY HOSPICE,209.73,,,,,,,92.6800,1334.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,960.48,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $960.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,827.08,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $827.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,960.48,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $960.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,960.48,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $960.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED COMPRESSION RPR,76936,CPT,402,RC,40200050,CDM,,,,both,,,1334.0000,880.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,800.40,,,,,,,92.6800,1334.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,334.00 in Billed Charges for Rev 402 Proc 76936 = $800.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,AETNA,AETNA HSHS,362.41,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $362.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,AETNA,ALL COMMERCIAL AETNA,561.00,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,ANTHEM,ANTEHM MEDICAID,51.53,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76937 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,47.8900,561.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,ANTHEM,ANTHEM PPO,500.00,,,,,,,47.8900,561.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,561.00,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,CENPATICO,ALL MEDICAID CENPATICO,561.00,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,476.85,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $476.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,CIGNA,ALL COMMERCIAL CIGNA,392.70,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $392.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,COFINITY,COFINITY,561.00,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.53,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76937 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.53,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76937 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,532.95,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $532.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,471.24,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $471.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,398.31,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $398.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,409.53,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $409.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,272.65,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $272.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,476.85,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $476.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,HUMANA,HUMANA CHOICE CARE HMO,47.89,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $47.89 from Fee Schedule 005543_205 for Rev 402 Proc 76937 Mod TC * Qty 1 = $47.89 at 100% = $47.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,HUMANA,HUMANA CHOICE CARE PPO,476.85,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $476.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,HUMANA,HUMANA NATIIONAL POS HMO,47.89,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $47.89 from Fee Schedule 005543_205 for Rev 402 Proc 76937 Mod TC * Qty 1 = $47.89 at 100% = $47.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,409.53,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $409.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,561.00,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $561.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.53,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76937 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.53,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76937 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,MOLINA HEALTHCARE,MOLINA MEDICAID,54.62,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76937 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53... $51.53 at 106% = $54.62 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,280.50,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $280.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,471.24,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $471.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,420.75,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $420.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,516.12,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $516.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,47.8900,561.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,47.8900,561.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,47.8900,561.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,47.8900,561.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,358.09,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $358.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,403.92,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $403.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,TRIOLOGY,TRILOGY MEDICAID,54.63,,,,,,,47.8900,561.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76937 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 106% = $54.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,561.00,,,,,,,47.8900,561.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $561.00, claim capped at $561.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,561.00,,,,,,,47.8900,561.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $561.00, claim capped at $561.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,561.00,,,,,,,47.8900,561.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76937 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $561.00, claim capped at $561.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,403.92,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $403.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,347.82,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $347.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,403.92,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $403.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,403.92,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $403.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDED VASCULAR ACCESS 76937,76937,CPT,402,RC,40200051,CDM,,,,both,,,561.0000,370.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,336.60,,,,,,,47.8900,561.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $561.00 in Billed Charges for Rev 402 Proc 76937 = $336.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,AETNA,AETNA HSHS,540.70,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $540.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,AETNA,ALL COMMERCIAL AETNA,837.00,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,ANTHEM,ANTEHM MEDICAID,51.53,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76940 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,ANTHEM,ANTHEM PPO,500.00,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,837.00,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,CENPATICO,ALL MEDICAID CENPATICO,837.00,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,711.45,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $711.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,CIGNA,ALL COMMERCIAL CIGNA,585.90,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $585.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,COFINITY,COFINITY,837.00,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,51.53,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76940 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,51.53,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76940 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,795.15,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $795.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,703.08,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $703.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,594.27,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $594.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,611.01,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $611.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,406.78,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $406.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,711.45,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $711.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,HUMANA,HUMANA CHOICE CARE HMO,139.58,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $139.58 from Fee Schedule 005543_205 for Rev 402 Proc 76940 Mod TC * Qty 1 = $139.58 at 100% = $139.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,HUMANA,HUMANA CHOICE CARE PPO,711.45,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $711.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,HUMANA,HUMANA NATIIONAL POS HMO,139.58,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $139.58 from Fee Schedule 005543_205 for Rev 402 Proc 76940 Mod TC * Qty 1 = $139.58 at 100% = $139.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,611.01,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $611.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,837.00,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $837.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,51.53,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76940 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,51.53,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76940 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,MOLINA HEALTHCARE,MOLINA MEDICAID,54.62,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76940 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 100% = $51.53... $51.53 at 106% = $54.62 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,418.50,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $418.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,703.08,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $703.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,627.75,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $627.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,770.04,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $770.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,534.26,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $534.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,602.64,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,TRIOLOGY,TRILOGY MEDICAID,54.63,,,,,,,51.5300,837.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00472 Proc 76940 at $125.60 (Base Rate) * 0.4103 (Relative Weight) = $51.53 (Total Line Payment) at 106% = $54.63. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,51.5300,837.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76940 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,602.64,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,518.94,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $518.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,602.64,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,602.64,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $602.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US GUIDANCE TISSUE ABLATION,76940,CPT,402,RC,40200052,CDM,,,,both,,,837.0000,552.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,502.20,,,,,,,51.5300,837.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $837.00 in Billed Charges for Rev 402 Proc 76940 = $502.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,AETNA,AETNA HSHS,788.12,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $788.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,AETNA,AETNA MEDICARE,231.76,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,AETNA,ALL COMMERCIAL AETNA,1220.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,ANTHEM,ANTEHM MEDICAID,77.18,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93975 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,231.76,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,ANTHEM,ANTHEM PPO,500.00,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1220.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,CENPATICO,ALL MEDICAID CENPATICO,1220.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1037.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,CIGNA,ALL COMMERCIAL CIGNA,854.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $854.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,COFINITY,COFINITY,1220.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,77.18,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93975 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,77.18,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93975 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1159.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,1024.80,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,024.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,866.20,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $866.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,890.60,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $890.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,592.92,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $592.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1037.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HUMANA,HUMANA CHOICE CARE HMO,410.37,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $410.37 from Fee Schedule 005543_205 for Rev 402 Proc 93975 Mod TC * Qty 1 = $410.37 at 100% = $410.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HUMANA,HUMANA CHOICE CARE PPO,1037.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,231.76,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,HUMANA,HUMANA NATIIONAL POS HMO,410.37,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $410.37 from Fee Schedule 005543_205 for Rev 402 Proc 93975 Mod TC * Qty 1 = $410.37 at 100% = $410.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,890.60,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $890.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1220.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,220.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,77.18,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93975 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,231.76,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,77.18,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93975 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,81.81,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93975 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 100% = $77.18... $77.18 at 106% = $81.81 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,231.76,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,610.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $610.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1024.80,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,024.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,521.46,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,915.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $915.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1122.40,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $1,122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,778.73,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $778.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,234.08,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,878.40,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $878.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,TRIOLOGY,TRILOGY MEDICAID,81.81,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00289 Proc 93975 at $125.60 (Base Rate) * 0.6145 (Relative Weight) = $77.18 (Total Line Payment) at 106% = $81.81. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,231.76,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,77.1800,1220.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93975 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,UNITY HEALTH PLAN,UNITY HOSPICE,231.76,,,,,,,77.1800,1220.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,878.40,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $878.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,756.40,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $756.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,878.40,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $878.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,878.40,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $878.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
VASCULAR STUDY,93975,CPT,402,RC,40200064,CDM,,,,both,,,1220.0000,805.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,732.00,,,,,,,77.1800,1220.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,220.00 in Billed Charges for Rev 402 Proc 93975 = $732.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,AETNA,AETNA HSHS,451.55,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $451.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,AETNA,ALL COMMERCIAL AETNA,699.00,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $699.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 93979 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,699.00,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $699.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,CENPATICO,ALL MEDICAID CENPATICO,699.00,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $699.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,594.15,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $594.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,CIGNA,ALL COMMERCIAL CIGNA,489.30,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $489.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,COFINITY,COFINITY,699.00,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $699.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 93979 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 93979 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,664.05,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $664.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,587.16,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $587.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,496.29,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $496.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,510.27,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $510.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,339.71,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $339.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,594.15,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $594.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HUMANA,HUMANA CHOICE CARE HMO,184.62,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $184.62 from Fee Schedule 005543_205 for Rev 402 Proc 93979 Mod TC * Qty 1 = $184.62 at 100% = $184.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HUMANA,HUMANA CHOICE CARE PPO,594.15,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $594.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,HUMANA,HUMANA NATIIONAL POS HMO,184.62,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $184.62 from Fee Schedule 005543_205 for Rev 402 Proc 93979 Mod TC * Qty 1 = $184.62 at 100% = $184.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,510.27,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $510.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,699.00,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $699.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 93979 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 93979 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 93979 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,349.50,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $349.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,587.16,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $587.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,524.25,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $524.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,643.08,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $643.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,446.17,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $446.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,503.28,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $503.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 93979 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,699.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 93979 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,699.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,503.28,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $503.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,433.38,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $433.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,503.28,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $503.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,503.28,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $503.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DUPLEX AORTA/IVC/GRAFT LTD,93979,CPT,402,RC,40200074,CDM,,,,both,,,699.0000,461.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,419.40,,,,,,,50.1000,699.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $699.00 in Billed Charges for Rev 402 Proc 93979 = $419.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,AETNA,AETNA HSHS,378.56,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $378.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,AETNA,AETNA MEDICARE,101.55,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,AETNA,ALL COMMERCIAL AETNA,586.00,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $586.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76706 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,ANTHEM,ANTHEM POS/HMO,500.00,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,ANTHEM,ANTHEM PPO,500.00,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 Qty 1 * $500.00 = $500.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,586.00,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $586.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,CENPATICO,ALL MEDICAID CENPATICO,586.00,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $586.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,498.10,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $498.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,CIGNA,ALL COMMERCIAL CIGNA,410.20,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $410.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,COFINITY,COFINITY,586.00,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $586.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76706 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76706 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,556.70,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $556.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,492.24,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $492.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,416.06,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $416.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,427.78,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $427.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,284.80,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $284.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,498.10,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $498.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HUMANA,HUMANA CHOICE CARE HMO,158.26,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $158.26 from Fee Schedule 005543_205 for Rev 402 Proc 76706 Mod TC * Qty 1 = $158.26 at 100% = $158.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HUMANA,HUMANA CHOICE CARE PPO,498.10,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $498.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,HUMANA,HUMANA NATIIONAL POS HMO,158.26,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $158.26 from Fee Schedule 005543_205 for Rev 402 Proc 76706 Mod TC * Qty 1 = $158.26 at 100% = $158.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,427.78,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $427.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,586.00,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $586.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76706 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76706 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76706 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,293.00,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $293.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,492.24,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $492.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,439.50,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $439.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,539.12,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $539.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,521.52,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,521.52,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,PREVEA HEALTH NETWORK,PREVEA360,521.52,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,521.52,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 1 Visit at $521.52 per Visit = $521.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,374.04,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $374.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,421.92,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $421.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76706 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,574.00,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,574.00,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,574.00,,,,,,,50.1000,586.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76706 1 Visit at $574.00 per Visit = $574.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,50.1000,586.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,421.92,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $421.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,363.32,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $363.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,421.92,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $421.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,421.92,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $421.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US AORTA (SCREENING),76706,CPT,402,RC,40200075,CDM,,,,both,,,586.0000,386.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,351.60,,,,,,,50.1000,586.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $586.00 in Billed Charges for Rev 402 Proc 76706 = $351.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,AETNA,AETNA HSHS,287.47,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $287.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,AETNA,AETNA MEDICARE,101.55,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,AETNA,ALL COMMERCIAL AETNA,445.00,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,ANTHEM,ANTEHM MEDICAID,46.16,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76813 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,ANTHEM,ANTHEM POS/HMO,445.00,,,,,,,46.1600,445.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 Qty 1 * $500.00 = $500.00 (Limited to $445.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,ANTHEM,ANTHEM PPO,445.00,,,,,,,46.1600,445.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 Qty 1 * $500.00 = $500.00 (Limited to $445.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,445.00,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,CENPATICO,ALL MEDICAID CENPATICO,445.00,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,378.25,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $378.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,CIGNA,ALL COMMERCIAL CIGNA,311.50,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $311.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,COFINITY,COFINITY,445.00,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,46.16,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76813 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,46.16,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76813 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,422.75,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $422.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,373.80,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $373.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,315.95,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $315.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,324.85,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $324.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,216.27,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $216.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,378.25,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $378.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HUMANA,HUMANA CHOICE CARE HMO,117.77,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $117.77 from Fee Schedule 005543_205 for Rev 402 Proc 76813 Mod TC * Qty 1 = $117.77 at 100% = $117.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HUMANA,HUMANA CHOICE CARE PPO,378.25,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $378.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,HUMANA,HUMANA NATIIONAL POS HMO,117.77,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $117.77 from Fee Schedule 005543_205 for Rev 402 Proc 76813 Mod TC * Qty 1 = $117.77 at 100% = $117.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,324.85,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $324.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,445.00,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $445.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,46.16,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76813 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,46.16,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76813 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,48.93,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76813 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 100% = $46.16... $46.16 at 106% = $48.93 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,222.50,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $222.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,373.80,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $373.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,333.75,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $333.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,409.40,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $409.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,445.00,,,,,,,46.1600,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,445.00,,,,,,,46.1600,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,PREVEA HEALTH NETWORK,PREVEA360,445.00,,,,,,,46.1600,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,445.00,,,,,,,46.1600,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,284.04,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $284.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,320.40,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,TRIOLOGY,TRILOGY MEDICAID,48.93,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00470 Proc 76813 at $125.60 (Base Rate) * 0.3675 (Relative Weight) = $46.16 (Total Line Payment) at 106% = $48.93. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,445.00,,,,,,,46.1600,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,445.00,,,,,,,46.1600,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,445.00,,,,,,,46.1600,445.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76813 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $445.00, claim capped at $445.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,46.1600,445.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,320.40,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,275.90,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $275.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,320.40,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,320.40,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $320.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC US FETAL NUCHAL TRANSLUCENCY SNG,76813,CPT,402,RC,40200092,CDM,,,,both,,,445.0000,293.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,267.00,,,,,,,46.1600,445.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $445.00 in Billed Charges for Rev 402 Proc 76813 = $267.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,AETNA,AETNA HSHS,217.70,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $217.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,AETNA,AETNA MEDICARE,101.55,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,AETNA,ALL COMMERCIAL AETNA,337.00,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,ANTHEM,ANTEHM MEDICAID,50.10,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76512 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,101.55,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,ANTHEM,ANTHEM POS/HMO,337.00,,,,,,,34.8500,337.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 Qty 1 * $500.00 = $500.00 (Limited to $337.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,ANTHEM,ANTHEM PPO,337.00,,,,,,,34.8500,337.0000,other,ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 Qty 1 * $500.00 = $500.00 (Limited to $337.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,337.00,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,CENPATICO,ALL MEDICAID CENPATICO,337.00,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,286.45,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $286.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,CIGNA,ALL COMMERCIAL CIGNA,235.90,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $235.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,COFINITY,COFINITY,337.00,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,50.10,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76512 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,50.10,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76512 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,320.15,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $320.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,283.08,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $283.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,239.27,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $239.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,246.01,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $246.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,163.78,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $163.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,286.45,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $286.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HUMANA,HUMANA CHOICE CARE HMO,34.85,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.85 from Fee Schedule 005543_205 for Rev 402 Proc 76512 Mod TC * Qty 1 = $34.85 at 100% = $34.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HUMANA,HUMANA CHOICE CARE PPO,286.45,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $286.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HUMANA,HUMANA MEDICARE ADVANTAGE,101.55,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,HUMANA,HUMANA NATIIONAL POS HMO,34.85,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.85 from Fee Schedule 005543_205 for Rev 402 Proc 76512 Mod TC * Qty 1 = $34.85 at 100% = $34.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,246.01,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $246.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,337.00,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $337.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,50.10,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76512 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.55,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,50.10,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76512 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,MOLINA HEALTHCARE,MOLINA MEDICAID,53.11,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76512 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 100% = $50.10... $50.10 at 106% = $53.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,MOLINA HEALTHCARE,MOLINA MEDICARE,101.55,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,168.50,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $168.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,283.08,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $283.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,NAPHCARE,ALL COMMERICAL NAPHCARE,228.48,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,252.75,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $252.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,310.04,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $310.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,337.00,,,,,,,34.8500,337.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $337.00, claim capped at $337.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,337.00,,,,,,,34.8500,337.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $337.00, claim capped at $337.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,PREVEA HEALTH NETWORK,PREVEA360,337.00,,,,,,,34.8500,337.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $337.00, claim capped at $337.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,337.00,,,,,,,34.8500,337.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 1 Visit at $521.52 per Visit = $521.52 (Service Line reduced to $337.00, claim capped at $337.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,215.11,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $215.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,102.57,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,242.64,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $242.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,TRIOLOGY,TRILOGY MEDICAID,53.11,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00288 Proc 76512 at $125.60 (Base Rate) * 0.3989 (Relative Weight) = $50.10 (Total Line Payment) at 106% = $53.11. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,337.00,,,,,,,34.8500,337.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $337.00, claim capped at $337.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,337.00,,,,,,,34.8500,337.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $337.00, claim capped at $337.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,101.55,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,337.00,,,,,,,34.8500,337.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 402 Proc 76512 1 Visit at $574.00 per Visit = $574.00 (Service Line reduced to $337.00, claim capped at $337.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,UNITY HEALTH PLAN,UNITY HOSPICE,101.55,,,,,,,34.8500,337.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,242.64,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $242.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,208.94,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $208.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,242.64,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $242.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,242.64,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $242.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPHTHALMIC US DIAG B-SCAN,76512,CPT,402,RC,40200096,CDM,,,,both,,,337.0000,222.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,202.20,,,,,,,34.8500,337.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $337.00 in Billed Charges for Rev 402 Proc 76512 = $202.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,AETNA,AETNA HSHS,5012.96,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,012.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,AETNA,AETNA MEDICARE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,AETNA,ALL COMMERCIAL AETNA,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,ANTHEM,ANTEHM MEDICAID,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78815 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,ANTHEM,ANTHEM POS/HMO,4600.00,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,ANTHEM,ANTHEM PPO,4600.00,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,CENPATICO,ALL MEDICAID CENPATICO,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6596.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $6,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,CIGNA,ALL COMMERCIAL CIGNA,5432.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,COFINITY,COFINITY,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78815 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78815 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7372.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $7,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,6518.40,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $6,518.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5509.60,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,509.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5664.80,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,664.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,3771.36,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $3,771.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6596.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $6,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,HUMANA CHOICE CARE HMO,5794.84,,,,,,,611.5800,7760.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,794.84 from Fee Schedule 005543_205 for Rev 404 Proc 78815 Mod TC * Qty 1 = $5,794.84 at 100% = $5,794.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,HUMANA CHOICE CARE PPO,6596.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $6,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,HUMANA NATIIONAL POS HMO,5794.84,,,,,,,611.5800,7760.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,794.84 from Fee Schedule 005543_205 for Rev 404 Proc 78815 Mod TC * Qty 1 = $5,794.84 at 100% = $5,794.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5664.80,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,664.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78815 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78815 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,648.27,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78815 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58... $611.58 at 106% = $648.27 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3880.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $3,880.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6518.40,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $6,518.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,3125.15,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5820.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,820.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7139.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $7,139.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3928.74,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3928.74,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,PREVEA HEALTH NETWORK,PREVEA360,3928.74,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3928.74,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4953.21,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $4,953.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1402.85,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5587.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,587.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,TRIOLOGY,TRILOGY MEDICAID,648.28,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78815 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 106% = $648.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,4115.50,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78815 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,UNITY HEALTH PLAN,UNITY HOSPICE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5587.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,587.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4811.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $4,811.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5587.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,587.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5587.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $5,587.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT TUMR SKULL MID-THIGH,78815,CPT,404,RC,40400004,CDM,,,,both,,,7760.0000,5121.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4656.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,760.00 in Billed Charges for Rev 404 Proc 78815 = $4,656.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,AETNA,AETNA HSHS,5012.96,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,012.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,AETNA,AETNA MEDICARE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,AETNA,ALL COMMERCIAL AETNA,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,ANTHEM,ANTEHM MEDICAID,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78816 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,ANTHEM,ANTHEM POS/HMO,4600.00,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,ANTHEM,ANTHEM PPO,4600.00,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,CENPATICO,ALL MEDICAID CENPATICO,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6596.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $6,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,CIGNA,ALL COMMERCIAL CIGNA,5432.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,432.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,COFINITY,COFINITY,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78816 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78816 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7372.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $7,372.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,6518.40,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $6,518.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5509.60,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,509.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5664.80,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,664.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,3771.36,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $3,771.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6596.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $6,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,HUMANA CHOICE CARE HMO,5794.84,,,,,,,611.5800,7760.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,794.84 from Fee Schedule 005543_205 for Rev 404 Proc 78816 Mod TC * Qty 1 = $5,794.84 at 100% = $5,794.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,HUMANA CHOICE CARE PPO,6596.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $6,596.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,HUMANA,HUMANA NATIIONAL POS HMO,5794.84,,,,,,,611.5800,7760.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,794.84 from Fee Schedule 005543_205 for Rev 404 Proc 78816 Mod TC * Qty 1 = $5,794.84 at 100% = $5,794.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5664.80,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,664.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,7760.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $7,760.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78816 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,611.58,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78816 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,648.27,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78816 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58... $611.58 at 106% = $648.27 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3880.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $3,880.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6518.40,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $6,518.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,3125.15,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5820.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,820.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7139.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $7,139.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3928.74,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3928.74,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,PREVEA HEALTH NETWORK,PREVEA360,3928.74,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3928.74,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4953.21,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $4,953.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1402.85,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5587.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,587.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,TRIOLOGY,TRILOGY MEDICAID,648.28,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78816 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 106% = $648.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,4115.50,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7760.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78816 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,UNITY HEALTH PLAN,UNITY HOSPICE,1388.96,,,,,,,611.5800,7760.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5587.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,587.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4811.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $4,811.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5587.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,587.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5587.20,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $5,587.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET W/CT MELAN IMAG WHOLE BODY,78816,CPT,404,RC,40400005,CDM,,,,both,,,7760.0000,5121.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4656.00,,,,,,,611.5800,7760.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,760.00 in Billed Charges for Rev 404 Proc 78816 = $4,656.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,AETNA,AETNA HSHS,4797.84,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $4,797.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,AETNA,AETNA MEDICARE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,AETNA,ALL COMMERCIAL AETNA,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,ANTHEM,ANTEHM MEDICAID,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78608 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,ANTHEM,ANTHEM POS/HMO,4600.00,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,ANTHEM,ANTHEM PPO,4600.00,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,CENPATICO,ALL MEDICAID CENPATICO,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6312.95,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $6,312.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,CIGNA,ALL COMMERCIAL CIGNA,5198.90,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,198.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,COFINITY,COFINITY,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78608 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78608 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7055.65,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $7,055.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,6238.68,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $6,238.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5273.17,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,273.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5421.71,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,421.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,3609.52,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $3,609.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6312.95,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $6,312.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,HUMANA CHOICE CARE HMO,2923.75,,,,,,,611.5800,7427.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,923.75 from Fee Schedule 005543_205 for Rev 404 Proc 78608 Mod TC * Qty 1 = $2,923.75 at 100% = $2,923.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,HUMANA CHOICE CARE PPO,6312.95,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $6,312.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,HUMANA MEDICARE ADVANTAGE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,HUMANA,HUMANA NATIIONAL POS HMO,2923.75,,,,,,,611.5800,7427.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,923.75 from Fee Schedule 005543_205 for Rev 404 Proc 78608 Mod TC * Qty 1 = $2,923.75 at 100% = $2,923.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5421.71,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,421.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,7427.00,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $7,427.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78608 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,611.58,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78608 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,MOLINA HEALTHCARE,MOLINA MEDICAID,648.27,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78608 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58... $611.58 at 106% = $648.27 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,MOLINA HEALTHCARE,MOLINA MEDICARE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3713.50,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $3,713.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6238.68,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $6,238.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,NAPHCARE,ALL COMMERICAL NAPHCARE,3125.15,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5570.25,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,570.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6832.84,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $6,832.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3928.74,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3928.74,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,PREVEA HEALTH NETWORK,PREVEA360,3928.74,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3928.74,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4740.65,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $4,740.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1402.85,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5347.44,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,347.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,TRIOLOGY,TRILOGY MEDICAID,648.28,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78608 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 106% = $648.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,4115.50,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7427.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78608 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,UNITY HEALTH PLAN,UNITY HOSPICE,1388.96,,,,,,,611.5800,7427.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5347.44,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,347.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4604.74,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $4,604.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5347.44,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,347.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5347.44,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $5,347.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET BRAIN LIMITED ALZHEIMERS,78608,CPT,404,RC,40400006,CDM,,,,both,,,7427.0000,4901.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4456.20,,,,,,,611.5800,7427.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,427.00 in Billed Charges for Rev 404 Proc 78608 = $4,456.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,AETNA,AETNA HSHS,5046.55,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,046.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,AETNA,AETNA MEDICARE,1257.53,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,AETNA,ALL COMMERCIAL AETNA,7812.00,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $7,812.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,ANTHEM,ANTEHM MEDICAID,611.58,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78811 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1257.53,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,ANTHEM,ANTHEM POS/HMO,4600.00,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,ANTHEM,ANTHEM PPO,4600.00,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $4,600.00 per Visit = $4,600.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7812.00,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $7,812.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,CENPATICO,ALL MEDICAID CENPATICO,7812.00,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $7,812.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6640.20,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $6,640.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,CIGNA,ALL COMMERCIAL CIGNA,5468.40,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,468.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,COFINITY,COFINITY,7812.00,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $7,812.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,611.58,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78811 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,611.58,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78811 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7421.40,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $7,421.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,6562.08,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $6,562.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5546.52,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,546.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5702.76,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,702.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,3796.63,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $3,796.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6640.20,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $6,640.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HUMANA,HUMANA CHOICE CARE HMO,4635.89,,,,,,,611.5800,7812.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,635.89 from Fee Schedule 005543_205 for Rev 404 Proc 78811 Mod TC * Qty 1 = $4,635.89 at 100% = $4,635.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HUMANA,HUMANA CHOICE CARE PPO,6640.20,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $6,640.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,1257.53,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,HUMANA,HUMANA NATIIONAL POS HMO,4635.89,,,,,,,611.5800,7812.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $4,635.89 from Fee Schedule 005543_205 for Rev 404 Proc 78811 Mod TC * Qty 1 = $4,635.89 at 100% = $4,635.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5702.76,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,702.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,7812.00,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $7,812.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,611.58,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78811 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1257.53,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,611.58,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78811 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,648.27,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78811 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 100% = $611.58... $611.58 at 106% = $648.27 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,1257.53,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3906.00,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $3,906.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6562.08,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $6,562.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,2829.45,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5859.00,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,859.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7187.04,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $7,187.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3928.74,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3928.74,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,PREVEA HEALTH NETWORK,PREVEA360,3928.74,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3928.74,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $3,928.74 per Visit = $3,928.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4986.40,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $4,986.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1270.11,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5624.64,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,624.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,TRIOLOGY,TRILOGY MEDICAID,648.28,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00290 Proc 78811 at $125.60 (Base Rate) * 4.8693 (Relative Weight) = $611.58 (Total Line Payment) at 106% = $648.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,4115.50,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1257.53,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,4115.50,,,,,,,611.5800,7812.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 404 Proc 78811 1 Visit at $4,115.50 per Visit = $4,115.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,UNITY HEALTH PLAN,UNITY HOSPICE,1257.53,,,,,,,611.5800,7812.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5624.64,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,624.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4843.44,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $4,843.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5624.64,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,624.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5624.64,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $5,624.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC PET IMAGING LIMITED AREA CHEST HEAD/NECK,78811,CPT,404,RC,40400008,CDM,,,,both,,,7812.0000,5155.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4687.20,,,,,,,611.5800,7812.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $7,812.00 in Billed Charges for Rev 404 Proc 78811 = $4,687.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,AETNA,AETNA HSHS,121.45,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $188.00 in Billed Charges for Rev 410 = $121.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,AETNA,ALL COMMERCIAL AETNA,188.00,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 410 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,ANTHEM,ANTHEM POS/HMO,127.84,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $188.00 in Billed Charges for Rev 410 = $127.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,ANTHEM,ANTHEM PPO,127.84,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $188.00 in Billed Charges for Rev 410 = $127.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,188.00,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 410 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,CENPATICO,ALL MEDICAID CENPATICO,188.00,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 410 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,159.80,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.00 in Billed Charges for Rev 410 = $159.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,CIGNA,ALL COMMERCIAL CIGNA,131.60,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $188.00 in Billed Charges for Rev 410 = $131.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,COFINITY,COFINITY,188.00,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 410 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,178.60,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $188.00 in Billed Charges for Rev 410 = $178.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,157.92,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $188.00 in Billed Charges for Rev 410 = $157.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,133.48,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $188.00 in Billed Charges for Rev 410 = $133.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,137.24,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $188.00 in Billed Charges for Rev 410 = $137.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,91.37,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $188.00 in Billed Charges for Rev 410 = $91.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,159.80,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.00 in Billed Charges for Rev 410 = $159.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,HUMANA,HUMANA CHOICE CARE HMO,119.38,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $188.00 in Billed Charges for Rev 410 = $119.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,HUMANA,HUMANA CHOICE CARE PPO,159.80,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.00 in Billed Charges for Rev 410 = $159.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,HUMANA,HUMANA NATIIONAL POS HMO,119.38,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $188.00 in Billed Charges for Rev 410 = $119.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,137.24,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $188.00 in Billed Charges for Rev 410 = $137.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,188.00,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.00 in Billed Charges for Rev 410 = $188.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,94.00,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $188.00 in Billed Charges for Rev 410 = $94.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,157.92,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $188.00 in Billed Charges for Rev 410 = $157.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,141.00,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $188.00 in Billed Charges for Rev 410 = $141.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,172.96,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $188.00 in Billed Charges for Rev 410 = $172.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,90.8900,188.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,90.8900,188.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,90.8900,188.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,90.8900,188.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,120.00,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $188.00 in Billed Charges for Rev 410 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,135.36,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.00 in Billed Charges for Rev 410 = $135.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,90.8900,188.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,90.8900,188.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,90.8900,188.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,135.36,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.00 in Billed Charges for Rev 410 = $135.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,116.56,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $188.00 in Billed Charges for Rev 410 = $116.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,135.36,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.00 in Billed Charges for Rev 410 = $135.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,135.36,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.00 in Billed Charges for Rev 410 = $135.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC COUGH ASSIST,410,RC,41000004,CDM,,,,,,both,,,188.0000,124.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,112.80,,,,,,,90.8900,188.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.00 in Billed Charges for Rev 410 = $112.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,AETNA,AETNA HSHS,589.15,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $589.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,AETNA,AETNA MEDICARE,209.73,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,AETNA,ALL COMMERCIAL AETNA,912.00,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $912.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,ANTHEM,ANTEHM MEDICAID,322.19,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00092 Proc 92950 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment) at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,209.73,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,ANTHEM,ANTHEM POS/HMO,620.16,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $620.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,ANTHEM,ANTHEM PPO,620.16,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $620.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,912.00,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $912.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,CENPATICO,ALL MEDICAID CENPATICO,912.00,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $912.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,775.20,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $775.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,CIGNA,ALL COMMERCIAL CIGNA,638.40,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $638.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,COFINITY,COFINITY,912.00,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $912.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,322.19,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00092 Proc 92950 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment) at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,322.19,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00092 Proc 92950 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment) at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,866.40,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $866.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,766.08,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $766.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,647.52,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $647.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,665.76,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $665.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,443.23,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $443.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,775.20,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $775.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HUMANA,HUMANA CHOICE CARE HMO,579.12,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $579.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HUMANA,HUMANA CHOICE CARE PPO,775.20,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $775.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HUMANA,HUMANA MEDICARE ADVANTAGE,209.73,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,HUMANA,HUMANA NATIIONAL POS HMO,579.12,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $579.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,665.76,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $665.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,912.00,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $912.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,322.19,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00092 Proc 92950 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment) at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,209.73,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,322.19,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00092 Proc 92950 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment) at 100% = $322.19. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,341.52,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00092 Proc 92950 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment) at 100% = $322.19... $322.19 at 106% = $341.52 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,MOLINA HEALTHCARE,MOLINA MEDICARE,209.73,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,456.00,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $456.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,766.08,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $766.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,NAPHCARE,ALL COMMERICAL NAPHCARE,471.90,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,684.00,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $684.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,839.04,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $839.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,912.00,,,,,,,209.7300,912.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 480 Proc 92950 1 Visit at $1,308.14 per Visit = $1,308.14 (Service Line reduced to $912.00, claim capped at $912.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,912.00,,,,,,,209.7300,912.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 480 Proc 92950 1 Visit at $1,308.14 per Visit = $1,308.14 (Service Line reduced to $912.00, claim capped at $912.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,PREVEA HEALTH NETWORK,PREVEA360,912.00,,,,,,,209.7300,912.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 480 Proc 92950 1 Visit at $1,308.14 per Visit = $1,308.14 (Service Line reduced to $912.00, claim capped at $912.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,912.00,,,,,,,209.7300,912.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 480 Proc 92950 1 Visit at $1,308.14 per Visit = $1,308.14 (Service Line reduced to $912.00, claim capped at $912.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,582.13,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $582.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,211.83,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,656.64,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $656.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,TRIOLOGY,TRILOGY MEDICAID,341.52,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00092 Proc 92950 at $125.60 (Base Rate) * 2.5652 (Relative Weight) = $322.19 (Total Line Payment) at 106% = $341.52. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,912.00,,,,,,,209.7300,912.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 480 Proc 92950 1 Visit at $1,370.50 per Visit = $1,370.50 (Service Line reduced to $912.00, claim capped at $912.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,912.00,,,,,,,209.7300,912.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 480 Proc 92950 1 Visit at $1,370.50 per Visit = $1,370.50 (Service Line reduced to $912.00, claim capped at $912.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,209.73,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,912.00,,,,,,,209.7300,912.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 480 Proc 92950 1 Visit at $1,370.50 per Visit = $1,370.50 (Service Line reduced to $912.00, claim capped at $912.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,UNITY HEALTH PLAN,UNITY HOSPICE,209.73,,,,,,,209.7300,912.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,656.64,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $656.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,565.44,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $565.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,656.64,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $656.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,656.64,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $656.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPR,92950,CPT,480,RC,41000005,CDM,,,,both,,,912.0000,601.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,547.20,,,,,,,209.7300,912.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $912.00 in Billed Charges for Rev 480 Proc 92950 = $547.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,AETNA,AETNA HSHS,253.23,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $392.00 in Billed Charges for Rev 410 = $253.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,AETNA,ALL COMMERCIAL AETNA,392.00,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 410 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,392.00,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 410 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,333.20,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 410 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,CIGNA,ALL COMMERCIAL CIGNA,274.40,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $392.00 in Billed Charges for Rev 410 = $274.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,COFINITY,COFINITY,392.00,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 410 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,372.40,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $392.00 in Billed Charges for Rev 410 = $372.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,329.28,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.00 in Billed Charges for Rev 410 = $329.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,278.32,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $392.00 in Billed Charges for Rev 410 = $278.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,286.16,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.00 in Billed Charges for Rev 410 = $286.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,190.51,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $392.00 in Billed Charges for Rev 410 = $190.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,333.20,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 410 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,HUMANA,HUMANA CHOICE CARE PPO,333.20,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.00 in Billed Charges for Rev 410 = $333.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,286.16,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.00 in Billed Charges for Rev 410 = $286.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,392.00,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.00 in Billed Charges for Rev 410 = $392.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,196.00,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $392.00 in Billed Charges for Rev 410 = $196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,329.28,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.00 in Billed Charges for Rev 410 = $329.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,294.00,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $392.00 in Billed Charges for Rev 410 = $294.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,360.64,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $392.00 in Billed Charges for Rev 410 = $360.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,250.21,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $392.00 in Billed Charges for Rev 410 = $250.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,282.24,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 410 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,282.24,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 410 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,243.04,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $392.00 in Billed Charges for Rev 410 = $243.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,282.24,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 410 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CPAP INITIATION&MGMT,410,RC,41000013,CDM,,,,,,inpatient,,,392.0000,258.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,282.24,,,,,,,190.5100,392.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.00 in Billed Charges for Rev 410 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,AETNA,AETNA HSHS,25.19,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $39.00 in Billed Charges for Rev 410 = $25.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,AETNA,ALL COMMERCIAL AETNA,39.00,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.00 in Billed Charges for Rev 410 = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,ANTHEM,ANTHEM POS/HMO,26.52,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $39.00 in Billed Charges for Rev 410 = $26.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,ANTHEM,ANTHEM PPO,26.52,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $39.00 in Billed Charges for Rev 410 = $26.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,39.00,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.00 in Billed Charges for Rev 410 = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,CENPATICO,ALL MEDICAID CENPATICO,39.00,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.00 in Billed Charges for Rev 410 = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,33.15,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.00 in Billed Charges for Rev 410 = $33.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,CIGNA,ALL COMMERCIAL CIGNA,27.30,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $39.00 in Billed Charges for Rev 410 = $27.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,COFINITY,COFINITY,39.00,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.00 in Billed Charges for Rev 410 = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,37.05,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $39.00 in Billed Charges for Rev 410 = $37.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,32.76,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $39.00 in Billed Charges for Rev 410 = $32.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,27.69,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $39.00 in Billed Charges for Rev 410 = $27.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,28.47,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $39.00 in Billed Charges for Rev 410 = $28.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,18.95,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $39.00 in Billed Charges for Rev 410 = $18.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,33.15,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.00 in Billed Charges for Rev 410 = $33.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,HUMANA,HUMANA CHOICE CARE HMO,24.77,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $39.00 in Billed Charges for Rev 410 = $24.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,HUMANA,HUMANA CHOICE CARE PPO,33.15,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.00 in Billed Charges for Rev 410 = $33.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,HUMANA,HUMANA NATIIONAL POS HMO,24.77,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $39.00 in Billed Charges for Rev 410 = $24.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,28.47,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $39.00 in Billed Charges for Rev 410 = $28.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,39.00,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.00 in Billed Charges for Rev 410 = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.50,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $39.00 in Billed Charges for Rev 410 = $19.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,32.76,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $39.00 in Billed Charges for Rev 410 = $32.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,29.25,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $39.00 in Billed Charges for Rev 410 = $29.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,35.88,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $39.00 in Billed Charges for Rev 410 = $35.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,39.00,,,,,,,18.9500,39.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 (Service Line reduced to $39.00, claim capped at $39.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,39.00,,,,,,,18.9500,39.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 (Service Line reduced to $39.00, claim capped at $39.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,PREVEA HEALTH NETWORK,PREVEA360,39.00,,,,,,,18.9500,39.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 (Service Line reduced to $39.00, claim capped at $39.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,39.00,,,,,,,18.9500,39.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 (Service Line reduced to $39.00, claim capped at $39.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,24.89,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $39.00 in Billed Charges for Rev 410 = $24.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,28.08,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.00 in Billed Charges for Rev 410 = $28.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,39.00,,,,,,,18.9500,39.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $39.00, claim capped at $39.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,39.00,,,,,,,18.9500,39.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $39.00, claim capped at $39.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,39.00,,,,,,,18.9500,39.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 (Service Line reduced to $39.00, claim capped at $39.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,28.08,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.00 in Billed Charges for Rev 410 = $28.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,24.18,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $39.00 in Billed Charges for Rev 410 = $24.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,28.08,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.00 in Billed Charges for Rev 410 = $28.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,28.08,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.00 in Billed Charges for Rev 410 = $28.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PULM REHAB IP SUBQ VIST/15 MINS,410,RC,41000021,CDM,,,,,,both,,,39.0000,25.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,23.40,,,,,,,18.9500,39.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $39.00 in Billed Charges for Rev 410 = $23.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,AETNA,AETNA HSHS,596.26,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $923.00 in Billed Charges for Rev 410 = $596.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,AETNA,ALL COMMERCIAL AETNA,923.00,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $923.00 in Billed Charges for Rev 410 = $923.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,ANTHEM,ANTHEM POS/HMO,627.64,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $923.00 in Billed Charges for Rev 410 = $627.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,ANTHEM,ANTHEM PPO,627.64,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $923.00 in Billed Charges for Rev 410 = $627.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,923.00,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $923.00 in Billed Charges for Rev 410 = $923.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,CENPATICO,ALL MEDICAID CENPATICO,923.00,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $923.00 in Billed Charges for Rev 410 = $923.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,784.55,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $923.00 in Billed Charges for Rev 410 = $784.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,CIGNA,ALL COMMERCIAL CIGNA,646.10,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $923.00 in Billed Charges for Rev 410 = $646.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,COFINITY,COFINITY,923.00,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $923.00 in Billed Charges for Rev 410 = $923.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,876.85,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $923.00 in Billed Charges for Rev 410 = $876.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,775.32,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $923.00 in Billed Charges for Rev 410 = $775.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,655.33,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $923.00 in Billed Charges for Rev 410 = $655.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,673.79,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $923.00 in Billed Charges for Rev 410 = $673.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,448.58,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $923.00 in Billed Charges for Rev 410 = $448.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,784.55,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $923.00 in Billed Charges for Rev 410 = $784.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,HUMANA,HUMANA CHOICE CARE HMO,586.11,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $923.00 in Billed Charges for Rev 410 = $586.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,HUMANA,HUMANA CHOICE CARE PPO,784.55,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $923.00 in Billed Charges for Rev 410 = $784.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,HUMANA,HUMANA NATIIONAL POS HMO,586.11,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $923.00 in Billed Charges for Rev 410 = $586.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,673.79,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $923.00 in Billed Charges for Rev 410 = $673.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,923.00,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $923.00 in Billed Charges for Rev 410 = $923.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,461.50,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $923.00 in Billed Charges for Rev 410 = $461.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,775.32,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $923.00 in Billed Charges for Rev 410 = $775.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,692.25,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $923.00 in Billed Charges for Rev 410 = $692.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,849.16,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $923.00 in Billed Charges for Rev 410 = $849.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,90.8900,923.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,90.8900,923.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,90.8900,923.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,90.8900,923.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,589.15,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $923.00 in Billed Charges for Rev 410 = $589.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,664.56,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $923.00 in Billed Charges for Rev 410 = $664.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,90.8900,923.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,90.8900,923.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,90.8900,923.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,664.56,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $923.00 in Billed Charges for Rev 410 = $664.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,572.26,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $923.00 in Billed Charges for Rev 410 = $572.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,664.56,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $923.00 in Billed Charges for Rev 410 = $664.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,664.56,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $923.00 in Billed Charges for Rev 410 = $664.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT NEONATAL,410,RC,41000022,CDM,,,,,,both,,,923.0000,609.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,553.80,,,,,,,90.8900,923.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $923.00 in Billed Charges for Rev 410 = $553.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,AETNA,AETNA HSHS,218.35,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $338.00 in Billed Charges for Rev 410 = $218.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,AETNA,ALL COMMERCIAL AETNA,338.00,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $338.00 in Billed Charges for Rev 410 = $338.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,338.00,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $338.00 in Billed Charges for Rev 410 = $338.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,287.30,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $338.00 in Billed Charges for Rev 410 = $287.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,CIGNA,ALL COMMERCIAL CIGNA,236.60,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $338.00 in Billed Charges for Rev 410 = $236.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,COFINITY,COFINITY,338.00,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $338.00 in Billed Charges for Rev 410 = $338.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,321.10,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $338.00 in Billed Charges for Rev 410 = $321.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,283.92,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $338.00 in Billed Charges for Rev 410 = $283.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,239.98,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $338.00 in Billed Charges for Rev 410 = $239.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,246.74,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $338.00 in Billed Charges for Rev 410 = $246.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,164.27,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $338.00 in Billed Charges for Rev 410 = $164.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,287.30,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $338.00 in Billed Charges for Rev 410 = $287.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,HUMANA,HUMANA CHOICE CARE PPO,287.30,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $338.00 in Billed Charges for Rev 410 = $287.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,246.74,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $338.00 in Billed Charges for Rev 410 = $246.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,338.00,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $338.00 in Billed Charges for Rev 410 = $338.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,169.00,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $338.00 in Billed Charges for Rev 410 = $169.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,283.92,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $338.00 in Billed Charges for Rev 410 = $283.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,253.50,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $338.00 in Billed Charges for Rev 410 = $253.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,310.96,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $338.00 in Billed Charges for Rev 410 = $310.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,215.75,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $338.00 in Billed Charges for Rev 410 = $215.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,243.36,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $338.00 in Billed Charges for Rev 410 = $243.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,243.36,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $338.00 in Billed Charges for Rev 410 = $243.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,209.56,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $338.00 in Billed Charges for Rev 410 = $209.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,243.36,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $338.00 in Billed Charges for Rev 410 = $243.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRANSPORT VENT ADULT/PED,410,RC,41000026,CDM,,,,,,inpatient,,,338.0000,223.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,243.36,,,,,,,164.2700,338.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $338.00 in Billed Charges for Rev 410 = $243.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,AETNA,AETNA HSHS,260.98,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $260.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,AETNA,AETNA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,AETNA,ALL COMMERCIAL AETNA,404.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,ANTHEM,ANTHEM POS/HMO,274.72,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $274.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,ANTHEM,ANTHEM PPO,274.72,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $274.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,404.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,CENPATICO,ALL MEDICAID CENPATICO,404.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,343.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $343.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,CIGNA,ALL COMMERCIAL CIGNA,282.80,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $282.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,COFINITY,COFINITY,404.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,383.80,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $383.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,339.36,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $339.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,286.84,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $286.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,294.92,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $294.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,196.34,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $196.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,343.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $343.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HUMANA,HUMANA CHOICE CARE HMO,256.54,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $256.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HUMANA,HUMANA CHOICE CARE PPO,343.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $343.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,HUMANA,HUMANA NATIIONAL POS HMO,256.54,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $256.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,294.92,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $294.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,404.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $404.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,202.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $202.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,339.36,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $339.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,303.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $303.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,371.68,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $371.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,257.87,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $257.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,290.88,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $290.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,290.88,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $290.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,250.48,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $250.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,290.88,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $290.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,290.88,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $290.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000035,CDM,,,,both,,,404.0000,266.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,242.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $404.00 in Billed Charges for Rev 410 Proc 94640 = $242.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,AETNA,AETNA HSHS,77.52,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $77.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,AETNA,AETNA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,AETNA,ALL COMMERCIAL AETNA,120.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,120.00,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,ANTHEM,ANTHEM POS/HMO,81.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,ANTHEM,ANTHEM PPO,81.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,120.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,CENPATICO,ALL MEDICAID CENPATICO,120.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,102.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,CIGNA,ALL COMMERCIAL CIGNA,84.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,COFINITY,COFINITY,120.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,114.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,100.80,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,85.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $85.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,87.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,58.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $58.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,102.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HUMANA,HUMANA CHOICE CARE HMO,76.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $76.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HUMANA,HUMANA CHOICE CARE PPO,102.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,120.00,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,HUMANA,HUMANA NATIIONAL POS HMO,76.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $76.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,87.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,120.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,60.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,100.80,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,90.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,110.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $110.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,76.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $76.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,86.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94640 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,120.00,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94640 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,86.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,74.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $74.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,86.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,86.40,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,41000041,CDM,,,,both,,,120.0000,79.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,72.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $120.00 in Billed Charges for Rev 410 Proc 94640 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,AETNA,AETNA HSHS,229.98,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $229.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,AETNA,AETNA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,AETNA,ALL COMMERCIAL AETNA,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94642 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,ANTHEM,ANTHEM POS/HMO,242.08,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $242.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,ANTHEM,ANTHEM PPO,242.08,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $242.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,CENPATICO,ALL MEDICAID CENPATICO,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,302.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $302.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,CIGNA,ALL COMMERCIAL CIGNA,249.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $249.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,COFINITY,COFINITY,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94642 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94642 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,338.20,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $338.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,299.04,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $299.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,252.76,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $252.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,259.88,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,173.02,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $173.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,302.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $302.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HUMANA,HUMANA CHOICE CARE HMO,226.06,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $226.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HUMANA,HUMANA CHOICE CARE PPO,302.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $302.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,HUMANA,HUMANA NATIIONAL POS HMO,226.06,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $226.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,259.88,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $259.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,356.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $356.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94642 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94642 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94642 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,178.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $178.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,299.04,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $299.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,267.00,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $267.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,327.52,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $327.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94642 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94642 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94642 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94642 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,227.23,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $227.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,256.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $256.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94642 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94642 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94642 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94642 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,26.4300,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,256.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $256.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,220.72,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $220.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,256.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $256.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,256.32,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $256.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL INHALATION PENTAMIDINE,94642,CPT,410,RC,41000049,CDM,,,,both,,,356.0000,234.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,213.60,,,,,,,26.4300,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $356.00 in Billed Charges for Rev 410 Proc 94642 = $213.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,AETNA,AETNA HSHS,235.79,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $235.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,AETNA,AETNA MEDICARE,129.23,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,AETNA,ALL COMMERCIAL AETNA,365.00,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94644 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,129.23,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,ANTHEM,ANTHEM POS/HMO,248.20,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $248.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,ANTHEM,ANTHEM PPO,248.20,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $248.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,365.00,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,CENPATICO,ALL MEDICAID CENPATICO,365.00,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,310.25,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $310.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,CIGNA,ALL COMMERCIAL CIGNA,255.50,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $255.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,COFINITY,COFINITY,365.00,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94644 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94644 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,346.75,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $346.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,306.60,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $306.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,259.15,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $259.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,266.45,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $266.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,177.39,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $177.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,310.25,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $310.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HUMANA,HUMANA CHOICE CARE HMO,231.78,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $231.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HUMANA,HUMANA CHOICE CARE PPO,310.25,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $310.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HUMANA,HUMANA MEDICARE ADVANTAGE,129.23,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,HUMANA,HUMANA NATIIONAL POS HMO,231.78,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $231.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,266.45,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $266.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,365.00,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $365.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94644 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,129.23,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94644 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94644 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,MOLINA HEALTHCARE,MOLINA MEDICARE,129.23,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,182.50,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $182.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,306.60,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $306.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,NAPHCARE,ALL COMMERICAL NAPHCARE,290.78,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,273.75,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $273.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,335.80,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $335.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,365.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94644 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,365.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94644 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,365.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94644 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,365.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94644 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,232.98,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $232.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,130.52,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,262.80,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94644 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,365.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94644 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,365.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94644 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,129.23,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,365.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94644 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,UNITY HEALTH PLAN,UNITY HOSPICE,129.23,,,,,,,26.4300,365.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,262.80,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,226.30,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $226.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,262.80,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,262.80,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $262.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC AEROSOL CONTINUOUS 1ST HR,94644,CPT,410,RC,41000050,CDM,,,,both,,,365.0000,240.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,219.00,,,,,,,26.4300,365.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $365.00 in Billed Charges for Rev 410 Proc 94644 = $219.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,AETNA,AETNA HSHS,280.36,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $280.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,AETNA,AETNA MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,AETNA,ALL COMMERCIAL AETNA,434.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $434.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,ANTHEM,ANTEHM MEDICAID,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,ANTHEM,ANTHEM POS/HMO,295.12,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $295.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,ANTHEM,ANTHEM PPO,295.12,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $295.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,434.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $434.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,CENPATICO,ALL MEDICAID CENPATICO,434.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $434.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,368.90,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $368.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,CIGNA,ALL COMMERCIAL CIGNA,303.80,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $303.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,COFINITY,COFINITY,434.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $434.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,412.30,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $412.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,364.56,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $364.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,308.14,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $308.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,316.82,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $316.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,210.92,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $210.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,368.90,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $368.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HUMANA,HUMANA CHOICE CARE HMO,275.59,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $275.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HUMANA,HUMANA CHOICE CARE PPO,368.90,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $368.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,HUMANA,HUMANA NATIIONAL POS HMO,275.59,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $275.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,316.82,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $316.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,434.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $434.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,60.95,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,MOLINA HEALTHCARE,MOLINA MEDICAID,64.61,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 100% = $60.95... $60.95 at 106% = $64.61 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,217.00,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,364.56,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $364.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,325.50,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $325.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,399.28,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $399.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,277.02,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $277.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,312.48,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $312.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,TRIOLOGY,TRILOGY MEDICAID,64.61,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 02020 Proc 94660 at $125.60 (Base Rate) * 0.4853 (Relative Weight) = $60.95 (Total Line Payment) at 106% = $64.61. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,60.9500,478.5700,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94660 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,60.9500,478.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,312.48,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $312.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,269.08,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $269.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,312.48,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $312.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,312.48,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $312.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP,94660,CPT,410,RC,41000052,CDM,,,,both,,,434.0000,286.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,260.40,,,,,,,60.9500,478.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $434.00 in Billed Charges for Rev 410 Proc 94660 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,AETNA,AETNA HSHS,314.60,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $314.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,AETNA,ALL COMMERCIAL AETNA,487.00,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,ANTHEM,ANTHEM POS/HMO,154.00,,,,,,,113.0000,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 Qty 1 * $154.00 = $154.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,ANTHEM,ANTHEM PPO,154.00,,,,,,,113.0000,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 Qty 1 * $154.00 = $154.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,487.00,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,CENPATICO,ALL MEDICAID CENPATICO,487.00,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,413.95,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,CIGNA,ALL COMMERCIAL CIGNA,340.90,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $340.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,COFINITY,COFINITY,487.00,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,462.65,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $462.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,409.08,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $409.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,345.77,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $345.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,355.51,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $355.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,236.68,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $236.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,413.95,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,HUMANA,HUMANA CHOICE CARE HMO,113.00,,,,,,,113.0000,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $113.00 per Visit = $113.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,HUMANA,HUMANA CHOICE CARE PPO,413.95,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $413.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,HUMANA,HUMANA NATIIONAL POS HMO,113.00,,,,,,,113.0000,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $113.00 per Visit = $113.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,355.51,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $355.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,487.00,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $487.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,243.50,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $243.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,409.08,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $409.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,365.25,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $365.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,448.04,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $448.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,292.20,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $292.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,292.20,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $292.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,PREVEA HEALTH NETWORK,PREVEA360,292.20,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $292.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,292.20,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $292.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,310.85,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $310.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,350.64,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $350.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,116.60,,,,,,,113.0000,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $116.60 per Visit = $116.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,116.60,,,,,,,113.0000,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $116.60 per Visit = $116.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,116.60,,,,,,,113.0000,487.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $116.60 per Visit = $116.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,350.64,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $350.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,301.94,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $301.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,350.64,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $350.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,350.64,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $350.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT INITIAL,99211,CPT,510,RC,41000055,CDM,,,,both,,,487.0000,321.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,292.20,,,,,,,113.0000,487.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $487.00 in Billed Charges for Rev 510 Proc 99211 = $292.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,AETNA,AETNA HSHS,288.76,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $288.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,AETNA,ALL COMMERCIAL AETNA,447.00,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $447.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,ANTHEM,ANTHEM POS/HMO,154.00,,,,,,,113.0000,447.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 Qty 1 * $154.00 = $154.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,ANTHEM,ANTHEM PPO,154.00,,,,,,,113.0000,447.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 Qty 1 * $154.00 = $154.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,447.00,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $447.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,CENPATICO,ALL MEDICAID CENPATICO,447.00,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $447.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,379.95,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $379.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,CIGNA,ALL COMMERCIAL CIGNA,312.90,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $312.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,COFINITY,COFINITY,447.00,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $447.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,424.65,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $424.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,375.48,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $375.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,317.37,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $317.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,326.31,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $326.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,217.24,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $217.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,379.95,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $379.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,HUMANA,HUMANA CHOICE CARE HMO,113.00,,,,,,,113.0000,447.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $113.00 per Visit = $113.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,HUMANA,HUMANA CHOICE CARE PPO,379.95,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $379.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,HUMANA,HUMANA NATIIONAL POS HMO,113.00,,,,,,,113.0000,447.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $113.00 per Visit = $113.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,326.31,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $326.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,447.00,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $447.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,223.50,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $223.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,375.48,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $375.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,335.25,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $335.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,411.24,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $411.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,268.20,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $268.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,268.20,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $268.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,PREVEA HEALTH NETWORK,PREVEA360,268.20,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $268.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,268.20,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $268.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,285.32,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $285.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,321.84,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $321.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,116.60,,,,,,,113.0000,447.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $116.60 per Visit = $116.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,116.60,,,,,,,113.0000,447.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $116.60 per Visit = $116.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,116.60,,,,,,,113.0000,447.0000,other,ST VINCENT HOSPITAL (ACU). Rev 510 Proc 99211 1 Visit at $116.60 per Visit = $116.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,321.84,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $321.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,277.14,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $277.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,321.84,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $321.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,321.84,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $321.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CPAP THERAPY CONSULT FOLLOW UP,99211,CPT,510,RC,41000056,CDM,,,,both,,,447.0000,295.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,268.20,,,,,,,113.0000,447.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $447.00 in Billed Charges for Rev 510 Proc 99211 = $268.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,AETNA,AETNA HSHS,77.52,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $77.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,AETNA,AETNA MEDICARE,28.09,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,AETNA,ALL COMMERCIAL AETNA,120.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,ANTHEM,ANTEHM MEDICAID,15.65,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0237 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.09,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,ANTHEM,ANTHEM POS/HMO,81.60,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,ANTHEM,ANTHEM PPO,81.60,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,120.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,CENPATICO,ALL MEDICAID CENPATICO,120.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,102.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,CIGNA,ALL COMMERCIAL CIGNA,84.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $84.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,COFINITY,COFINITY,120.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.65,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0237 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.65,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0237 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,114.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,100.80,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,85.20,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $85.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,87.60,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,58.32,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $58.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,102.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HUMANA,HUMANA CHOICE CARE HMO,76.20,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $76.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HUMANA,HUMANA CHOICE CARE PPO,102.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $102.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HUMANA,HUMANA MEDICARE ADVANTAGE,28.09,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,HUMANA,HUMANA NATIIONAL POS HMO,76.20,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $76.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,87.60,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,120.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $120.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.65,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0237 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.09,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.65,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0237 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,MOLINA HEALTHCARE,MOLINA MEDICAID,16.59,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0237 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65... $15.65 at 106% = $16.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,MOLINA HEALTHCARE,MOLINA MEDICARE,28.09,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,60.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $60.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,100.80,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $100.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,NAPHCARE,ALL COMMERICAL NAPHCARE,63.21,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,90.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $90.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,110.40,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $110.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,15.6500,120.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0237 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,15.6500,120.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0237 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,15.6500,120.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0237 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,15.6500,120.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0237 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,76.60,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $76.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,28.37,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,86.40,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,TRIOLOGY,TRILOGY MEDICAID,16.59,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0237 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 106% = $16.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,15.6500,120.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0237 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,15.6500,120.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0237 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.09,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,15.6500,120.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0237 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,UNITY HEALTH PLAN,UNITY HOSPICE,28.09,,,,,,,15.6500,120.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,86.40,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,74.40,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $74.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,86.40,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,86.40,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP STRENGTH/ENDURANCE,G0237,HCPCS,410,RC,41000068,CDM,,,,both,,,120.0000,79.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,72.00,,,,,,,15.6500,120.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $120.00 in Billed Charges for Rev 410 Proc G0237 = $72.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,AETNA,AETNA HSHS,82.69,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $82.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,AETNA,AETNA MEDICARE,28.09,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,AETNA,ALL COMMERCIAL AETNA,128.00,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,ANTHEM,ANTEHM MEDICAID,15.65,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0238 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.09,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,ANTHEM,ANTHEM POS/HMO,87.04,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $87.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,ANTHEM,ANTHEM PPO,87.04,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $87.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,128.00,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,CENPATICO,ALL MEDICAID CENPATICO,128.00,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,108.80,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,CIGNA,ALL COMMERCIAL CIGNA,89.60,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $89.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,COFINITY,COFINITY,128.00,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.65,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0238 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.65,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0238 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,121.60,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $121.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,107.52,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $107.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,90.88,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $90.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,93.44,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $93.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,62.21,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $62.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,108.80,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HUMANA,HUMANA CHOICE CARE HMO,81.28,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $81.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HUMANA,HUMANA CHOICE CARE PPO,108.80,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HUMANA,HUMANA MEDICARE ADVANTAGE,28.09,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,HUMANA,HUMANA NATIIONAL POS HMO,81.28,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $81.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,93.44,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $93.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,128.00,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $128.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.65,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0238 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.09,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.65,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0238 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,MOLINA HEALTHCARE,MOLINA MEDICAID,16.59,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0238 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65... $15.65 at 106% = $16.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,MOLINA HEALTHCARE,MOLINA MEDICARE,28.09,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,64.00,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $64.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,107.52,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $107.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,NAPHCARE,ALL COMMERICAL NAPHCARE,63.21,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,96.00,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $96.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,117.76,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $117.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,15.6500,128.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0238 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,15.6500,128.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0238 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,15.6500,128.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0238 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,15.6500,128.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0238 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,81.70,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $81.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,28.37,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,92.16,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $92.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,TRIOLOGY,TRILOGY MEDICAID,16.59,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0238 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 106% = $16.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,15.6500,128.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0238 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,15.6500,128.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0238 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.09,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,15.6500,128.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0238 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,UNITY HEALTH PLAN,UNITY HOSPICE,28.09,,,,,,,15.6500,128.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,92.16,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $92.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,79.36,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $79.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,92.16,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $92.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,92.16,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $92.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC RESP THRP FUNCTION,G0238,HCPCS,410,RC,41000069,CDM,,,,both,,,128.0000,84.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,76.80,,,,,,,15.6500,128.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $128.00 in Billed Charges for Rev 410 Proc G0238 = $76.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,AETNA,AETNA HSHS,164.08,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $164.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,AETNA,AETNA MEDICARE,36.28,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,AETNA,ALL COMMERCIAL AETNA,254.00,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,ANTHEM,ANTEHM MEDICAID,15.65,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0239 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,36.28,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,ANTHEM,ANTHEM POS/HMO,172.72,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $172.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,ANTHEM,ANTHEM PPO,172.72,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $172.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,254.00,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,CENPATICO,ALL MEDICAID CENPATICO,254.00,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,215.90,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $215.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,CIGNA,ALL COMMERCIAL CIGNA,177.80,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $177.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,COFINITY,COFINITY,254.00,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.65,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0239 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.65,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0239 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,241.30,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $241.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,213.36,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $213.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,180.34,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $180.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,185.42,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $185.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,123.44,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $123.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,215.90,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $215.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HUMANA,HUMANA CHOICE CARE HMO,161.29,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $161.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HUMANA,HUMANA CHOICE CARE PPO,215.90,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $215.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HUMANA,HUMANA MEDICARE ADVANTAGE,36.28,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,HUMANA,HUMANA NATIIONAL POS HMO,161.29,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $161.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,185.42,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $185.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,254.00,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $254.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.65,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0239 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,36.28,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.65,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0239 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,MOLINA HEALTHCARE,MOLINA MEDICAID,16.59,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0239 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65... $15.65 at 106% = $16.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,MOLINA HEALTHCARE,MOLINA MEDICARE,36.28,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,127.00,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $127.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,213.36,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $213.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,NAPHCARE,ALL COMMERICAL NAPHCARE,81.63,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,190.50,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $190.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,233.68,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $233.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,15.6500,254.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0239 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,15.6500,254.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0239 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,15.6500,254.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0239 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,15.6500,254.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0239 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,162.13,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $162.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,36.64,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,182.88,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $182.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,TRIOLOGY,TRILOGY MEDICAID,16.59,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc G0239 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 106% = $16.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,15.6500,254.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0239 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,15.6500,254.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0239 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,36.28,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,15.6500,254.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc G0239 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,UNITY HEALTH PLAN,UNITY HOSPICE,36.28,,,,,,,15.6500,254.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,182.88,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $182.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,157.48,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $157.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,182.88,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $182.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,182.88,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $182.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERAPEUTIC RT EXERCISE GROUP,G0239,HCPCS,410,RC,41000070,CDM,,,,both,,,254.0000,167.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,152.40,,,,,,,15.6500,254.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $254.00 in Billed Charges for Rev 410 Proc G0239 = $152.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,AETNA,AETNA HSHS,514.86,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $514.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,AETNA,AETNA MEDICARE,212.70,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,AETNA,ALL COMMERCIAL AETNA,797.00,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $797.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,ANTHEM,ANTEHM MEDICAID,26.43,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,212.70,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,ANTHEM,ANTHEM POS/HMO,541.96,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $541.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,ANTHEM,ANTHEM PPO,541.96,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $541.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,797.00,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $797.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,CENPATICO,ALL MEDICAID CENPATICO,797.00,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $797.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,677.45,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $677.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,CIGNA,ALL COMMERCIAL CIGNA,557.90,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $557.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,COFINITY,COFINITY,797.00,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $797.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.43,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.43,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,757.15,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $757.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,669.48,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $669.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,565.87,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $565.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,581.81,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $581.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,387.34,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $387.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,677.45,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $677.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HUMANA,HUMANA CHOICE CARE HMO,506.10,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $506.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HUMANA,HUMANA CHOICE CARE PPO,677.45,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $677.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,212.70,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,HUMANA,HUMANA NATIIONAL POS HMO,506.10,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $506.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,581.81,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $581.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,797.00,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $797.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.43,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,212.70,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.43,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,MOLINA HEALTHCARE,MOLINA MEDICAID,28.02,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 100% = $26.43... $26.43 at 106% = $28.02 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,212.70,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,398.50,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $398.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,669.48,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $669.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,478.57,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,597.75,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $597.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,733.24,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $733.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.89,,,,,,,26.4300,797.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.89,,,,,,,26.4300,797.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,PREVEA HEALTH NETWORK,PREVEA360,90.89,,,,,,,26.4300,797.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.89,,,,,,,26.4300,797.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $90.89 per Visit = $90.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,508.73,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $508.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,214.83,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,573.84,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $573.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,TRIOLOGY,TRILOGY MEDICAID,28.01,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00412 Proc 94669 at $125.60 (Base Rate) * 0.2104 (Relative Weight) = $26.43 (Total Line Payment) at 106% = $28.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,100.60,,,,,,,26.4300,797.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,100.60,,,,,,,26.4300,797.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,212.70,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,100.60,,,,,,,26.4300,797.0000,other,ST VINCENT HOSPITAL (ACU). Rev 410 Proc 94669 1 Visit at $100.60 per Visit = $100.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,UNITY HEALTH PLAN,UNITY HOSPICE,212.70,,,,,,,26.4300,797.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,573.84,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $573.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,494.14,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $494.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,573.84,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $573.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,573.84,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $573.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC MECHANICAL CHEST WALL OSCILLATION SUBSQ,94669,CPT,410,RC,41000088,CDM,,,,both,,,797.0000,526.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,478.20,,,,,,,26.4300,797.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $797.00 in Billed Charges for Rev 410 Proc 94669 = $478.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,AETNA,AETNA HSHS,34.75,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $34.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,AETNA,ALL COMMERCIAL AETNA,53.80,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $53.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,ANTHEM,ANTHEM POS/HMO,1.09,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 170% = $1.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,ANTHEM,ANTHEM PPO,1.34,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 210% = $1.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,53.80,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $53.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,CENPATICO,ALL MEDICAID CENPATICO,53.80,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $53.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,45.73,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $45.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,CIGNA,ALL COMMERCIAL CIGNA,37.66,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $37.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,COFINITY,COFINITY,53.80,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $53.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,51.11,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $51.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,45.19,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $45.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,38.20,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $38.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,39.27,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $39.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,26.15,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $26.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,45.73,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $45.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,HUMANA,HUMANA CHOICE CARE HMO,1.89,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.89 from Fee Schedule 005543_170 for Rev 636 Proc J3420 * Qty 1 = $1.89 at 100% = $1.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,HUMANA,HUMANA CHOICE CARE PPO,45.73,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $45.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,HUMANA,HUMANA NATIIONAL POS HMO,1.89,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.89 from Fee Schedule 005543_170 for Rev 636 Proc J3420 * Qty 1 = $1.89 at 100% = $1.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,39.27,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $39.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,53.80,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $53.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.90,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $26.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,45.19,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $45.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,40.35,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $40.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,49.50,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $49.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.15,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 179% = $1.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.15,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 179% = $1.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,PREVEA HEALTH NETWORK,PREVEA360,1.15,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 179% = $1.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.15,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 179% = $1.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,34.34,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $34.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,38.74,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $38.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.06,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.06 from Fee Schedule UHC_31190C for Rev 636 Proc J3420 * Qty 1 = $1.06 at 100% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,UNITED HEALTHCARE,UHC ONEIDA NATION,1.06,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.06 from Fee Schedule UHC_31190C for Rev 636 Proc J3420 * Qty 1 = $1.06 at 100% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,UNITED HEALTHCARE,UNITED HEALTHCARE,1.06,,,,,,,1.0600,53.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.06 from Fee Schedule UHC_31190C for Rev 636 Proc J3420 * Qty 1 = $1.06 at 100% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,38.74,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $38.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,33.36,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $33.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,38.74,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $38.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,38.74,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $38.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 1000 MCG/ML SOLN per 1000 mcg,J3420,HCPCS,636,RC,0517-0031-25,CDM,,,,both,1.000000,ME,53.8000,35.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,32.28,,,,,,,1.0600,53.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $53.80 in Billed Charges for Rev 636 Proc J3420 = $32.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,1.09,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 170% = $1.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,ANTHEM,ANTHEM PPO,1.34,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 210% = $1.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,1.89,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.89 from Fee Schedule 005543_170 for Rev 636 Proc J3420 * Qty 1 = $1.89 at 100% = $1.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,1.89,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.89 from Fee Schedule 005543_170 for Rev 636 Proc J3420 * Qty 1 = $1.89 at 100% = $1.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.15,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 179% = $1.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.15,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 179% = $1.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,1.15,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 179% = $1.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.15,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.64 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3420 * Qty 1 = $0.64 at 179% = $1.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.06,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.06 from Fee Schedule UHC_31190C for Rev 636 Proc J3420 * Qty 1 = $1.06 at 100% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,1.06,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.06 from Fee Schedule UHC_31190C for Rev 636 Proc J3420 * Qty 1 = $1.06 at 100% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,1.06,,,,,,,1.0600,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.06 from Fee Schedule UHC_31190C for Rev 636 Proc J3420 * Qty 1 = $1.06 at 100% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
VITAMIN B12 INJECTION,J3420,HCPCS,636,RC,25021-502-01,CDM,,,,both,1.000000,ME,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,1.0600,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 636 Proc J3420 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,AETNA,AETNA HSHS,0.34,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,AETNA,ALL COMMERCIAL AETNA,0.53,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.53,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,CENPATICO,ALL MEDICAID CENPATICO,0.53,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.45,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,CIGNA,ALL COMMERCIAL CIGNA,0.37,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,COFINITY,COFINITY,0.53,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.50,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,0.45,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.38,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.39,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,0.26,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.45,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,HUMANA,HUMANA CHOICE CARE HMO,0.03,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,HUMANA,HUMANA CHOICE CARE PPO,0.45,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,HUMANA,HUMANA NATIIONAL POS HMO,0.03,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.39,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.53,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.27,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.45,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.40,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.49,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.34,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.38,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0300,0.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.38,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.33,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.38,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.38,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 350 MG SOLR per 1 mg,J0878,HCPCS,636,RC,71288-017-15,CDM,,,,both,1.000000,ME,0.5300,0.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.32,,,,,,,0.0300,0.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.53 in Billed Charges for Rev 636 Proc J0878 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,AETNA,AETNA HSHS,0.65,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,AETNA,ALL COMMERCIAL AETNA,1.00,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1.00,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,CENPATICO,ALL MEDICAID CENPATICO,1.00,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.85,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,CIGNA,ALL COMMERCIAL CIGNA,0.70,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,COFINITY,COFINITY,1.00,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.95,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,0.84,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.71,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.73,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,0.49,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.85,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,HUMANA,HUMANA CHOICE CARE HMO,0.03,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,HUMANA,HUMANA CHOICE CARE PPO,0.85,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,HUMANA,HUMANA NATIIONAL POS HMO,0.03,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.73,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1.00,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.50,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.84,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.75,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.92,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.64,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.72,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0300,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.72,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.62,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.72,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.72,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN 500 MG SOLR per 1 mg,J0878,HCPCS,636,RC,43598-413-11,CDM,,,,both,1.000000,ME,1.0000,0.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.60,,,,,,,0.0300,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $1.00 in Billed Charges for Rev 636 Proc J0878 = $0.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,AETNA,AETNA HSHS,0.28,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,AETNA,ALL COMMERCIAL AETNA,0.44,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.44,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,CENPATICO,ALL MEDICAID CENPATICO,0.44,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.37,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,CIGNA,ALL COMMERCIAL CIGNA,0.31,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,COFINITY,COFINITY,0.44,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.42,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,HEALTH CARE ALLIANCE,THE ALLIANCE,0.37,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.31,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.32,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,HSHS EMPLOYEES,HSHS EMPLOYEES,0.21,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.37,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,HUMANA,HUMANA CHOICE CARE HMO,0.03,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,HUMANA,HUMANA CHOICE CARE PPO,0.37,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,HUMANA,HUMANA NATIIONAL POS HMO,0.03,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.32,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.44,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.22,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.37,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.33,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.40,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.28,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.32,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0300,0.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.32,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.27,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.32,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.32,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,71288-016-15,CDM,,,,both,1.000000,ME,0.4400,0.2900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.26,,,,,,,0.0300,0.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.44 in Billed Charges for Rev 636 Proc J0878 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,AETNA,AETNA HSHS,233.49,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $233.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,AETNA,AETNA MEDICARE,70.79,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,AETNA,ALL COMMERCIAL AETNA,361.44,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $361.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,ANTHEM,ANTEHM MEDICAID,361.44,,,,,,,70.7900,383.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $361.44, claim capped at $361.44 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,70.79,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,ANTHEM,ANTHEM POS/HMO,120.34,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 170% = $120.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,ANTHEM,ANTHEM PPO,148.66,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 210% = $148.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,361.44,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $361.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,CENPATICO,ALL MEDICAID CENPATICO,361.44,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $361.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,307.22,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $307.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,CIGNA,ALL COMMERCIAL CIGNA,253.01,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $253.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,COFINITY,COFINITY,361.44,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $361.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,361.44,,,,,,,70.7900,383.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $361.44, claim capped at $361.44 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,361.44,,,,,,,70.7900,383.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $361.44, claim capped at $361.44 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,343.37,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $343.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,303.61,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $303.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,256.62,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $256.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,263.85,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $263.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,175.66,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $175.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,307.22,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $307.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HUMANA,HUMANA CHOICE CARE HMO,109.45,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $109.45 from Fee Schedule 005543_170 for Rev 636 Proc J9145 * Qty 1 = $109.45 at 100% = $109.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HUMANA,HUMANA CHOICE CARE PPO,307.22,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $307.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HUMANA,HUMANA MEDICARE ADVANTAGE,70.79,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,HUMANA,HUMANA NATIIONAL POS HMO,109.45,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $109.45 from Fee Schedule 005543_170 for Rev 636 Proc J9145 * Qty 1 = $109.45 at 100% = $109.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,263.85,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $263.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,361.44,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $361.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,361.44,,,,,,,70.7900,383.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $361.44, claim capped at $361.44 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,70.79,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,361.44,,,,,,,70.7900,383.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $361.44, claim capped at $361.44 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,MOLINA HEALTHCARE,MOLINA MEDICAID,383.13,,,,,,,70.7900,383.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $361.44, claim capped at $361.44 in billed charges)... $361.44 at 106% = $383.13 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,MOLINA HEALTHCARE,MOLINA MEDICARE,70.79,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.72,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $180.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,303.61,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $303.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,NAPHCARE,ALL COMMERICAL NAPHCARE,159.27,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,271.08,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $271.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,332.52,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $332.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,126.71,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 179% = $126.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,126.71,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 179% = $126.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,PREVEA HEALTH NETWORK,PREVEA360,126.71,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 179% = $126.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,126.71,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 179% = $126.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,230.71,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $230.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,71.50,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,260.24,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $260.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,TRIOLOGY,TRILOGY MEDICAID,361.44,,,,,,,70.7900,383.1300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 106% = $1,730.10 (Service Line reduced to $361.44, claim capped at $361.44 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,116.80,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $116.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9145 * Qty 1 = $116.80 at 100% = $116.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,UNITED HEALTHCARE,UHC ONEIDA NATION,116.80,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $116.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9145 * Qty 1 = $116.80 at 100% = $116.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,70.79,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,UNITED HEALTHCARE,UNITED HEALTHCARE,116.80,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $116.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9145 * Qty 1 = $116.80 at 100% = $116.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,UNITY HEALTH PLAN,UNITY HOSPICE,70.79,,,,,,,70.7900,383.1300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,260.24,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $260.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,224.09,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $224.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,260.24,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $260.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,260.24,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $260.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 100 MG/5ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-05,CDM,,,,both,10.000000,ME,361.4400,238.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.86,,,,,,,70.7900,383.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $361.44 in Billed Charges for Rev 636 Proc J9145 = $216.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,AETNA,AETNA HSHS,948.04,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $948.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,AETNA,AETNA MEDICARE,3.02,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,AETNA,ALL COMMERCIAL AETNA,1467.55,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,467.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,ANTHEM,ANTEHM MEDICAID,208.24,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.02,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,ANTHEM,ANTHEM POS/HMO,5.13,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 170% = $5.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,ANTHEM,ANTHEM PPO,6.34,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 210% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1467.55,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,467.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,CENPATICO,ALL MEDICAID CENPATICO,1467.55,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,467.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1247.42,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,247.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,CIGNA,ALL COMMERCIAL CIGNA,1027.29,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,027.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,COFINITY,COFINITY,1467.55,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,467.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,208.24,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,208.24,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1394.17,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,394.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,1232.74,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,232.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1041.96,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,041.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1071.31,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,071.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,713.23,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $713.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1247.42,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,247.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HUMANA,HUMANA CHOICE CARE HMO,5.20,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.20 from Fee Schedule 005543_170 for Rev 636 Proc J0881 * Qty 1 = $5.20 at 100% = $5.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HUMANA,HUMANA CHOICE CARE PPO,1247.42,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,247.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HUMANA,HUMANA MEDICARE ADVANTAGE,3.02,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,HUMANA,HUMANA NATIIONAL POS HMO,5.20,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.20 from Fee Schedule 005543_170 for Rev 636 Proc J0881 * Qty 1 = $5.20 at 100% = $5.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1071.31,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,071.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,1467.55,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,467.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,208.24,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.02,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,208.24,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,MOLINA HEALTHCARE,MOLINA MEDICAID,220.73,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24... $208.24 at 106% = $220.73 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,MOLINA HEALTHCARE,MOLINA MEDICARE,3.02,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,733.78,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $733.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1232.74,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,232.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,NAPHCARE,ALL COMMERICAL NAPHCARE,6.80,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1100.66,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,100.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1350.15,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,350.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.41,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.41,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,PREVEA HEALTH NETWORK,PREVEA360,5.41,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.41,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,936.74,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $936.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.05,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1056.64,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,056.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,TRIOLOGY,TRILOGY MEDICAID,220.74,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 106% = $220.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.98,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.98,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.02,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.98,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,UNITY HEALTH PLAN,UNITY HOSPICE,3.02,,,,,,,3.0200,1467.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1056.64,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,056.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,909.88,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $909.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1056.64,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,056.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1056.64,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $1,056.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 40 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-003-01,CDM,,,,both,1.000000,ML,1467.5500,968.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,880.53,,,,,,,3.0200,1467.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,467.55 in Billed Charges for Rev 636 Proc J0881 = $880.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,AETNA,AETNA HSHS,9450.08,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $9,450.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,AETNA,AETNA MEDICARE,3.02,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,AETNA,ALL COMMERCIAL AETNA,14628.60,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $14,628.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,ANTHEM,ANTEHM MEDICAID,208.24,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.02,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,ANTHEM,ANTHEM POS/HMO,5.13,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 170% = $5.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,ANTHEM,ANTHEM PPO,6.34,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 210% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14628.60,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $14,628.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,CENPATICO,ALL MEDICAID CENPATICO,14628.60,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $14,628.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12434.31,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $12,434.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,CIGNA,ALL COMMERCIAL CIGNA,10240.02,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,240.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,COFINITY,COFINITY,14628.60,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $14,628.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,208.24,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,208.24,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13897.17,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $13,897.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,12288.02,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $12,288.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10386.31,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,386.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10678.88,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,678.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,7109.50,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $7,109.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12434.31,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $12,434.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HUMANA,HUMANA CHOICE CARE HMO,5.20,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.20 from Fee Schedule 005543_170 for Rev 636 Proc J0881 * Qty 1 = $5.20 at 100% = $5.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HUMANA,HUMANA CHOICE CARE PPO,12434.31,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $12,434.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HUMANA,HUMANA MEDICARE ADVANTAGE,3.02,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,HUMANA,HUMANA NATIIONAL POS HMO,5.20,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.20 from Fee Schedule 005543_170 for Rev 636 Proc J0881 * Qty 1 = $5.20 at 100% = $5.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10678.88,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,678.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,14628.60,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $14,628.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,208.24,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.02,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,208.24,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,MOLINA HEALTHCARE,MOLINA MEDICAID,220.73,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24... $208.24 at 106% = $220.73 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,MOLINA HEALTHCARE,MOLINA MEDICARE,3.02,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7314.30,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $7,314.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12288.02,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $12,288.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,NAPHCARE,ALL COMMERICAL NAPHCARE,6.80,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10971.45,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,971.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13458.31,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $13,458.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.41,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.41,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,PREVEA HEALTH NETWORK,PREVEA360,5.41,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.41,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9337.44,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $9,337.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.05,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10532.59,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,532.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,TRIOLOGY,TRILOGY MEDICAID,220.74,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 106% = $220.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.98,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.98,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.02,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.98,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,UNITY HEALTH PLAN,UNITY HOSPICE,3.02,,,,,,,3.0200,14628.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10532.59,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,532.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9069.73,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $9,069.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10532.59,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,532.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10532.59,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $10,532.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 500 MCG/ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-032-01,CDM,,,,both,1.000000,ML,14628.6000,9654.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8777.16,,,,,,,3.0200,14628.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $14,628.60 in Billed Charges for Rev 636 Proc J0881 = $8,777.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,AETNA,AETNA HSHS,1134.02,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,134.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,AETNA,AETNA MEDICARE,3.02,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,AETNA,ALL COMMERCIAL AETNA,1755.45,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,755.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,ANTHEM,ANTEHM MEDICAID,208.24,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.02,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,ANTHEM,ANTHEM POS/HMO,5.13,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 170% = $5.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,ANTHEM,ANTHEM PPO,6.34,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 210% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1755.45,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,755.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,CENPATICO,ALL MEDICAID CENPATICO,1755.45,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,755.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1492.13,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,492.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,CIGNA,ALL COMMERCIAL CIGNA,1228.82,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,228.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,COFINITY,COFINITY,1755.45,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,755.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,208.24,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,208.24,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1667.68,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,667.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,1474.58,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,474.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1246.37,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,246.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1281.48,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,281.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,853.15,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $853.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1492.13,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,492.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HUMANA,HUMANA CHOICE CARE HMO,5.20,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.20 from Fee Schedule 005543_170 for Rev 636 Proc J0881 * Qty 1 = $5.20 at 100% = $5.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HUMANA,HUMANA CHOICE CARE PPO,1492.13,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,492.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,3.02,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,HUMANA,HUMANA NATIIONAL POS HMO,5.20,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.20 from Fee Schedule 005543_170 for Rev 636 Proc J0881 * Qty 1 = $5.20 at 100% = $5.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1281.48,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,281.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1755.45,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,755.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,208.24,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.02,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,208.24,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,MOLINA HEALTHCARE,MOLINA MEDICAID,220.73,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24... $208.24 at 106% = $220.73 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,3.02,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,877.73,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $877.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1474.58,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,474.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,6.80,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1316.59,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,316.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1615.01,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,615.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.41,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.41,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,PREVEA HEALTH NETWORK,PREVEA360,5.41,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.41,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1120.50,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,120.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.05,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1263.92,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,263.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,TRIOLOGY,TRILOGY MEDICAID,220.74,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 106% = $220.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.98,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,4.98,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.02,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,4.98,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,UNITY HEALTH PLAN,UNITY HOSPICE,3.02,,,,,,,3.0200,1755.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1263.92,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,263.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1088.38,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,088.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1263.92,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,263.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1263.92,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,263.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 60 MCG/ML SOLN per 1 mcg,J0881,HCPCS,636,RC,55513-004-01,CDM,,,,both,1.000000,ML,1755.4500,1158.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1053.27,,,,,,,3.0200,1755.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,755.45 in Billed Charges for Rev 636 Proc J0881 = $1,053.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,AETNA,AETNA HSHS,233.14,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $233.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,AETNA,ALL COMMERCIAL AETNA,360.90,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $360.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,ANTHEM,ANTEHM MEDICAID,56.96,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9150 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,ANTHEM,ANTHEM POS/HMO,44.76,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9150 * Qty 1 = $26.33 at 170% = $44.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,ANTHEM,ANTHEM PPO,55.29,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9150 * Qty 1 = $26.33 at 210% = $55.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,360.90,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $360.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,CENPATICO,ALL MEDICAID CENPATICO,360.90,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $360.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,306.77,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,CIGNA,ALL COMMERCIAL CIGNA,252.63,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $252.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,COFINITY,COFINITY,360.90,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $360.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,56.96,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9150 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,56.96,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9150 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,342.86,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $342.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,303.16,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $303.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,256.24,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $256.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,263.46,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $263.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,175.40,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $175.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,306.77,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,HUMANA,HUMANA CHOICE CARE HMO,45.32,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $45.32 from Fee Schedule 005543_170 for Rev 636 Proc J9150 * Qty 1 = $45.32 at 100% = $45.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,HUMANA,HUMANA CHOICE CARE PPO,306.77,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $306.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,HUMANA,HUMANA NATIIONAL POS HMO,45.32,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $45.32 from Fee Schedule 005543_170 for Rev 636 Proc J9150 * Qty 1 = $45.32 at 100% = $45.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,263.46,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $263.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,360.90,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $360.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,56.96,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9150 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,56.96,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9150 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,MOLINA HEALTHCARE,MOLINA MEDICAID,60.38,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9150 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96... $56.96 at 106% = $60.38 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,180.45,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $180.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,303.16,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $303.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,270.68,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $270.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,332.03,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $332.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,47.13,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9150 * Qty 1 = $26.33 at 179% = $47.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,47.13,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9150 * Qty 1 = $26.33 at 179% = $47.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,PREVEA HEALTH NETWORK,PREVEA360,47.13,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9150 * Qty 1 = $26.33 at 179% = $47.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,47.13,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9150 * Qty 1 = $26.33 at 179% = $47.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,230.36,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $230.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,259.85,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $259.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,TRIOLOGY,TRILOGY MEDICAID,60.38,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9150 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 106% = $60.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,43.44,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.44 from Fee Schedule UHC_31190C for Rev 636 Proc J9150 * Qty 1 = $43.44 at 100% = $43.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,UNITED HEALTHCARE,UHC ONEIDA NATION,43.44,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.44 from Fee Schedule UHC_31190C for Rev 636 Proc J9150 * Qty 1 = $43.44 at 100% = $43.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,UNITED HEALTHCARE,UNITED HEALTHCARE,43.44,,,,,,,43.4400,360.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $43.44 from Fee Schedule UHC_31190C for Rev 636 Proc J9150 * Qty 1 = $43.44 at 100% = $43.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,259.85,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $259.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,223.76,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $223.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,259.85,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $259.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,259.85,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $259.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN 20 MG/4ML SOLN 4 ML VIAL per 10 mg,J9150,HCPCS,636,RC,42658-021-01,CDM,,,,both,10.000000,ME,360.9000,238.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,216.54,,,,,,,43.4400,360.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $360.90 in Billed Charges for Rev 636 Proc J9150 = $216.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,AETNA,AETNA HSHS,460.35,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $460.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,AETNA,AETNA MEDICARE,260.49,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,AETNA,ALL COMMERCIAL AETNA,712.61,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $712.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,ANTHEM,ANTEHM MEDICAID,712.61,,,,,,,260.4900,755.3700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9153 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $712.61, claim capped at $712.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,260.49,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,ANTHEM,ANTHEM POS/HMO,442.83,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $260.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9153 * Qty 1 = $260.49 at 170% = $442.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,ANTHEM,ANTHEM PPO,547.03,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $260.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9153 * Qty 1 = $260.49 at 210% = $547.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,712.61,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $712.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,CENPATICO,ALL MEDICAID CENPATICO,712.61,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $712.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,605.72,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $605.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,CIGNA,ALL COMMERCIAL CIGNA,498.83,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $498.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,COFINITY,COFINITY,712.61,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $712.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,712.61,,,,,,,260.4900,755.3700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9153 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $712.61, claim capped at $712.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,712.61,,,,,,,260.4900,755.3700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9153 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $712.61, claim capped at $712.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,676.98,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $676.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,598.59,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $598.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,505.95,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $505.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,520.21,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $520.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,346.33,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $346.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,605.72,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $605.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HUMANA,HUMANA CHOICE CARE HMO,410.74,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $410.74 from Fee Schedule 005543_170 for Rev 636 Proc J9153 * Qty 1 = $410.74 at 100% = $410.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HUMANA,HUMANA CHOICE CARE PPO,605.72,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $605.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,260.49,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,HUMANA,HUMANA NATIIONAL POS HMO,410.74,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $410.74 from Fee Schedule 005543_170 for Rev 636 Proc J9153 * Qty 1 = $410.74 at 100% = $410.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,520.21,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $520.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,712.61,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $712.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,712.61,,,,,,,260.4900,755.3700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9153 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $712.61, claim capped at $712.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,260.49,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,712.61,,,,,,,260.4900,755.3700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9153 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $712.61, claim capped at $712.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,755.37,,,,,,,260.4900,755.3700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9153 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $712.61, claim capped at $712.61 in billed charges)... $712.61 at 106% = $755.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,260.49,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,356.31,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $356.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,598.59,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $598.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,586.10,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,534.46,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $534.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,655.60,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $655.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,466.28,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $260.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9153 * Qty 1 = $260.49 at 179% = $466.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,466.28,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $260.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9153 * Qty 1 = $260.49 at 179% = $466.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,PREVEA HEALTH NETWORK,PREVEA360,466.28,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $260.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9153 * Qty 1 = $260.49 at 179% = $466.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,466.28,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $260.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9153 * Qty 1 = $260.49 at 179% = $466.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,454.86,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $454.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,263.09,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,513.08,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $513.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,TRIOLOGY,TRILOGY MEDICAID,712.61,,,,,,,260.4900,755.3700,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9153 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 106% = $3,433.75 (Service Line reduced to $712.61, claim capped at $712.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,429.81,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $429.81 from Fee Schedule UHC_31190C for Rev 636 Proc J9153 * Qty 1 = $429.81 at 100% = $429.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,429.81,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $429.81 from Fee Schedule UHC_31190C for Rev 636 Proc J9153 * Qty 1 = $429.81 at 100% = $429.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,260.49,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,429.81,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $429.81 from Fee Schedule UHC_31190C for Rev 636 Proc J9153 * Qty 1 = $429.81 at 100% = $429.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,UNITY HEALTH PLAN,UNITY HOSPICE,260.49,,,,,,,260.4900,755.3700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,513.08,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $513.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,441.82,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $441.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,513.08,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $513.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,513.08,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $513.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAUNORUBICIN-CYTARABINE LIPOSOME 44-100 MG SUSR 1 EACH VIAL per 1 mg,J9153,HCPCS,636,RC,68727-745-01,CDM,,,,both,1.000000,ME,712.6100,470.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,427.57,,,,,,,260.4900,755.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $712.61 in Billed Charges for Rev 636 Proc J9153 = $427.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,AETNA,AETNA HSHS,6.77,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $6.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,AETNA,ALL COMMERCIAL AETNA,10.48,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $10.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,ANTHEM,ANTEHM MEDICAID,10.48,,,,,,,1.0700,11.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $10.48, claim capped at $10.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,ANTHEM,ANTHEM POS/HMO,1.11,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 170% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,ANTHEM,ANTHEM PPO,1.37,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 210% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.48,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $10.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,CENPATICO,ALL MEDICAID CENPATICO,10.48,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $10.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8.91,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $8.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,CIGNA,ALL COMMERCIAL CIGNA,7.34,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,COFINITY,COFINITY,10.48,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $10.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.48,,,,,,,1.0700,11.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $10.48, claim capped at $10.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.48,,,,,,,1.0700,11.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $10.48, claim capped at $10.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9.96,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $9.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,8.80,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $8.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.44,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.65,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,5.09,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $5.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8.91,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $8.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,HUMANA,HUMANA CHOICE CARE HMO,2.43,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule 005543_170 for Rev 636 Proc J0894 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,HUMANA,HUMANA CHOICE CARE PPO,8.91,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $8.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,HUMANA,HUMANA NATIIONAL POS HMO,2.43,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule 005543_170 for Rev 636 Proc J0894 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.65,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.48,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $10.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.48,,,,,,,1.0700,11.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $10.48, claim capped at $10.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.48,,,,,,,1.0700,11.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $10.48, claim capped at $10.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,MOLINA HEALTHCARE,MOLINA MEDICAID,11.11,,,,,,,1.0700,11.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $10.48, claim capped at $10.48 in billed charges)... $10.48 at 106% = $11.11 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.24,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8.80,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $8.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.86,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.64,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $9.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.16,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.16,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,PREVEA HEALTH NETWORK,PREVEA360,1.16,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.16,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.69,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $6.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.55,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,TRIOLOGY,TRILOGY MEDICAID,10.48,,,,,,,1.0700,11.1100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 106% = $17.44 (Service Line reduced to $10.48, claim capped at $10.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.07,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0894 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,1.07,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0894 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,1.07,,,,,,,1.0700,11.1100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0894 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.55,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.50,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $6.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.55,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.55,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $7.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,25021-219-20,CDM,,,,both,1.000000,ME,10.4800,6.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.29,,,,,,,1.0700,11.1100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.48 in Billed Charges for Rev 636 Proc J0894 = $6.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,AETNA,AETNA HSHS,54.60,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $54.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,AETNA,AETNA MEDICARE,29.46,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,AETNA,ALL COMMERCIAL AETNA,84.52,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $84.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,ANTHEM,ANTEHM MEDICAID,84.52,,,,,,,29.4600,89.5900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $84.52, claim capped at $84.52 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,29.46,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,ANTHEM,ANTHEM POS/HMO,50.08,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 170% = $50.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,ANTHEM,ANTHEM PPO,61.87,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 210% = $61.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,84.52,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $84.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,CENPATICO,ALL MEDICAID CENPATICO,84.52,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $84.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,71.84,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $71.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,CIGNA,ALL COMMERCIAL CIGNA,59.16,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $59.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,COFINITY,COFINITY,84.52,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $84.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,84.52,,,,,,,29.4600,89.5900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $84.52, claim capped at $84.52 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,84.52,,,,,,,29.4600,89.5900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $84.52, claim capped at $84.52 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,80.29,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $80.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,71.00,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,60.01,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $60.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,61.70,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $61.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,41.08,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $41.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,71.84,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $71.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HUMANA,HUMANA CHOICE CARE HMO,45.48,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $45.48 from Fee Schedule 005543_170 for Rev 636 Proc J0897 * Qty 1 = $45.48 at 100% = $45.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HUMANA,HUMANA CHOICE CARE PPO,71.84,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $71.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,29.46,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,HUMANA,HUMANA NATIIONAL POS HMO,45.48,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $45.48 from Fee Schedule 005543_170 for Rev 636 Proc J0897 * Qty 1 = $45.48 at 100% = $45.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,61.70,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $61.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,84.52,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $84.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,84.52,,,,,,,29.4600,89.5900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $84.52, claim capped at $84.52 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,29.46,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,84.52,,,,,,,29.4600,89.5900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $84.52, claim capped at $84.52 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,89.59,,,,,,,29.4600,89.5900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $84.52, claim capped at $84.52 in billed charges)... $84.52 at 106% = $89.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,29.46,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,42.26,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $42.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,71.00,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $71.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,66.28,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,63.39,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $63.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,77.76,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $77.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,52.73,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 179% = $52.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,52.73,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 179% = $52.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,PREVEA HEALTH NETWORK,PREVEA360,52.73,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 179% = $52.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,52.73,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 179% = $52.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,53.95,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $53.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,29.75,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,60.85,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $60.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,TRIOLOGY,TRILOGY MEDICAID,84.52,,,,,,,29.4600,89.5900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 106% = $448.75 (Service Line reduced to $84.52, claim capped at $84.52 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,48.61,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $48.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0897 * Qty 1 = $48.61 at 100% = $48.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,48.61,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $48.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0897 * Qty 1 = $48.61 at 100% = $48.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,29.46,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,48.61,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). $48.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0897 * Qty 1 = $48.61 at 100% = $48.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,UNITY HEALTH PLAN,UNITY HOSPICE,29.46,,,,,,,29.4600,89.5900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,60.85,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $60.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,52.40,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $52.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,60.85,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $60.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,60.85,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $60.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 120 MG/1.7ML SOLN per 1 mg,J0897,HCPCS,636,RC,55513-730-01,CDM,,,,both,1.000000,ME,84.5200,55.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,50.71,,,,,,,29.4600,89.5900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $84.52 in Billed Charges for Rev 636 Proc J0897 = $50.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,AETNA,AETNA HSHS,59.37,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $59.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,AETNA,AETNA MEDICARE,29.46,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,AETNA,ALL COMMERCIAL AETNA,91.90,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $91.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,ANTHEM,ANTEHM MEDICAID,91.90,,,,,,,29.4600,97.4100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $91.90, claim capped at $91.90 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,29.46,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,ANTHEM,ANTHEM POS/HMO,50.08,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 170% = $50.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,ANTHEM,ANTHEM PPO,61.87,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 210% = $61.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,91.90,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $91.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,CENPATICO,ALL MEDICAID CENPATICO,91.90,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $91.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,78.12,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $78.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,CIGNA,ALL COMMERCIAL CIGNA,64.33,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $64.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,COFINITY,COFINITY,91.90,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $91.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,91.90,,,,,,,29.4600,97.4100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $91.90, claim capped at $91.90 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,91.90,,,,,,,29.4600,97.4100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $91.90, claim capped at $91.90 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,87.31,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $87.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,77.20,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $77.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,65.25,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $65.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,67.09,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $67.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,44.66,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $44.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,78.12,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $78.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HUMANA,HUMANA CHOICE CARE HMO,45.48,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $45.48 from Fee Schedule 005543_170 for Rev 636 Proc J0897 * Qty 1 = $45.48 at 100% = $45.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HUMANA,HUMANA CHOICE CARE PPO,78.12,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $78.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HUMANA,HUMANA MEDICARE ADVANTAGE,29.46,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,HUMANA,HUMANA NATIIONAL POS HMO,45.48,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $45.48 from Fee Schedule 005543_170 for Rev 636 Proc J0897 * Qty 1 = $45.48 at 100% = $45.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,67.09,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $67.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,91.90,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $91.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,91.90,,,,,,,29.4600,97.4100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $91.90, claim capped at $91.90 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,29.46,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,91.90,,,,,,,29.4600,97.4100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $91.90, claim capped at $91.90 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,MOLINA HEALTHCARE,MOLINA MEDICAID,97.41,,,,,,,29.4600,97.4100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 100% = $423.35 (Service Line reduced to $91.90, claim capped at $91.90 in billed charges)... $91.90 at 106% = $97.41 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,MOLINA HEALTHCARE,MOLINA MEDICARE,29.46,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.95,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $45.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,77.20,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $77.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,NAPHCARE,ALL COMMERICAL NAPHCARE,66.28,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,68.93,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $68.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,84.55,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $84.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,52.73,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 179% = $52.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,52.73,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 179% = $52.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,PREVEA HEALTH NETWORK,PREVEA360,52.73,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 179% = $52.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,52.73,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $29.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0897 * Qty 1 = $29.46 at 179% = $52.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,58.66,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $58.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,29.75,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,66.17,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $66.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,TRIOLOGY,TRILOGY MEDICAID,91.90,,,,,,,29.4600,97.4100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00443 Proc J0897 at $125.60 (Base Rate) * 3.3706 (Relative Weight) = $423.35 (Total Line Payment) at 106% = $448.75 (Service Line reduced to $91.90, claim capped at $91.90 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,48.61,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $48.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0897 * Qty 1 = $48.61 at 100% = $48.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,UNITED HEALTHCARE,UHC ONEIDA NATION,48.61,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $48.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0897 * Qty 1 = $48.61 at 100% = $48.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,29.46,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,UNITED HEALTHCARE,UNITED HEALTHCARE,48.61,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). $48.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0897 * Qty 1 = $48.61 at 100% = $48.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,UNITY HEALTH PLAN,UNITY HOSPICE,29.46,,,,,,,29.4600,97.4100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,66.17,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $66.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,56.98,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $56.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,66.17,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $66.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,66.17,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $66.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DENOSUMAB 60 MG/ML SOSY per 1 mg,J0897,HCPCS,636,RC,55513-710-01,CDM,,,,both,1.000000,ME,91.9000,60.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.14,,,,,,,29.4600,97.4100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $91.90 in Billed Charges for Rev 636 Proc J0897 = $55.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,AETNA,AETNA HSHS,4.52,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $4.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,AETNA,AETNA MEDICARE,0.59,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,AETNA,ALL COMMERCIAL AETNA,7.00,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $7.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,0.59,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,ANTHEM,ANTHEM POS/HMO,1.00,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 170% = $1.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,ANTHEM,ANTHEM PPO,1.24,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 210% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7.00,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $7.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,CENPATICO,ALL MEDICAID CENPATICO,7.00,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $7.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.95,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,CIGNA,ALL COMMERCIAL CIGNA,4.90,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,COFINITY,COFINITY,7.00,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $7.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6.65,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $6.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,5.88,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.97,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $4.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.11,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,3.40,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $3.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.95,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HUMANA,HUMANA CHOICE CARE HMO,4.45,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $7.00 in Billed Charges at 63.5% = $4.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HUMANA,HUMANA CHOICE CARE PPO,5.95,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HUMANA,HUMANA MEDICARE ADVANTAGE,0.59,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,HUMANA,HUMANA NATIIONAL POS HMO,4.45,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $7.00 in Billed Charges at 63.5% = $4.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.11,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,7.00,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $7.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,0.59,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,MOLINA HEALTHCARE,MOLINA MEDICARE,0.59,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.50,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $3.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.88,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,NAPHCARE,ALL COMMERICAL NAPHCARE,1.32,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5.25,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6.44,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $6.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.06,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.06,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,PREVEA HEALTH NETWORK,PREVEA360,1.06,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.06,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.47,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $4.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,0.60,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.04,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.97,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,UNITED HEALTHCARE,UHC ONEIDA NATION,0.97,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,0.59,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,UNITED HEALTHCARE,UNITED HEALTHCARE,0.97,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,UNITY HEALTH PLAN,UNITY HOSPICE,0.59,,,,,,,0.5900,7.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.04,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.34,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $4.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.04,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.04,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $5.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-956-01,CDM,,,,both,5.000000,ME,7.0000,4.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.20,,,,,,,0.5900,7.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $7.00 in Billed Charges for Rev 636 Proc J9075 = $4.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,AETNA,AETNA HSHS,3.46,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,AETNA,AETNA MEDICARE,0.59,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,AETNA,ALL COMMERCIAL AETNA,5.35,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $5.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,0.59,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,ANTHEM,ANTHEM POS/HMO,1.00,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 170% = $1.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,ANTHEM,ANTHEM PPO,1.24,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 210% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.35,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $5.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,CENPATICO,ALL MEDICAID CENPATICO,5.35,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $5.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.55,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,CIGNA,ALL COMMERCIAL CIGNA,3.75,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,COFINITY,COFINITY,5.35,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $5.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.08,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HEALTH CARE ALLIANCE,THE ALLIANCE,4.49,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $4.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.80,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.91,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HSHS EMPLOYEES,HSHS EMPLOYEES,2.60,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $2.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.55,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HUMANA,HUMANA CHOICE CARE HMO,3.40,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $5.35 in Billed Charges at 63.5% = $3.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HUMANA,HUMANA CHOICE CARE PPO,4.55,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HUMANA,HUMANA MEDICARE ADVANTAGE,0.59,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,HUMANA,HUMANA NATIIONAL POS HMO,3.40,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $5.35 in Billed Charges at 63.5% = $3.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.91,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.35,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $5.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,0.59,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,MOLINA HEALTHCARE,MOLINA MEDICARE,0.59,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.68,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $2.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.49,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $4.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,NAPHCARE,ALL COMMERICAL NAPHCARE,1.32,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.01,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $4.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4.92,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.06,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.06,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,PREVEA HEALTH NETWORK,PREVEA360,1.06,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.06,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.41,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,0.60,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.85,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.97,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.97,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,0.59,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.97,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,UNITY HEALTH PLAN,UNITY HOSPICE,0.59,,,,,,,0.5900,5.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.85,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.32,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.85,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.85,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,70121-1239-1,CDM,,,,both,5.000000,ME,5.3500,3.5300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.21,,,,,,,0.5900,5.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.35 in Billed Charges for Rev 636 Proc J9075 = $3.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,AETNA,AETNA HSHS,9.46,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $9.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,AETNA,AETNA MEDICARE,3.84,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,AETNA,ALL COMMERCIAL AETNA,14.65,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.84,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,ANTHEM,ANTHEM POS/HMO,6.53,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 170% = $6.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,ANTHEM,ANTHEM PPO,8.06,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 210% = $8.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14.65,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,CENPATICO,ALL MEDICAID CENPATICO,14.65,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.45,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,CIGNA,ALL COMMERCIAL CIGNA,10.26,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,COFINITY,COFINITY,14.65,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13.92,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $13.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,12.31,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.40,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.69,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,7.12,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $7.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.45,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HUMANA,HUMANA CHOICE CARE HMO,9.30,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9074 $14.65 in Billed Charges at 63.5% = $9.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HUMANA,HUMANA CHOICE CARE PPO,12.45,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HUMANA,HUMANA MEDICARE ADVANTAGE,3.84,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,HUMANA,HUMANA NATIIONAL POS HMO,9.30,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9074 $14.65 in Billed Charges at 63.5% = $9.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.69,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,14.65,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.84,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,MOLINA HEALTHCARE,MOLINA MEDICARE,3.84,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.33,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $7.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.31,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,NAPHCARE,ALL COMMERICAL NAPHCARE,8.64,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.99,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.48,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $13.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.87,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 179% = $6.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.87,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 179% = $6.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,PREVEA HEALTH NETWORK,PREVEA360,6.87,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 179% = $6.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.87,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 179% = $6.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.35,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $9.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.88,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.55,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.34,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9074 * Qty 1 = $6.34 at 100% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,UNITED HEALTHCARE,UHC ONEIDA NATION,6.34,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9074 * Qty 1 = $6.34 at 100% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.84,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,UNITED HEALTHCARE,UNITED HEALTHCARE,6.34,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9074 * Qty 1 = $6.34 at 100% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,UNITY HEALTH PLAN,UNITY HOSPICE,3.84,,,,,,,3.8400,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.55,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.08,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $9.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.55,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.55,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3233-94,CDM,,,,both,5.000000,ME,14.6500,9.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.79,,,,,,,3.8400,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.65 in Billed Charges for Rev 636 Proc J9074 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,AETNA,AETNA HSHS,10.62,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $10.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,AETNA,AETNA MEDICARE,0.59,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,AETNA,ALL COMMERCIAL AETNA,16.44,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $16.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,0.59,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,ANTHEM,ANTHEM POS/HMO,1.00,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 170% = $1.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,ANTHEM,ANTHEM PPO,1.24,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 210% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.44,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $16.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,CENPATICO,ALL MEDICAID CENPATICO,16.44,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $16.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.97,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $13.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,CIGNA,ALL COMMERCIAL CIGNA,11.51,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $11.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,COFINITY,COFINITY,16.44,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $16.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.62,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $15.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HEALTH CARE ALLIANCE,THE ALLIANCE,13.81,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $13.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.67,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $11.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.00,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HSHS EMPLOYEES,HSHS EMPLOYEES,7.99,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $7.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.97,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $13.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HUMANA,HUMANA CHOICE CARE HMO,10.44,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $16.44 in Billed Charges at 63.5% = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HUMANA,HUMANA CHOICE CARE PPO,13.97,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $13.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HUMANA,HUMANA MEDICARE ADVANTAGE,0.59,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,HUMANA,HUMANA NATIIONAL POS HMO,10.44,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $16.44 in Billed Charges at 63.5% = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.00,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.44,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $16.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,0.59,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,MOLINA HEALTHCARE,MOLINA MEDICARE,0.59,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.22,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $8.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.81,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $13.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,NAPHCARE,ALL COMMERICAL NAPHCARE,1.32,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.33,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $12.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.12,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $15.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.06,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.06,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,PREVEA HEALTH NETWORK,PREVEA360,1.06,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.06,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.49,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $10.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,0.60,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.84,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $11.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.97,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,UNITED HEALTHCARE,UHC ONEIDA NATION,0.97,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,0.59,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,UNITED HEALTHCARE,UNITED HEALTHCARE,0.97,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,UNITY HEALTH PLAN,UNITY HOSPICE,0.59,,,,,,,0.5900,16.4400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.84,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $11.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.19,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $10.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.84,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $11.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.84,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $11.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CYCLOPHOSPHAMIDE, NOS",J9075,HCPCS,636,RC,10019-955-50,CDM,,,,both,5.000000,ME,16.4400,10.8500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.86,,,,,,,0.5900,16.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.44 in Billed Charges for Rev 636 Proc J9075 = $9.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,AETNA,AETNA HSHS,3.52,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,AETNA,AETNA MEDICARE,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,AETNA,ALL COMMERCIAL AETNA,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,ANTHEM,ANTHEM POS/HMO,1.00,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 170% = $1.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,ANTHEM,ANTHEM PPO,1.24,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 210% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,CENPATICO,ALL MEDICAID CENPATICO,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.63,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,CIGNA,ALL COMMERCIAL CIGNA,3.82,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,COFINITY,COFINITY,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.18,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,4.58,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.87,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.98,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,2.65,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $2.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.63,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HUMANA,HUMANA CHOICE CARE HMO,3.46,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $5.45 in Billed Charges at 63.5% = $3.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HUMANA,HUMANA CHOICE CARE PPO,4.63,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HUMANA,HUMANA MEDICARE ADVANTAGE,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,HUMANA,HUMANA NATIIONAL POS HMO,3.46,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $5.45 in Billed Charges at 63.5% = $3.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.98,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.45,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,MOLINA HEALTHCARE,MOLINA MEDICARE,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.73,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $2.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.58,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,NAPHCARE,ALL COMMERICAL NAPHCARE,1.32,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.09,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $4.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.01,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $5.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.06,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.06,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,PREVEA HEALTH NETWORK,PREVEA360,1.06,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.06,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.48,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,0.60,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.92,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.97,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,0.97,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,0.97,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,UNITY HEALTH PLAN,UNITY HOSPICE,0.59,,,,,,,0.5900,5.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.92,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.38,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.92,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.92,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,70121-1238-1,CDM,,,,both,5.000000,ME,5.4500,3.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.27,,,,,,,0.5900,5.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.45 in Billed Charges for Rev 636 Proc J9075 = $3.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,AETNA,AETNA HSHS,3.02,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,AETNA,ALL COMMERCIAL AETNA,4.68,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $4.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,ANTHEM,ANTHEM POS/HMO,0.90,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7515 * Qty 1 = $0.53 at 170% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,ANTHEM,ANTHEM PPO,1.11,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7515 * Qty 1 = $0.53 at 210% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4.68,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $4.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,CENPATICO,ALL MEDICAID CENPATICO,4.68,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $4.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3.98,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,CIGNA,ALL COMMERCIAL CIGNA,3.28,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,COFINITY,COFINITY,4.68,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $4.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4.45,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $4.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,3.93,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.32,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.42,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,2.27,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $2.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3.98,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,HUMANA,HUMANA CHOICE CARE HMO,1.36,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.36 from Fee Schedule 005543_170 for Rev 636 Proc J7515 * Qty 1 = $1.36 at 100% = $1.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,HUMANA,HUMANA CHOICE CARE PPO,3.98,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,HUMANA,HUMANA NATIIONAL POS HMO,1.36,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.36 from Fee Schedule 005543_170 for Rev 636 Proc J7515 * Qty 1 = $1.36 at 100% = $1.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.42,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,4.68,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $4.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.34,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $2.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3.93,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.51,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4.31,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $4.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.95,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7515 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.95,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7515 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,PREVEA HEALTH NETWORK,PREVEA360,0.95,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7515 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.95,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7515 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2.99,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $2.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.37,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.87,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J7515 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.87,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J7515 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.87,,,,,,,0.8700,4.6800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J7515 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.37,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2.90,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $2.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.37,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.37,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 25 MG CAPS per 25 mg,J7515,HCPCS,636,RC,0093-9018-19,CDM,,,,both,25.000000,ME,4.6800,3.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.81,,,,,,,0.8700,4.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.68 in Billed Charges for Rev 636 Proc J7515 = $2.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,AETNA,AETNA HSHS,17.60,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $17.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,AETNA,AETNA MEDICARE,2.86,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,AETNA,ALL COMMERCIAL AETNA,27.25,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $27.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.86,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,ANTHEM,ANTHEM POS/HMO,18.53,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $27.25 in Billed Charges at 68% = $18.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,ANTHEM,ANTHEM PPO,18.53,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $27.25 in Billed Charges at 68% = $18.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,27.25,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $27.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,CENPATICO,ALL MEDICAID CENPATICO,27.25,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $27.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,23.16,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $23.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,CIGNA,ALL COMMERCIAL CIGNA,19.08,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $19.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,COFINITY,COFINITY,27.25,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $27.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,25.89,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $25.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,22.89,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $22.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19.35,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $19.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,19.89,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $19.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,13.24,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $13.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,23.16,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $23.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HUMANA,HUMANA CHOICE CARE HMO,17.30,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $27.25 in Billed Charges at 63.5% = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HUMANA,HUMANA CHOICE CARE PPO,23.16,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $23.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HUMANA,HUMANA MEDICARE ADVANTAGE,2.86,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,HUMANA,HUMANA NATIIONAL POS HMO,17.30,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $27.25 in Billed Charges at 63.5% = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,19.89,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $19.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,27.25,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $27.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.86,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,MOLINA HEALTHCARE,MOLINA MEDICARE,2.86,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.63,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $13.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,22.89,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $22.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,NAPHCARE,ALL COMMERICAL NAPHCARE,6.44,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20.44,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $20.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,25.07,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $25.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.35,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $27.25 in Billed Charges at 60% = $16.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.35,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $27.25 in Billed Charges at 60% = $16.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,PREVEA HEALTH NETWORK,PREVEA360,16.35,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $27.25 in Billed Charges at 60% = $16.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.35,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $27.25 in Billed Charges at 60% = $16.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.39,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $17.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.89,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,19.62,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $19.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.72,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.72 from Fee Schedule UHC_31190C for Rev 636 Proc J0759 * Qty 1 = $4.72 at 100% = $4.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,UNITED HEALTHCARE,UHC ONEIDA NATION,4.72,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.72 from Fee Schedule UHC_31190C for Rev 636 Proc J0759 * Qty 1 = $4.72 at 100% = $4.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.86,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,UNITED HEALTHCARE,UNITED HEALTHCARE,4.72,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.72 from Fee Schedule UHC_31190C for Rev 636 Proc J0759 * Qty 1 = $4.72 at 100% = $4.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,UNITY HEALTH PLAN,UNITY HOSPICE,2.86,,,,,,,2.8600,27.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,19.62,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $19.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.90,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $16.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,19.62,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $19.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,19.62,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $19.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-610-01,CDM,,,,both,1.000000,ME,27.2500,17.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16.35,,,,,,,2.8600,27.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.25 in Billed Charges for Rev 636 Proc J0759 = $16.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,AETNA,AETNA HSHS,17.20,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $17.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,AETNA,AETNA MEDICARE,2.86,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,AETNA,ALL COMMERCIAL AETNA,26.63,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $26.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.86,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,ANTHEM,ANTHEM POS/HMO,18.11,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $26.63 in Billed Charges at 68% = $18.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,ANTHEM,ANTHEM PPO,18.11,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $26.63 in Billed Charges at 68% = $18.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,26.63,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $26.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,CENPATICO,ALL MEDICAID CENPATICO,26.63,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $26.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,22.64,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $22.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,CIGNA,ALL COMMERCIAL CIGNA,18.64,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $18.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,COFINITY,COFINITY,26.63,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $26.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,25.30,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $25.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,22.37,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $22.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,18.91,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $18.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,19.44,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,12.94,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $12.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,22.64,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $22.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HUMANA,HUMANA CHOICE CARE HMO,16.91,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $26.63 in Billed Charges at 63.5% = $16.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HUMANA,HUMANA CHOICE CARE PPO,22.64,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $22.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HUMANA,HUMANA MEDICARE ADVANTAGE,2.86,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,HUMANA,HUMANA NATIIONAL POS HMO,16.91,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $26.63 in Billed Charges at 63.5% = $16.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,19.44,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,26.63,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $26.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.86,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,MOLINA HEALTHCARE,MOLINA MEDICARE,2.86,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.32,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $13.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,22.37,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $22.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,NAPHCARE,ALL COMMERICAL NAPHCARE,6.44,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,19.97,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $19.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,24.50,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.98,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $26.63 in Billed Charges at 60% = $15.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.98,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $26.63 in Billed Charges at 60% = $15.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,PREVEA HEALTH NETWORK,PREVEA360,15.98,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $26.63 in Billed Charges at 60% = $15.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.98,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0759 $26.63 in Billed Charges at 60% = $15.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.00,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $17.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.89,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,19.17,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $19.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.72,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.72 from Fee Schedule UHC_31190C for Rev 636 Proc J0759 * Qty 1 = $4.72 at 100% = $4.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.72,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.72 from Fee Schedule UHC_31190C for Rev 636 Proc J0759 * Qty 1 = $4.72 at 100% = $4.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.86,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.72,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.72 from Fee Schedule UHC_31190C for Rev 636 Proc J0759 * Qty 1 = $4.72 at 100% = $4.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,UNITY HEALTH PLAN,UNITY HOSPICE,2.86,,,,,,,2.8600,26.6300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,19.17,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $19.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.51,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,19.17,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $19.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,19.17,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $19.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLEVIDIPINE 50 MG/100ML EMUL per 1 mg,J0759,HCPCS,636,RC,10122-611-01,CDM,,,,both,1.000000,ME,26.6300,17.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.98,,,,,,,2.8600,26.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.63 in Billed Charges for Rev 636 Proc J0759 = $15.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,AETNA,AETNA HSHS,188.10,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $188.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,AETNA,ALL COMMERCIAL AETNA,291.18,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $291.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,ANTHEM,ANTHEM POS/HMO,3.59,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 170% = $3.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,ANTHEM,ANTHEM PPO,4.43,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 210% = $4.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,291.18,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $291.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,CENPATICO,ALL MEDICAID CENPATICO,291.18,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $291.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,247.50,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,CIGNA,ALL COMMERCIAL CIGNA,203.83,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $203.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,COFINITY,COFINITY,291.18,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $291.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,276.62,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $276.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,244.59,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $244.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,206.74,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $206.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,212.56,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $212.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,141.51,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $141.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,247.50,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,HUMANA,HUMANA CHOICE CARE HMO,6.38,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule 005543_170 for Rev 636 Proc J9060 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,HUMANA,HUMANA CHOICE CARE PPO,247.50,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,HUMANA,HUMANA NATIIONAL POS HMO,6.38,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule 005543_170 for Rev 636 Proc J9060 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,212.56,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $212.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,291.18,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $291.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,145.59,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $145.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,244.59,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $244.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,218.39,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $218.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,267.89,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $267.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.78,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.78,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,PREVEA HEALTH NETWORK,PREVEA360,3.78,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.78,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,185.86,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $185.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,209.65,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $209.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.48,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,3.48,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,3.48,,,,,,,3.4800,291.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,209.65,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $209.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,180.53,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $180.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,209.65,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $209.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,209.65,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $209.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG SOLR 1 EACH VIAL per 10 mg,J9060,HCPCS,636,RC,44567-530-01,CDM,,,,both,10.000000,ME,291.1800,192.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,174.71,,,,,,,3.4800,291.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $291.18 in Billed Charges for Rev 636 Proc J9060 = $174.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,AETNA,AETNA HSHS,15.25,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $15.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,AETNA,ALL COMMERCIAL AETNA,23.60,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $23.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,ANTHEM,ANTHEM POS/HMO,3.59,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 170% = $3.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,ANTHEM,ANTHEM PPO,4.43,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 210% = $4.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,23.60,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $23.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,CENPATICO,ALL MEDICAID CENPATICO,23.60,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $23.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.06,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $20.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,CIGNA,ALL COMMERCIAL CIGNA,16.52,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $16.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,COFINITY,COFINITY,23.60,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $23.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,22.42,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $22.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,19.82,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $19.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,16.76,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $16.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.23,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $17.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,11.47,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $11.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.06,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $20.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,HUMANA,HUMANA CHOICE CARE HMO,6.38,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule 005543_170 for Rev 636 Proc J9060 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,HUMANA,HUMANA CHOICE CARE PPO,20.06,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $20.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,HUMANA,HUMANA NATIIONAL POS HMO,6.38,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule 005543_170 for Rev 636 Proc J9060 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.23,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $17.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,23.60,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $23.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.80,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $11.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,19.82,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $19.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,17.70,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $17.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,21.71,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $21.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.78,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.78,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,PREVEA HEALTH NETWORK,PREVEA360,3.78,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.78,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.06,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $15.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,16.99,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $16.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.48,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,3.48,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,3.48,,,,,,,3.4800,23.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,16.99,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $16.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.63,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $14.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,16.99,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $16.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,16.99,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $16.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 100 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-51,CDM,,,,both,10.000000,ME,23.6000,15.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.16,,,,,,,3.4800,23.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.60 in Billed Charges for Rev 636 Proc J9060 = $14.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,AETNA,AETNA HSHS,26.68,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $26.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,AETNA,ALL COMMERCIAL AETNA,41.30,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $41.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,ANTHEM,ANTHEM POS/HMO,3.40,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 170% = $3.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,ANTHEM,ANTHEM PPO,4.20,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 210% = $4.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,41.30,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $41.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,CENPATICO,ALL MEDICAID CENPATICO,41.30,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $41.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,35.11,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $35.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,CIGNA,ALL COMMERCIAL CIGNA,28.91,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $28.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,COFINITY,COFINITY,41.30,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $41.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,39.24,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $39.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,34.69,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $34.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.32,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $29.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,30.15,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $30.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,20.07,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $20.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,35.11,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $35.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,HUMANA,HUMANA CHOICE CARE HMO,3.15,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule 005543_170 for Rev 636 Proc J0744 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,HUMANA,HUMANA CHOICE CARE PPO,35.11,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $35.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,HUMANA,HUMANA NATIIONAL POS HMO,3.15,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule 005543_170 for Rev 636 Proc J0744 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,30.15,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $30.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,41.30,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $41.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,20.65,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $20.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,34.69,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $34.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,30.98,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $30.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,38.00,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.58,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 179% = $3.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.58,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 179% = $3.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,PREVEA HEALTH NETWORK,PREVEA360,3.58,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 179% = $3.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.58,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 179% = $3.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.36,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $26.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,29.74,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $29.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.30,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.30 from Fee Schedule UHC_31190C for Rev 636 Proc J0744 * Qty 1 = $3.30 at 100% = $3.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,3.30,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.30 from Fee Schedule UHC_31190C for Rev 636 Proc J0744 * Qty 1 = $3.30 at 100% = $3.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,3.30,,,,,,,3.1500,41.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.30 from Fee Schedule UHC_31190C for Rev 636 Proc J0744 * Qty 1 = $3.30 at 100% = $3.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,29.74,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $29.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,25.61,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $25.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,29.74,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $29.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,29.74,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $29.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 400 MG/200ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-3300-01,CDM,,,,both,200.000000,ME,41.3000,27.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,24.78,,,,,,,3.1500,41.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.30 in Billed Charges for Rev 636 Proc J0744 = $24.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,AETNA,AETNA HSHS,10.55,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,AETNA,ALL COMMERCIAL AETNA,16.33,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,ANTHEM,ANTHEM POS/HMO,3.25,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 170% = $3.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,ANTHEM,ANTHEM PPO,4.01,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 210% = $4.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.33,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,CENPATICO,ALL MEDICAID CENPATICO,16.33,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.88,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,CIGNA,ALL COMMERCIAL CIGNA,11.43,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,COFINITY,COFINITY,16.33,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.51,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,13.72,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.59,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $11.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.92,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,7.94,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $7.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.88,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,HUMANA,HUMANA CHOICE CARE HMO,4.06,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.06 from Fee Schedule 005543_170 for Rev 636 Proc J0736 * Qty 1 = $4.06 at 100% = $4.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,HUMANA,HUMANA CHOICE CARE PPO,13.88,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,HUMANA,HUMANA NATIIONAL POS HMO,4.06,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.06 from Fee Schedule 005543_170 for Rev 636 Proc J0736 * Qty 1 = $4.06 at 100% = $4.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.92,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.33,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.17,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.72,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.25,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.02,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $15.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.42,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.42,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA360,3.42,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.42,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.42,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $10.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.76,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.15,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,3.15,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,3.15,,,,,,,3.1500,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.76,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.12,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $10.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.76,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.76,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 900 MG/6ML SOLN per 300 mg,J0736,HCPCS,636,RC,0009-0902-11,CDM,,,,both,300.000000,ME,16.3300,10.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.80,,,,,,,3.1500,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.33 in Billed Charges for Rev 636 Proc J0736 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,AETNA,AETNA HSHS,35.47,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $35.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,AETNA,ALL COMMERCIAL AETNA,54.90,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $54.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,ANTHEM,ANTHEM POS/HMO,3.40,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 170% = $3.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,ANTHEM,ANTHEM PPO,4.20,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 210% = $4.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,54.90,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $54.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,CENPATICO,ALL MEDICAID CENPATICO,54.90,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $54.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,46.67,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $46.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,CIGNA,ALL COMMERCIAL CIGNA,38.43,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $38.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,COFINITY,COFINITY,54.90,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $54.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,52.16,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $52.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,46.12,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $46.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,38.98,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $38.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,40.08,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $40.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,26.68,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $26.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,46.67,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $46.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,HUMANA,HUMANA CHOICE CARE HMO,3.15,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule 005543_170 for Rev 636 Proc J0744 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,HUMANA,HUMANA CHOICE CARE PPO,46.67,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $46.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,HUMANA,HUMANA NATIIONAL POS HMO,3.15,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule 005543_170 for Rev 636 Proc J0744 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,40.08,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $40.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,54.90,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $54.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27.45,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $27.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,46.12,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $46.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,41.18,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $41.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,50.51,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $50.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.58,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 179% = $3.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.58,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 179% = $3.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,PREVEA HEALTH NETWORK,PREVEA360,3.58,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 179% = $3.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.58,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0744 * Qty 1 = $2.00 at 179% = $3.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,35.04,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $35.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,39.53,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $39.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.30,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.30 from Fee Schedule UHC_31190C for Rev 636 Proc J0744 * Qty 1 = $3.30 at 100% = $3.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,UNITED HEALTHCARE,UHC ONEIDA NATION,3.30,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.30 from Fee Schedule UHC_31190C for Rev 636 Proc J0744 * Qty 1 = $3.30 at 100% = $3.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,UNITED HEALTHCARE,UNITED HEALTHCARE,3.30,,,,,,,3.1500,54.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.30 from Fee Schedule UHC_31190C for Rev 636 Proc J0744 * Qty 1 = $3.30 at 100% = $3.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,39.53,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $39.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,34.04,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $34.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,39.53,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $39.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,39.53,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $39.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 200 MG/100ML SOLN per 200 mg,J0744,HCPCS,636,RC,0409-2300-01,CDM,,,,both,200.000000,ME,54.9000,36.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,32.94,,,,,,,3.1500,54.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $54.90 in Billed Charges for Rev 636 Proc J0744 = $32.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,AETNA,AETNA HSHS,157.82,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $157.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,AETNA,ALL COMMERCIAL AETNA,244.30,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $244.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,ANTHEM,ANTHEM POS/HMO,40.41,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.77 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3230 * Qty 1 = $23.77 at 170% = $40.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,ANTHEM,ANTHEM PPO,49.92,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.77 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3230 * Qty 1 = $23.77 at 210% = $49.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,244.30,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $244.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,CENPATICO,ALL MEDICAID CENPATICO,244.30,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $244.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,207.66,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $207.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,CIGNA,ALL COMMERCIAL CIGNA,171.01,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $171.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,COFINITY,COFINITY,244.30,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $244.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,232.09,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $232.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,205.21,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $205.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,173.45,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $173.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,178.34,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $178.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,118.73,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $118.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,207.66,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $207.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,HUMANA,HUMANA CHOICE CARE HMO,51.15,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.15 from Fee Schedule 005543_170 for Rev 636 Proc J3230 * Qty 1 = $51.15 at 100% = $51.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,HUMANA,HUMANA CHOICE CARE PPO,207.66,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $207.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,HUMANA,HUMANA NATIIONAL POS HMO,51.15,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $51.15 from Fee Schedule 005543_170 for Rev 636 Proc J3230 * Qty 1 = $51.15 at 100% = $51.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,178.34,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $178.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,244.30,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $244.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,122.15,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $122.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,205.21,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $205.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,183.23,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $183.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,224.76,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $224.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,42.55,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.77 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3230 * Qty 1 = $23.77 at 179% = $42.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,42.55,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.77 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3230 * Qty 1 = $23.77 at 179% = $42.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,PREVEA HEALTH NETWORK,PREVEA360,42.55,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.77 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3230 * Qty 1 = $23.77 at 179% = $42.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,42.55,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.77 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3230 * Qty 1 = $23.77 at 179% = $42.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,155.94,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $155.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,175.90,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $175.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,39.22,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.22 from Fee Schedule UHC_31190C for Rev 636 Proc J3230 * Qty 1 = $39.22 at 100% = $39.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,39.22,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.22 from Fee Schedule UHC_31190C for Rev 636 Proc J3230 * Qty 1 = $39.22 at 100% = $39.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,39.22,,,,,,,39.2200,244.3000,fee schedule,ST VINCENT HOSPITAL (ACU). $39.22 from Fee Schedule UHC_31190C for Rev 636 Proc J3230 * Qty 1 = $39.22 at 100% = $39.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,175.90,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $175.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,151.47,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $151.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,175.90,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $175.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,175.90,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $175.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE HCL INJECTION,J3230,HCPCS,636,RC,0641-1398-31,CDM,,,,both,50.000000,ME,244.3000,161.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,146.58,,,,,,,39.2200,244.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.30 in Billed Charges for Rev 636 Proc J3230 = $146.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,AETNA,AETNA HSHS,23.84,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $23.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,AETNA,ALL COMMERCIAL AETNA,36.90,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $36.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,ANTHEM,ANTHEM POS/HMO,8.06,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0694 * Qty 1 = $4.74 at 170% = $8.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,ANTHEM,ANTHEM PPO,9.95,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0694 * Qty 1 = $4.74 at 210% = $9.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,36.90,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $36.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,CENPATICO,ALL MEDICAID CENPATICO,36.90,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $36.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,31.37,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $31.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,CIGNA,ALL COMMERCIAL CIGNA,25.83,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $25.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,COFINITY,COFINITY,36.90,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $36.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,35.06,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $35.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,31.00,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $31.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,26.20,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $26.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,26.94,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $26.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,17.93,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $17.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,31.37,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $31.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,HUMANA,HUMANA CHOICE CARE HMO,7.62,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.62 from Fee Schedule 005543_170 for Rev 636 Proc J0694 * Qty 1 = $7.62 at 100% = $7.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,HUMANA,HUMANA CHOICE CARE PPO,31.37,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $31.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,HUMANA,HUMANA NATIIONAL POS HMO,7.62,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.62 from Fee Schedule 005543_170 for Rev 636 Proc J0694 * Qty 1 = $7.62 at 100% = $7.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,26.94,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $26.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,36.90,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $36.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,18.45,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $18.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,31.00,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $31.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,27.68,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $27.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,33.95,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $33.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.48,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0694 * Qty 1 = $4.74 at 179% = $8.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.48,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0694 * Qty 1 = $4.74 at 179% = $8.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,PREVEA HEALTH NETWORK,PREVEA360,8.48,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0694 * Qty 1 = $4.74 at 179% = $8.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.48,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0694 * Qty 1 = $4.74 at 179% = $8.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,23.55,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $23.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,26.57,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $26.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.82,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.82 from Fee Schedule UHC_31190C for Rev 636 Proc J0694 * Qty 1 = $7.82 at 100% = $7.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,UNITED HEALTHCARE,UHC ONEIDA NATION,7.82,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.82 from Fee Schedule UHC_31190C for Rev 636 Proc J0694 * Qty 1 = $7.82 at 100% = $7.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,UNITED HEALTHCARE,UNITED HEALTHCARE,7.82,,,,,,,7.6200,36.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $7.82 from Fee Schedule UHC_31190C for Rev 636 Proc J0694 * Qty 1 = $7.82 at 100% = $7.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,26.57,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $26.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,22.88,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $22.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,26.57,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $26.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,26.57,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $26.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFOXITIN 2 G SOLR 1 EACH VIAL per 1 g,J0694,HCPCS,636,RC,25021-110-20,CDM,,,,both,1.000000,GM,36.9000,24.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,22.14,,,,,,,7.6200,36.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $36.90 in Billed Charges for Rev 636 Proc J0694 = $22.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,AETNA,AETNA HSHS,57.58,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $57.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,AETNA,AETNA MEDICARE,28.69,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,AETNA,ALL COMMERCIAL AETNA,89.14,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $89.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,ANTHEM,ANTEHM MEDICAID,89.14,,,,,,,28.6900,94.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9119 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $89.14, claim capped at $89.14 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.69,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,ANTHEM,ANTHEM POS/HMO,48.77,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $28.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9119 * Qty 1 = $28.69 at 170% = $48.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,ANTHEM,ANTHEM PPO,60.25,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $28.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9119 * Qty 1 = $28.69 at 210% = $60.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,89.14,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $89.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,CENPATICO,ALL MEDICAID CENPATICO,89.14,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $89.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,75.77,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $75.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,CIGNA,ALL COMMERCIAL CIGNA,62.40,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $62.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,COFINITY,COFINITY,89.14,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $89.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,89.14,,,,,,,28.6900,94.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9119 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $89.14, claim capped at $89.14 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,89.14,,,,,,,28.6900,94.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9119 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $89.14, claim capped at $89.14 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,84.68,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $84.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,74.88,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.29,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $63.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,65.07,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $65.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,43.32,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $43.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,75.77,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $75.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HUMANA,HUMANA CHOICE CARE HMO,47.09,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $47.09 from Fee Schedule 005543_170 for Rev 636 Proc J9119 * Qty 1 = $47.09 at 100% = $47.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HUMANA,HUMANA CHOICE CARE PPO,75.77,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $75.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HUMANA,HUMANA MEDICARE ADVANTAGE,28.69,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,HUMANA,HUMANA NATIIONAL POS HMO,47.09,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $47.09 from Fee Schedule 005543_170 for Rev 636 Proc J9119 * Qty 1 = $47.09 at 100% = $47.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,65.07,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $65.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,89.14,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $89.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,89.14,,,,,,,28.6900,94.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9119 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $89.14, claim capped at $89.14 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.69,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,89.14,,,,,,,28.6900,94.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9119 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $89.14, claim capped at $89.14 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,MOLINA HEALTHCARE,MOLINA MEDICAID,94.49,,,,,,,28.6900,94.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9119 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07 (Service Line reduced to $89.14, claim capped at $89.14 in billed charges)... $89.14 at 106% = $94.49 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,MOLINA HEALTHCARE,MOLINA MEDICARE,28.69,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,44.57,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $44.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,74.88,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $74.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,NAPHCARE,ALL COMMERICAL NAPHCARE,64.55,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,66.86,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $66.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,82.01,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $82.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,51.36,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $28.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9119 * Qty 1 = $28.69 at 179% = $51.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,51.36,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $28.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9119 * Qty 1 = $28.69 at 179% = $51.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,PREVEA HEALTH NETWORK,PREVEA360,51.36,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $28.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9119 * Qty 1 = $28.69 at 179% = $51.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,51.36,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $28.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9119 * Qty 1 = $28.69 at 179% = $51.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,56.90,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $56.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,28.98,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,64.18,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $64.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,TRIOLOGY,TRILOGY MEDICAID,89.14,,,,,,,28.6900,94.4900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J9119 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 106% = $2,153.99 (Service Line reduced to $89.14, claim capped at $89.14 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,47.34,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $47.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9119 * Qty 1 = $47.34 at 100% = $47.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,UNITED HEALTHCARE,UHC ONEIDA NATION,47.34,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $47.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9119 * Qty 1 = $47.34 at 100% = $47.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.69,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,UNITED HEALTHCARE,UNITED HEALTHCARE,47.34,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $47.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9119 * Qty 1 = $47.34 at 100% = $47.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,UNITY HEALTH PLAN,UNITY HOSPICE,28.69,,,,,,,28.6900,94.4900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,64.18,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $64.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.27,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $55.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,64.18,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $64.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,64.18,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $64.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEMIPLIMAB-RWLC 350 MG/7ML SOLN 7 ML VIAL per 1 mg,J9119,HCPCS,636,RC,61755-008-01,CDM,,,,both,1.000000,ME,89.1400,58.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,53.48,,,,,,,28.6900,94.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $89.14 in Billed Charges for Rev 636 Proc J9119 = $53.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,AETNA,AETNA HSHS,28.49,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $28.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,AETNA,AETNA MEDICARE,3.87,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,AETNA,ALL COMMERCIAL AETNA,44.10,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $44.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,ANTHEM,ANTEHM MEDICAID,44.10,,,,,,,3.8700,46.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0717 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $44.10, claim capped at $44.10 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.87,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,ANTHEM,ANTHEM POS/HMO,6.58,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0717 * Qty 1 = $3.87 at 170% = $6.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,ANTHEM,ANTHEM PPO,8.13,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0717 * Qty 1 = $3.87 at 210% = $8.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,44.10,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $44.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,CENPATICO,ALL MEDICAID CENPATICO,44.10,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $44.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,37.49,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $37.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,CIGNA,ALL COMMERCIAL CIGNA,30.87,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $30.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,COFINITY,COFINITY,44.10,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $44.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,44.10,,,,,,,3.8700,46.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0717 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $44.10, claim capped at $44.10 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,44.10,,,,,,,3.8700,46.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0717 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $44.10, claim capped at $44.10 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,41.90,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $41.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,37.04,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $37.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,31.31,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $31.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,32.19,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $32.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,21.43,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $21.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,37.49,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $37.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HUMANA,HUMANA CHOICE CARE HMO,7.58,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $7.58 from Fee Schedule 005543_170 for Rev 636 Proc J0717 * Qty 1 = $7.58 at 100% = $7.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HUMANA,HUMANA CHOICE CARE PPO,37.49,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $37.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HUMANA,HUMANA MEDICARE ADVANTAGE,3.87,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,HUMANA,HUMANA NATIIONAL POS HMO,7.58,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $7.58 from Fee Schedule 005543_170 for Rev 636 Proc J0717 * Qty 1 = $7.58 at 100% = $7.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,32.19,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $32.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,44.10,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $44.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,44.10,,,,,,,3.8700,46.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0717 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $44.10, claim capped at $44.10 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.87,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,44.10,,,,,,,3.8700,46.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0717 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $44.10, claim capped at $44.10 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,MOLINA HEALTHCARE,MOLINA MEDICAID,46.75,,,,,,,3.8700,46.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0717 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $44.10, claim capped at $44.10 in billed charges)... $44.10 at 106% = $46.75 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,MOLINA HEALTHCARE,MOLINA MEDICARE,3.87,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,22.05,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $22.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,37.04,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $37.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,NAPHCARE,ALL COMMERICAL NAPHCARE,8.70,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,33.08,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $33.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,40.57,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $40.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.93,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0717 * Qty 1 = $3.87 at 179% = $6.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.93,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0717 * Qty 1 = $3.87 at 179% = $6.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,PREVEA HEALTH NETWORK,PREVEA360,6.93,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0717 * Qty 1 = $3.87 at 179% = $6.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.93,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0717 * Qty 1 = $3.87 at 179% = $6.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,28.15,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $28.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.91,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,31.75,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $31.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,TRIOLOGY,TRILOGY MEDICAID,44.10,,,,,,,3.8700,46.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0717 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 106% = $612.69 (Service Line reduced to $44.10, claim capped at $44.10 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.39,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.39 from Fee Schedule UHC_31190C for Rev 636 Proc J0717 * Qty 1 = $6.39 at 100% = $6.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,UNITED HEALTHCARE,UHC ONEIDA NATION,6.39,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.39 from Fee Schedule UHC_31190C for Rev 636 Proc J0717 * Qty 1 = $6.39 at 100% = $6.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.87,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,UNITED HEALTHCARE,UNITED HEALTHCARE,6.39,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.39 from Fee Schedule UHC_31190C for Rev 636 Proc J0717 * Qty 1 = $6.39 at 100% = $6.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,UNITY HEALTH PLAN,UNITY HOSPICE,3.87,,,,,,,3.8700,46.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,31.75,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $31.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,27.34,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $27.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,31.75,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $31.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,31.75,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $31.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CERTOLIZUMAB PEGOL 200 MG/ML PSKT per 1 mg,J0717,HCPCS,636,RC,50474-710-79,CDM,,,,both,1.000000,ME,44.1000,29.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,26.46,,,,,,,3.8700,46.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $44.10 in Billed Charges for Rev 636 Proc J0717 = $26.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,AETNA,AETNA HSHS,39.04,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $39.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,AETNA,ALL COMMERCIAL AETNA,60.43,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $60.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,ANTHEM,ANTHEM POS/HMO,7.00,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 170% = $7.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,ANTHEM,ANTHEM PPO,8.65,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 210% = $8.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,60.43,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $60.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,CENPATICO,ALL MEDICAID CENPATICO,60.43,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $60.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,51.37,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $51.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,CIGNA,ALL COMMERCIAL CIGNA,42.30,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $42.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,COFINITY,COFINITY,60.43,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $60.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,57.41,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $57.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,50.76,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $50.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42.91,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $42.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,44.11,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $44.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,29.37,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $29.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,51.37,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $51.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,HUMANA,HUMANA CHOICE CARE HMO,6.12,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $6.12 from Fee Schedule 005543_170 for Rev 636 Proc J9130 * Qty 1 = $6.12 at 100% = $6.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,HUMANA,HUMANA CHOICE CARE PPO,51.37,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $51.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,HUMANA,HUMANA NATIIONAL POS HMO,6.12,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $6.12 from Fee Schedule 005543_170 for Rev 636 Proc J9130 * Qty 1 = $6.12 at 100% = $6.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,44.11,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $44.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,60.43,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $60.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,30.22,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $30.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,50.76,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $50.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,45.32,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $45.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,55.60,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $55.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.37,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 179% = $7.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.37,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 179% = $7.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,PREVEA HEALTH NETWORK,PREVEA360,7.37,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 179% = $7.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.37,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 179% = $7.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38.57,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $38.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,43.51,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $43.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.80,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $6.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9130 * Qty 1 = $6.80 at 100% = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,6.80,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $6.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9130 * Qty 1 = $6.80 at 100% = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,6.80,,,,,,,6.1200,60.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $6.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9130 * Qty 1 = $6.80 at 100% = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,43.51,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $43.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37.47,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $37.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,43.51,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $43.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,43.51,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $43.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG INJ,J9130,HCPCS,636,RC,63323-128-00,CDM,,,,both,100.000000,ME,60.4300,39.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,36.26,,,,,,,6.1200,60.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $60.43 in Billed Charges for Rev 636 Proc J9130 = $36.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,AETNA,AETNA HSHS,839.80,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $839.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,AETNA,AETNA MEDICARE,58.01,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,AETNA,ALL COMMERCIAL AETNA,1300.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,ANTHEM,ANTEHM MEDICAID,266.39,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,58.01,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,ANTHEM,ANTHEM POS/HMO,98.62,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 170% = $98.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,ANTHEM,ANTHEM PPO,121.82,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 210% = $121.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1300.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,CENPATICO,ALL MEDICAID CENPATICO,1300.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1105.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,CIGNA,ALL COMMERCIAL CIGNA,910.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $910.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,COFINITY,COFINITY,1300.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,266.39,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,266.39,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1235.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,235.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,1092.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,092.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,923.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $923.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,949.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $949.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,631.80,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $631.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1105.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HUMANA,HUMANA CHOICE CARE HMO,171.14,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.14 from Fee Schedule 005543_170 for Rev 636 Proc J1190 * Qty 1 = $171.14 at 100% = $171.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HUMANA,HUMANA CHOICE CARE PPO,1105.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,105.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,58.01,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,HUMANA,HUMANA NATIIONAL POS HMO,171.14,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.14 from Fee Schedule 005543_170 for Rev 636 Proc J1190 * Qty 1 = $171.14 at 100% = $171.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,949.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $949.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1300.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,300.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,266.39,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,58.01,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,266.39,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,282.37,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39... $266.39 at 106% = $282.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,58.01,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,650.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $650.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1092.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,092.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,130.53,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,975.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $975.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1196.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $1,196.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,103.84,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,103.84,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,PREVEA HEALTH NETWORK,PREVEA360,103.84,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,103.84,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,829.79,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $829.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,58.59,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,936.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,TRIOLOGY,TRILOGY MEDICAID,282.37,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 106% = $282.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,95.72,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,95.72,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,58.01,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,95.72,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,UNITY HEALTH PLAN,UNITY HOSPICE,58.01,,,,,,,58.0100,1300.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,936.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,806.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $806.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,936.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,936.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $936.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL INJECTION,J1190,HCPCS,636,RC,0143-9247-01,CDM,,,,both,250.000000,ME,1300.0000,858.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,780.00,,,,,,,58.0100,1300.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,300.00 in Billed Charges for Rev 636 Proc J1190 = $780.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,AETNA,AETNA HSHS,559.82,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $559.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,AETNA,AETNA MEDICARE,58.01,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,AETNA,ALL COMMERCIAL AETNA,866.60,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $866.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,ANTHEM,ANTEHM MEDICAID,266.39,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,58.01,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,ANTHEM,ANTHEM POS/HMO,98.62,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 170% = $98.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,ANTHEM,ANTHEM PPO,121.82,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 210% = $121.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,866.60,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $866.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,CENPATICO,ALL MEDICAID CENPATICO,866.60,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $866.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,736.61,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $736.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,CIGNA,ALL COMMERCIAL CIGNA,606.62,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $606.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,COFINITY,COFINITY,866.60,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $866.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,266.39,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,266.39,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,823.27,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $823.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,727.94,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $727.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,615.29,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $615.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,632.62,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $632.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,421.17,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $421.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,736.61,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $736.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HUMANA,HUMANA CHOICE CARE HMO,171.14,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.14 from Fee Schedule 005543_170 for Rev 636 Proc J1190 * Qty 1 = $171.14 at 100% = $171.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HUMANA,HUMANA CHOICE CARE PPO,736.61,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $736.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,58.01,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,HUMANA,HUMANA NATIIONAL POS HMO,171.14,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.14 from Fee Schedule 005543_170 for Rev 636 Proc J1190 * Qty 1 = $171.14 at 100% = $171.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,632.62,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $632.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,866.60,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $866.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,266.39,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,58.01,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,266.39,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,282.37,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39... $266.39 at 106% = $282.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,58.01,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,433.30,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $433.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,727.94,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $727.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,130.53,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,649.95,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $649.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,797.27,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $797.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,103.84,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,103.84,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,PREVEA HEALTH NETWORK,PREVEA360,103.84,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,103.84,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,553.15,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $553.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,58.59,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,623.95,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $623.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,TRIOLOGY,TRILOGY MEDICAID,282.37,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 106% = $282.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,95.72,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,95.72,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,58.01,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,95.72,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,UNITY HEALTH PLAN,UNITY HOSPICE,58.01,,,,,,,58.0100,866.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,623.95,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $623.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,537.29,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $537.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,623.95,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $623.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,623.95,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $623.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-101-01,CDM,,,,both,250.000000,ME,866.6000,571.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,519.96,,,,,,,58.0100,866.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $866.60 in Billed Charges for Rev 636 Proc J1190 = $519.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,AETNA,AETNA HSHS,0.35,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,AETNA,ALL COMMERCIAL AETNA,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,CENPATICO,ALL MEDICAID CENPATICO,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.46,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,CIGNA,ALL COMMERCIAL CIGNA,0.38,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,COFINITY,COFINITY,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.51,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,0.45,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.38,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,0.26,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.46,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,HUMANA,HUMANA CHOICE CARE HMO,0.11,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,HUMANA,HUMANA CHOICE CARE PPO,0.46,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,HUMANA,HUMANA NATIIONAL POS HMO,0.11,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.54,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.27,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.45,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.41,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.50,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.34,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.33,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.39,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 10 MG/ML SOLN per 0.25 mg,J8540,HCPCS,636,RC,70069-021-01,CDM,,,,both,0.250000,ME,0.5400,0.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.32,,,,,,,0.0200,0.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.54 in Billed Charges for Rev 636 Proc J8540 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,AETNA,AETNA HSHS,2.64,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,AETNA,ALL COMMERCIAL AETNA,4.08,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $4.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,ANTHEM,ANTHEM POS/HMO,0.19,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 170% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,ANTHEM,ANTHEM PPO,0.23,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 210% = $0.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4.08,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $4.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,CENPATICO,ALL MEDICAID CENPATICO,4.08,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $4.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3.47,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $3.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,CIGNA,ALL COMMERCIAL CIGNA,2.86,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,COFINITY,COFINITY,4.08,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $4.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3.88,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $3.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,3.43,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2.90,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2.98,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,1.98,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $1.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3.47,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $3.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,HUMANA,HUMANA CHOICE CARE HMO,0.19,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,HUMANA,HUMANA CHOICE CARE PPO,3.47,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $3.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,HUMANA,HUMANA NATIIONAL POS HMO,0.19,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2.98,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,4.08,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $4.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.04,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3.43,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.06,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $3.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3.75,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $3.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.20,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.20,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,PREVEA HEALTH NETWORK,PREVEA360,0.20,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.20,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2.60,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2.94,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.18,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.18,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.18,,,,,,,0.1800,4.0800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2.94,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2.53,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2.94,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2.94,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 120 MG/30ML SOLN 30 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-30,CDM,,,,both,1.000000,ME,4.0800,2.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.45,,,,,,,0.1800,4.0800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.08 in Billed Charges for Rev 636 Proc J1100 = $2.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,AETNA,AETNA HSHS,0.32,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,AETNA,ALL COMMERCIAL AETNA,0.50,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.50,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,CENPATICO,ALL MEDICAID CENPATICO,0.50,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.43,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,CIGNA,ALL COMMERCIAL CIGNA,0.35,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,COFINITY,COFINITY,0.50,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.48,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,0.42,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.36,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.37,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,0.24,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.43,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,HUMANA,HUMANA CHOICE CARE HMO,0.11,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,HUMANA,HUMANA CHOICE CARE PPO,0.43,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,HUMANA,HUMANA NATIIONAL POS HMO,0.11,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.37,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.50,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.25,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.42,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.38,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.46,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.32,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.36,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.36,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.31,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.36,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.36,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ORAL DEXAMETHASONE,J8540,HCPCS,636,RC,60687-773-11,CDM,,,,both,0.250000,ME,0.5000,0.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.30,,,,,,,0.0200,0.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.50 in Billed Charges for Rev 636 Proc J8540 = $0.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,AETNA,AETNA HSHS,0.16,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,AETNA,ALL COMMERCIAL AETNA,0.25,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.25,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,CENPATICO,ALL MEDICAID CENPATICO,0.25,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.21,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,CIGNA,ALL COMMERCIAL CIGNA,0.18,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,COFINITY,COFINITY,0.25,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.24,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,0.21,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.18,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.18,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,0.12,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.21,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,HUMANA,HUMANA CHOICE CARE HMO,0.11,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,HUMANA,HUMANA CHOICE CARE PPO,0.21,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,HUMANA,HUMANA NATIIONAL POS HMO,0.11,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.18,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.25,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.13,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.21,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.19,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.23,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.16,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.18,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.18,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.16,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.18,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.18,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60687-718-11,CDM,,,,both,0.250000,ME,0.2500,0.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.15,,,,,,,0.0200,0.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.25 in Billed Charges for Rev 636 Proc J8540 = $0.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,AETNA,AETNA HSHS,1.91,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $1.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,AETNA,ALL COMMERCIAL AETNA,2.95,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,ANTHEM,ANTHEM POS/HMO,0.19,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 170% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,ANTHEM,ANTHEM PPO,0.23,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 210% = $0.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2.95,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,CENPATICO,ALL MEDICAID CENPATICO,2.95,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2.51,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,CIGNA,ALL COMMERCIAL CIGNA,2.07,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,COFINITY,COFINITY,2.95,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2.80,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,HEALTH CARE ALLIANCE,THE ALLIANCE,2.48,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2.09,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2.15,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,HSHS EMPLOYEES,HSHS EMPLOYEES,1.43,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $1.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2.51,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,HUMANA,HUMANA CHOICE CARE HMO,0.19,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,HUMANA,HUMANA CHOICE CARE PPO,2.51,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,HUMANA,HUMANA NATIIONAL POS HMO,0.19,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2.15,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,LIVE360,LIVE360 HSHS HEALTHY PLAN,2.95,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.48,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $1.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2.48,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2.21,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2.71,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.20,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.20,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,PREVEA HEALTH NETWORK,PREVEA360,0.20,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.20,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.88,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $1.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2.12,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.18,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,UNITED HEALTHCARE,UHC ONEIDA NATION,0.18,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,UNITED HEALTHCARE,UNITED HEALTHCARE,0.18,,,,,,,0.1800,2.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2.12,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.83,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $1.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2.12,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2.12,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $2.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL per 1 mg,J1100,HCPCS,636,RC,63323-165-02,CDM,,,,both,1.000000,ME,2.9500,1.9500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1.77,,,,,,,0.1800,2.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $2.95 in Billed Charges for Rev 636 Proc J1100 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,AETNA,AETNA HSHS,58.69,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $58.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,AETNA,ALL COMMERCIAL AETNA,90.85,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $90.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,ANTHEM,ANTHEM POS/HMO,11.37,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 170% = $11.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,ANTHEM,ANTHEM PPO,14.05,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 210% = $14.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,90.85,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $90.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,CENPATICO,ALL MEDICAID CENPATICO,90.85,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $90.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,77.22,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $77.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,CIGNA,ALL COMMERCIAL CIGNA,63.60,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,COFINITY,COFINITY,90.85,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $90.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,86.31,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $86.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,76.31,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $76.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,64.50,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $64.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,66.32,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $66.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,44.15,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $44.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,77.22,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $77.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,HUMANA,HUMANA CHOICE CARE HMO,9.27,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $9.27 from Fee Schedule 005543_170 for Rev 636 Proc J3360 * Qty 1 = $9.27 at 100% = $9.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,HUMANA,HUMANA CHOICE CARE PPO,77.22,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $77.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,HUMANA,HUMANA NATIIONAL POS HMO,9.27,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $9.27 from Fee Schedule 005543_170 for Rev 636 Proc J3360 * Qty 1 = $9.27 at 100% = $9.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,66.32,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $66.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,90.85,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $90.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,45.43,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $45.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,76.31,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $76.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,68.14,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $68.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,83.58,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $83.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.98,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 179% = $11.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.98,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 179% = $11.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,PREVEA HEALTH NETWORK,PREVEA360,11.98,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 179% = $11.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.98,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 179% = $11.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,57.99,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $57.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,65.41,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $65.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.04,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $11.04 from Fee Schedule UHC_31190C for Rev 636 Proc J3360 * Qty 1 = $11.04 at 100% = $11.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,11.04,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $11.04 from Fee Schedule UHC_31190C for Rev 636 Proc J3360 * Qty 1 = $11.04 at 100% = $11.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,11.04,,,,,,,9.2700,90.8500,fee schedule,ST VINCENT HOSPITAL (ACU). $11.04 from Fee Schedule UHC_31190C for Rev 636 Proc J3360 * Qty 1 = $11.04 at 100% = $11.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,65.41,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $65.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,56.33,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $56.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,65.41,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $65.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,65.41,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $65.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,69339-136-34,CDM,,,,both,5.000000,ME,90.8500,59.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,54.51,,,,,,,9.2700,90.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $90.85 in Billed Charges for Rev 636 Proc J3360 = $54.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,5.00,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.94 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7070 * Qty 1 = $2.94 at 170% = $5.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM PPO,6.17,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.94 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7070 * Qty 1 = $2.94 at 210% = $6.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,5.71,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.71 from Fee Schedule 005543_170 for Rev 636 Proc J7070 * Qty 1 = $5.71 at 100% = $5.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,5.71,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.71 from Fee Schedule 005543_170 for Rev 636 Proc J7070 * Qty 1 = $5.71 at 100% = $5.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.26,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.94 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7070 * Qty 1 = $2.94 at 179% = $5.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.26,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.94 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7070 * Qty 1 = $2.94 at 179% = $5.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,5.26,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.94 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7070 * Qty 1 = $2.94 at 179% = $5.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.26,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.94 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7070 * Qty 1 = $2.94 at 179% = $5.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.85,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.85 from Fee Schedule UHC_31190C for Rev 636 Proc J7070 * Qty 1 = $4.85 at 100% = $4.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,4.85,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.85 from Fee Schedule UHC_31190C for Rev 636 Proc J7070 * Qty 1 = $4.85 at 100% = $4.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,4.85,,,,,,,4.8500,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.85 from Fee Schedule UHC_31190C for Rev 636 Proc J7070 * Qty 1 = $4.85 at 100% = $4.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7070,HCPCS,636,RC,0338-0017-04,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,4.8500,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 636 Proc J7070 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,AETNA,AETNA HSHS,14.21,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $14.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,AETNA,ALL COMMERCIAL AETNA,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,ANTHEM,ANTHEM POS/HMO,14.96,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 68% = $14.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,ANTHEM,ANTHEM PPO,14.96,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 68% = $14.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,CENPATICO,ALL MEDICAID CENPATICO,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,CIGNA,ALL COMMERCIAL CIGNA,15.40,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,COFINITY,COFINITY,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,20.90,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $20.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,18.48,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15.62,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16.06,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $16.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,10.69,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $10.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,HUMANA,HUMANA CHOICE CARE PPO,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16.06,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $16.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $11.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18.48,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16.50,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $16.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,20.24,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $20.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 60% = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 60% = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA360,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 60% = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 60% = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14.04,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $14.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13.64,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $13.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-11,CDM,,,,both,50.000000,ML,22.0000,14.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,2.98,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.75 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7060 * Qty 1 = $1.75 at 170% = $2.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM PPO,3.68,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.75 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7060 * Qty 1 = $1.75 at 210% = $3.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,2.86,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.86 from Fee Schedule 005543_170 for Rev 636 Proc J7060 * Qty 1 = $2.86 at 100% = $2.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,2.86,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.86 from Fee Schedule 005543_170 for Rev 636 Proc J7060 * Qty 1 = $2.86 at 100% = $2.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.13,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.75 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7060 * Qty 1 = $1.75 at 179% = $3.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.13,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.75 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7060 * Qty 1 = $1.75 at 179% = $3.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,3.13,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.75 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7060 * Qty 1 = $1.75 at 179% = $3.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.13,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.75 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7060 * Qty 1 = $1.75 at 179% = $3.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.89,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.89 from Fee Schedule UHC_31190C for Rev 636 Proc J7060 * Qty 1 = $2.89 at 100% = $2.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,2.89,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.89 from Fee Schedule UHC_31190C for Rev 636 Proc J7060 * Qty 1 = $2.89 at 100% = $2.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,2.89,,,,,,,2.8600,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.89 from Fee Schedule UHC_31190C for Rev 636 Proc J7060 * Qty 1 = $2.89 at 100% = $2.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 500 ML FLEX CONT per 500 mL,J7060,HCPCS,636,RC,0338-0017-03,CDM,,,,both,500.000000,ML,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,2.8600,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 636 Proc J7060 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,AETNA,AETNA HSHS,443.38,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $443.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,AETNA,AETNA MEDICARE,247.44,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,AETNA,ALL COMMERCIAL AETNA,686.34,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $686.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,ANTHEM,ANTEHM MEDICAID,686.34,,,,,,,247.4400,727.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9272 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $686.34, claim capped at $686.34 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,247.44,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,ANTHEM,ANTHEM POS/HMO,420.65,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $247.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9272 * Qty 1 = $247.44 at 170% = $420.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,ANTHEM,ANTHEM PPO,519.62,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $247.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9272 * Qty 1 = $247.44 at 210% = $519.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,686.34,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $686.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,CENPATICO,ALL MEDICAID CENPATICO,686.34,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $686.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,583.39,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $583.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,CIGNA,ALL COMMERCIAL CIGNA,480.44,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $480.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,COFINITY,COFINITY,686.34,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $686.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,686.34,,,,,,,247.4400,727.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9272 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $686.34, claim capped at $686.34 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,686.34,,,,,,,247.4400,727.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9272 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $686.34, claim capped at $686.34 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,652.02,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $652.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,576.53,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $576.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,487.30,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $487.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,501.03,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $501.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,333.56,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $333.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,583.39,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $583.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HUMANA,HUMANA CHOICE CARE HMO,402.00,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $402.00 from Fee Schedule 005543_170 for Rev 636 Proc J9272 * Qty 1 = $402.00 at 100% = $402.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HUMANA,HUMANA CHOICE CARE PPO,583.39,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $583.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HUMANA,HUMANA MEDICARE ADVANTAGE,247.44,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,HUMANA,HUMANA NATIIONAL POS HMO,402.00,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $402.00 from Fee Schedule 005543_170 for Rev 636 Proc J9272 * Qty 1 = $402.00 at 100% = $402.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,501.03,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $501.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,686.34,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $686.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,686.34,,,,,,,247.4400,727.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9272 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $686.34, claim capped at $686.34 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,247.44,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,686.34,,,,,,,247.4400,727.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9272 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $686.34, claim capped at $686.34 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,MOLINA HEALTHCARE,MOLINA MEDICAID,727.52,,,,,,,247.4400,727.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9272 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $686.34, claim capped at $686.34 in billed charges)... $686.34 at 106% = $727.52 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,MOLINA HEALTHCARE,MOLINA MEDICARE,247.44,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,343.17,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $343.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,576.53,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $576.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,NAPHCARE,ALL COMMERICAL NAPHCARE,556.73,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,514.76,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $514.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,631.43,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $631.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,442.92,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $247.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9272 * Qty 1 = $247.44 at 179% = $442.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,442.92,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $247.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9272 * Qty 1 = $247.44 at 179% = $442.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,PREVEA HEALTH NETWORK,PREVEA360,442.92,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $247.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9272 * Qty 1 = $247.44 at 179% = $442.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,442.92,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $247.44 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9272 * Qty 1 = $247.44 at 179% = $442.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,438.09,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $438.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,249.91,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,494.16,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $494.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,TRIOLOGY,TRILOGY MEDICAID,686.34,,,,,,,247.4400,727.5200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9272 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 106% = $3,433.75 (Service Line reduced to $686.34, claim capped at $686.34 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,408.28,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $408.28 from Fee Schedule UHC_31190C for Rev 636 Proc J9272 * Qty 1 = $408.28 at 100% = $408.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,UNITED HEALTHCARE,UHC ONEIDA NATION,408.28,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $408.28 from Fee Schedule UHC_31190C for Rev 636 Proc J9272 * Qty 1 = $408.28 at 100% = $408.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,247.44,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,UNITED HEALTHCARE,UNITED HEALTHCARE,408.28,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $408.28 from Fee Schedule UHC_31190C for Rev 636 Proc J9272 * Qty 1 = $408.28 at 100% = $408.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,UNITY HEALTH PLAN,UNITY HOSPICE,247.44,,,,,,,247.4400,727.5200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,494.16,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $494.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,425.53,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $425.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,494.16,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $494.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,494.16,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $494.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL per 10 mg,J9272,HCPCS,636,RC,0173-0898-03,CDM,,,,both,10.000000,ME,686.3400,452.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,411.80,,,,,,,247.4400,727.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $686.34 in Billed Charges for Rev 636 Proc J9272 = $411.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,AETNA,AETNA HSHS,8.75,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $8.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,AETNA,ALL COMMERCIAL AETNA,13.55,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $13.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,ANTHEM,ANTHEM POS/HMO,1.36,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 170% = $1.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,ANTHEM,ANTHEM PPO,1.68,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 210% = $1.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13.55,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $13.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,CENPATICO,ALL MEDICAID CENPATICO,13.55,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $13.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11.52,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $11.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,CIGNA,ALL COMMERCIAL CIGNA,9.49,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,COFINITY,COFINITY,13.55,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $13.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12.87,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $12.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,11.38,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $11.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9.62,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $9.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.89,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $9.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,6.59,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $6.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11.52,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $11.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,HUMANA,HUMANA CHOICE CARE HMO,1.34,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule 005543_170 for Rev 636 Proc J1265 * Qty 1 = $1.34 at 100% = $1.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,HUMANA,HUMANA CHOICE CARE PPO,11.52,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $11.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,HUMANA,HUMANA NATIIONAL POS HMO,1.34,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule 005543_170 for Rev 636 Proc J1265 * Qty 1 = $1.34 at 100% = $1.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.89,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $9.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,13.55,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $13.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.78,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11.38,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $11.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.16,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $10.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12.47,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $12.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.43,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.43,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,PREVEA HEALTH NETWORK,PREVEA360,1.43,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.43,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.65,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $8.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.76,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $9.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.32,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,1.32,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,1.32,,,,,,,1.3200,13.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.76,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $9.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.40,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $8.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.76,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $9.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.76,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $9.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML PLAS CONT per 40 mg,J1265,HCPCS,636,RC,0338-1007-02,CDM,,,,both,40.000000,ME,13.5500,8.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.13,,,,,,,1.3200,13.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.55 in Billed Charges for Rev 636 Proc J1265 = $8.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,AETNA,AETNA HSHS,139.31,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $139.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,AETNA,ALL COMMERCIAL AETNA,215.65,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $215.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,ANTHEM,ANTEHM MEDICAID,9.76,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00414 Proc 90700 at $125.60 (Base Rate) * 0.0777 (Relative Weight) = $9.76 (Total Line Payment) at 100% = $9.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,ANTHEM,ANTHEM POS/HMO,146.64,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc 90700 $215.65 in Billed Charges at 68% = $146.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,ANTHEM,ANTHEM PPO,146.64,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc 90700 $215.65 in Billed Charges at 68% = $146.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,215.65,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $215.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,CENPATICO,ALL MEDICAID CENPATICO,215.65,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $215.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,183.30,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $183.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,CIGNA,ALL COMMERCIAL CIGNA,150.96,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $150.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,COFINITY,COFINITY,215.65,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $215.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,9.76,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00414 Proc 90700 at $125.60 (Base Rate) * 0.0777 (Relative Weight) = $9.76 (Total Line Payment) at 100% = $9.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,9.76,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00414 Proc 90700 at $125.60 (Base Rate) * 0.0777 (Relative Weight) = $9.76 (Total Line Payment) at 100% = $9.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,204.87,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $204.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,181.15,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $181.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,153.11,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $153.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,157.42,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $157.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,104.81,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $104.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,183.30,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $183.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,HUMANA,HUMANA CHOICE CARE HMO,51.66,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $51.66 from Fee Schedule 005543_170 for Rev 636 Proc 90700 * Qty 1 = $51.66 at 100% = $51.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,HUMANA,HUMANA CHOICE CARE PPO,183.30,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $183.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,HUMANA,HUMANA NATIIONAL POS HMO,51.66,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $51.66 from Fee Schedule 005543_170 for Rev 636 Proc 90700 * Qty 1 = $51.66 at 100% = $51.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,157.42,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $157.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,215.65,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $215.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,9.76,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00414 Proc 90700 at $125.60 (Base Rate) * 0.0777 (Relative Weight) = $9.76 (Total Line Payment) at 100% = $9.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,9.76,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00414 Proc 90700 at $125.60 (Base Rate) * 0.0777 (Relative Weight) = $9.76 (Total Line Payment) at 100% = $9.76. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,MOLINA HEALTHCARE,MOLINA MEDICAID,10.35,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00414 Proc 90700 at $125.60 (Base Rate) * 0.0777 (Relative Weight) = $9.76 (Total Line Payment) at 100% = $9.76... $9.76 at 106% = $10.35 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,107.83,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $107.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,181.15,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $181.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,161.74,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $161.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,198.40,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $198.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,129.39,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc 90700 $215.65 in Billed Charges at 60% = $129.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,129.39,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc 90700 $215.65 in Billed Charges at 60% = $129.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,PREVEA HEALTH NETWORK,PREVEA360,129.39,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc 90700 $215.65 in Billed Charges at 60% = $129.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,129.39,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc 90700 $215.65 in Billed Charges at 60% = $129.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,137.65,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $137.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,155.27,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $155.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,TRIOLOGY,TRILOGY MEDICAID,10.34,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00414 Proc 90700 at $125.60 (Base Rate) * 0.0777 (Relative Weight) = $9.76 (Total Line Payment) at 106% = $10.34. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,61.12,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $61.12 from Fee Schedule UHC_31190C for Rev 636 Proc 90700 * Qty 1 = $61.12 at 100% = $61.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,61.12,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $61.12 from Fee Schedule UHC_31190C for Rev 636 Proc 90700 * Qty 1 = $61.12 at 100% = $61.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,61.12,,,,,,,9.7600,215.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $61.12 from Fee Schedule UHC_31190C for Rev 636 Proc 90700 * Qty 1 = $61.12 at 100% = $61.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,155.27,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $155.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,133.70,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $133.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,155.27,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $155.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,155.27,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $155.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPTHERIA-ACELLULAR PERTUSSIS-TETANUS DTAP 25-58-10 LF-MCG/0.5 SUSP per 0.5 mL,90700,CPT,636,RC,58160-810-43,CDM,,,,both,0.500000,ME,215.6500,142.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,129.39,,,,,,,9.7600,215.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $215.65 in Billed Charges for Rev 636 Proc 90700 = $129.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,AETNA,AETNA HSHS,127.23,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $127.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,AETNA,ALL COMMERCIAL AETNA,196.95,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $196.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,ANTHEM,ANTHEM POS/HMO,13.63,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 170% = $13.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,ANTHEM,ANTHEM PPO,16.84,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 210% = $16.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,196.95,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $196.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,CENPATICO,ALL MEDICAID CENPATICO,196.95,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $196.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,167.41,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $167.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,CIGNA,ALL COMMERCIAL CIGNA,137.87,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $137.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,COFINITY,COFINITY,196.95,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $196.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,187.10,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $187.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,165.44,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $165.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.83,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $139.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.77,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $143.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,95.72,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $95.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,167.41,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $167.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,HUMANA,HUMANA CHOICE CARE HMO,12.89,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $12.89 from Fee Schedule 005543_170 for Rev 636 Proc J1250 * Qty 1 = $12.89 at 100% = $12.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,HUMANA,HUMANA CHOICE CARE PPO,167.41,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $167.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,HUMANA,HUMANA NATIIONAL POS HMO,12.89,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $12.89 from Fee Schedule 005543_170 for Rev 636 Proc J1250 * Qty 1 = $12.89 at 100% = $12.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.77,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $143.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,196.95,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $196.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.48,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $98.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,165.44,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $165.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.71,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $147.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,181.19,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $181.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.36,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.36,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,PREVEA HEALTH NETWORK,PREVEA360,14.36,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.36,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.71,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $125.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.80,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $141.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,13.23,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,UNITED HEALTHCARE,UHC ONEIDA NATION,13.23,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,UNITED HEALTHCARE,UNITED HEALTHCARE,13.23,,,,,,,12.8900,196.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.80,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $141.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,122.11,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $122.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.80,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $141.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.80,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $141.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0338-1073-02,CDM,,,,both,250.000000,ME,196.9500,129.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,118.17,,,,,,,12.8900,196.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $196.95 in Billed Charges for Rev 636 Proc J1250 = $118.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,AETNA,AETNA HSHS,125.26,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $125.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,AETNA,ALL COMMERCIAL AETNA,193.90,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $193.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,ANTHEM,ANTHEM POS/HMO,13.63,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 170% = $13.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,ANTHEM,ANTHEM PPO,16.84,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 210% = $16.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,193.90,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $193.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,CENPATICO,ALL MEDICAID CENPATICO,193.90,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $193.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,164.82,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $164.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,CIGNA,ALL COMMERCIAL CIGNA,135.73,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $135.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,COFINITY,COFINITY,193.90,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $193.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,184.21,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $184.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,162.88,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $162.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,137.67,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $137.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,141.55,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $141.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,94.24,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $94.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,164.82,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $164.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,HUMANA,HUMANA CHOICE CARE HMO,12.89,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.89 from Fee Schedule 005543_170 for Rev 636 Proc J1250 * Qty 1 = $12.89 at 100% = $12.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,HUMANA,HUMANA CHOICE CARE PPO,164.82,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $164.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,HUMANA,HUMANA NATIIONAL POS HMO,12.89,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.89 from Fee Schedule 005543_170 for Rev 636 Proc J1250 * Qty 1 = $12.89 at 100% = $12.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,141.55,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $141.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,193.90,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $193.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,96.95,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $96.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,162.88,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $162.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,145.43,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $145.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,178.39,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $178.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.36,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.36,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,PREVEA HEALTH NETWORK,PREVEA360,14.36,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.36,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,123.77,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $123.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,139.61,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $139.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,13.23,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,UNITED HEALTHCARE,UHC ONEIDA NATION,13.23,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,UNITED HEALTHCARE,UNITED HEALTHCARE,13.23,,,,,,,12.8900,193.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,139.61,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $139.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,120.22,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $120.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,139.61,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $139.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,139.61,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $139.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 1 MG/ML SOLN per 250 mg,J1250,HCPCS,636,RC,0409-2346-31,CDM,,,,both,250.000000,ME,193.9000,127.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,116.34,,,,,,,12.8900,193.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $193.90 in Billed Charges for Rev 636 Proc J1250 = $116.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,AETNA,AETNA HSHS,3.62,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $3.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,AETNA,ALL COMMERCIAL AETNA,5.61,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $5.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,ANTHEM,ANTEHM MEDICAID,5.61,,,,,,,1.0700,5.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J9171 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $5.61, claim capped at $5.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,ANTHEM,ANTHEM POS/HMO,1.11,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9171 * Qty 1 = $0.65 at 170% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,ANTHEM,ANTHEM PPO,1.37,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9171 * Qty 1 = $0.65 at 210% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.61,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $5.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,CENPATICO,ALL MEDICAID CENPATICO,5.61,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $5.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.77,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,CIGNA,ALL COMMERCIAL CIGNA,3.93,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $3.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,COFINITY,COFINITY,5.61,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $5.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,5.61,,,,,,,1.0700,5.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J9171 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $5.61, claim capped at $5.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,5.61,,,,,,,1.0700,5.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J9171 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $5.61, claim capped at $5.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.33,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $5.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,4.71,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.98,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.10,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,2.73,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $2.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.77,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,HUMANA,HUMANA CHOICE CARE HMO,1.46,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.46 from Fee Schedule 005543_170 for Rev 636 Proc J9171 * Qty 1 = $1.46 at 100% = $1.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,HUMANA,HUMANA CHOICE CARE PPO,4.77,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,HUMANA,HUMANA NATIIONAL POS HMO,1.46,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.46 from Fee Schedule 005543_170 for Rev 636 Proc J9171 * Qty 1 = $1.46 at 100% = $1.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.10,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.61,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $5.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,5.61,,,,,,,1.0700,5.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J9171 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $5.61, claim capped at $5.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,5.61,,,,,,,1.0700,5.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J9171 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $5.61, claim capped at $5.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,5.95,,,,,,,1.0700,5.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J9171 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45 (Service Line reduced to $5.61, claim capped at $5.61 in billed charges)... $5.61 at 106% = $5.95 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.81,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $2.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.71,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.21,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.16,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $5.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.16,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9171 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.16,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9171 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,PREVEA HEALTH NETWORK,PREVEA360,1.16,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9171 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.16,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9171 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.58,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $3.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.04,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,TRIOLOGY,TRILOGY MEDICAID,5.61,,,,,,,1.0700,5.9500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00431 Proc J9171 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 106% = $17.44 (Service Line reduced to $5.61, claim capped at $5.61 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.07,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J9171 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,1.07,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J9171 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,1.07,,,,,,,1.0700,5.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J9171 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.04,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.48,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.04,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.04,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $4.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOCETAXEL 80 MG/4ML CONC 8 ML VIAL per 1 mg,J9171,HCPCS,636,RC,23155-905-31,CDM,,,,both,1.000000,ME,5.6100,3.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.37,,,,,,,1.0700,5.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.61 in Billed Charges for Rev 636 Proc J9171 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,AETNA,AETNA HSHS,0.32,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,AETNA,ALL COMMERCIAL AETNA,0.49,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.49,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,CENPATICO,ALL MEDICAID CENPATICO,0.49,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.42,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,CIGNA,ALL COMMERCIAL CIGNA,0.34,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,COFINITY,COFINITY,0.49,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.47,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,0.41,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.35,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.36,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,0.24,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.42,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HUMANA,HUMANA CHOICE CARE HMO,0.31,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1163 $0.49 in Billed Charges at 63.5% = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HUMANA,HUMANA CHOICE CARE PPO,0.42,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HUMANA,HUMANA NATIIONAL POS HMO,0.31,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1163 $0.49 in Billed Charges at 63.5% = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.36,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.49,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.25,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.41,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.37,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.45,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.31,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.35,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.35,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.30,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.35,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.35,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,25021-319-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.29,,,,,,,0.0500,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.49 in Billed Charges for Rev 636 Proc J1163 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,AETNA,AETNA HSHS,12145.93,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $12,145.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,AETNA,AETNA MEDICARE,5166.99,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,AETNA,ALL COMMERCIAL AETNA,18801.75,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $18,801.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,ANTHEM,ANTEHM MEDICAID,2032.07,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J1162 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,5166.99,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,ANTHEM,ANTHEM POS/HMO,8783.88,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,166.99 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1162 * Qty 1 = $5,166.99 at 170% = $8,783.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,ANTHEM,ANTHEM PPO,10850.68,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,166.99 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1162 * Qty 1 = $5,166.99 at 210% = $10,850.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,18801.75,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $18,801.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,CENPATICO,ALL MEDICAID CENPATICO,18801.75,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $18,801.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15981.49,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $15,981.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,CIGNA,ALL COMMERCIAL CIGNA,13161.23,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $13,161.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,COFINITY,COFINITY,18801.75,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $18,801.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2032.07,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J1162 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2032.07,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J1162 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17861.66,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $17,861.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,15793.47,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $15,793.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13349.24,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $13,349.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13725.28,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $13,725.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,9137.65,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $9,137.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15981.49,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $15,981.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HUMANA,HUMANA CHOICE CARE HMO,8121.65,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,121.65 from Fee Schedule 005543_170 for Rev 636 Proc J1162 * Qty 1 = $8,121.65 at 100% = $8,121.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HUMANA,HUMANA CHOICE CARE PPO,15981.49,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $15,981.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HUMANA,HUMANA MEDICARE ADVANTAGE,5166.99,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,HUMANA,HUMANA NATIIONAL POS HMO,8121.65,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,121.65 from Fee Schedule 005543_170 for Rev 636 Proc J1162 * Qty 1 = $8,121.65 at 100% = $8,121.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13725.28,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $13,725.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,18801.75,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $18,801.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2032.07,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J1162 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,5166.99,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2032.07,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J1162 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,MOLINA HEALTHCARE,MOLINA MEDICAID,2153.99,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J1162 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07... $2,032.07 at 106% = $2,153.99 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,MOLINA HEALTHCARE,MOLINA MEDICARE,5166.99,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9400.88,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $9,400.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15793.47,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $15,793.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,NAPHCARE,ALL COMMERICAL NAPHCARE,11625.73,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14101.31,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $14,101.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,17297.61,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $17,297.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9248.91,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,166.99 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1162 * Qty 1 = $5,166.99 at 179% = $9,248.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9248.91,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,166.99 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1162 * Qty 1 = $5,166.99 at 179% = $9,248.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,PREVEA HEALTH NETWORK,PREVEA360,9248.91,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,166.99 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1162 * Qty 1 = $5,166.99 at 179% = $9,248.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9248.91,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $5,166.99 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1162 * Qty 1 = $5,166.99 at 179% = $9,248.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12001.16,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $12,001.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,5218.66,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13537.26,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $13,537.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,TRIOLOGY,TRILOGY MEDICAID,2153.99,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J1162 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 106% = $2,153.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8525.53,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,525.53 from Fee Schedule UHC_31190C for Rev 636 Proc J1162 * Qty 1 = $8,525.53 at 100% = $8,525.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,8525.53,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,525.53 from Fee Schedule UHC_31190C for Rev 636 Proc J1162 * Qty 1 = $8,525.53 at 100% = $8,525.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,5166.99,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,8525.53,,,,,,,2032.0700,18801.7500,fee schedule,"ST VINCENT HOSPITAL (ACU). $8,525.53 from Fee Schedule UHC_31190C for Rev 636 Proc J1162 * Qty 1 = $8,525.53 at 100% = $8,525.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,UNITY HEALTH PLAN,UNITY HOSPICE,5166.99,,,,,,,2032.0700,18801.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13537.26,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $13,537.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11657.09,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $11,657.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13537.26,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $13,537.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13537.26,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $13,537.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL per 1 vial,J1162,HCPCS,636,RC,50633-120-11,CDM,,,,both,1.000000,EA,18801.7500,12409.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11281.05,,,,,,,2032.0700,18801.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $18,801.75 in Billed Charges for Rev 636 Proc J1162 = $11,281.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,AETNA,AETNA HSHS,127.26,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $127.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,AETNA,AETNA MEDICARE,39.63,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,AETNA,ALL COMMERCIAL AETNA,197.00,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,39.63,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,ANTHEM,ANTHEM POS/HMO,197.00,,,,,,,17.5100,197.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $331.00 per Visit = $331.00 (Limited to $197.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,ANTHEM,ANTHEM PPO,197.00,,,,,,,17.5100,197.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $331.00 per Visit = $331.00 (Limited to $197.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,197.00,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,CENPATICO,ALL MEDICAID CENPATICO,197.00,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,167.45,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $167.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,CIGNA,ALL COMMERCIAL CIGNA,137.90,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $137.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,COFINITY,COFINITY,197.00,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,187.15,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $187.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,165.48,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $165.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,139.87,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $139.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,143.81,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $143.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,95.74,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $95.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,167.45,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $167.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HUMANA,HUMANA CHOICE CARE HMO,125.10,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $125.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HUMANA,HUMANA CHOICE CARE PPO,167.45,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $167.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HUMANA,HUMANA MEDICARE ADVANTAGE,39.63,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,HUMANA,HUMANA NATIIONAL POS HMO,125.10,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $125.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,143.81,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $143.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,197.00,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,39.63,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,MOLINA HEALTHCARE,MOLINA MEDICARE,39.63,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.50,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $98.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,165.48,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $165.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,NAPHCARE,ALL COMMERICAL NAPHCARE,89.17,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.75,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $147.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,181.24,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $181.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,197.00,,,,,,,17.5100,197.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $197.00, claim capped at $197.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,197.00,,,,,,,17.5100,197.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $197.00, claim capped at $197.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,PREVEA HEALTH NETWORK,PREVEA360,197.00,,,,,,,17.5100,197.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $197.00, claim capped at $197.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,197.00,,,,,,,17.5100,197.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $197.00, claim capped at $197.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.75,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $125.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,40.03,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,141.84,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $141.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,TRIOLOGY,TRILOGY MEDICAID,17.51,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00269 Proc 95992 at $125.60 (Base Rate) * 0.1315 (Relative Weight) = $16.52 (Total Line Payment) at 106% = $17.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,197.00,,,,,,,17.5100,197.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $197.00, claim capped at $197.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,197.00,,,,,,,17.5100,197.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $197.00, claim capped at $197.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,39.63,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,197.00,,,,,,,17.5100,197.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 95992 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $197.00, claim capped at $197.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,UNITY HEALTH PLAN,UNITY HOSPICE,39.63,,,,,,,17.5100,197.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,141.84,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $141.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,122.14,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $122.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,141.84,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $141.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,141.84,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $141.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC CANALITH REPOSITIONING,95992,CPT,420,RC,42000008,CDM,,,,both,,,197.0000,130.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,118.20,,,,,,,17.5100,197.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $197.00 in Billed Charges for Rev 420 Proc 95992 = $118.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA MEDICARE,13.88,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTEHM MEDICAID,25.78,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.78 from Fee Schedule WIMCD_THX for Rev 420 Proc 97012 * Qty 1 = $25.78 at 100% = $25.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.88,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,106.00,,,,,,,13.8800,106.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $331.00 per Visit = $331.00 (Limited to $106.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM PPO,106.00,,,,,,,13.8800,106.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $331.00 per Visit = $331.00 (Limited to $106.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,25.78,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.78 from Fee Schedule WIMCD_THX for Rev 420 Proc 97012 * Qty 1 = $25.78 at 100% = $25.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,25.78,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.78 from Fee Schedule WIMCD_THX for Rev 420 Proc 97012 * Qty 1 = $25.78 at 100% = $25.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,67.31,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,13.88,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,67.31,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,25.78,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.78 from Fee Schedule WIMCD_THX for Rev 420 Proc 97012 * Qty 1 = $25.78 at 100% = $25.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.88,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,25.78,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.78 from Fee Schedule WIMCD_THX for Rev 420 Proc 97012 * Qty 1 = $25.78 at 100% = $25.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,27.33,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $25.78 from Fee Schedule WIMCD_THX for Rev 420 Proc 97012 * Qty 1 = $25.78 at 100% = $25.78... $25.78 at 106% = $27.33 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,13.88,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,31.23,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,106.00,,,,,,,13.8800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,106.00,,,,,,,13.8800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,106.00,,,,,,,13.8800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,106.00,,,,,,,13.8800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.02,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97012 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,106.00,,,,,,,13.8800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,106.00,,,,,,,13.8800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.88,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,106.00,,,,,,,13.8800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97012 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,UNITY HEALTH PLAN,UNITY HOSPICE,13.88,,,,,,,13.8800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC TRACTION MECH APP,97012,CPT,420,RC,42000009,CDM,,,,both,,,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,13.8800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 420 Proc 97012 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA HSHS,61.37,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA MEDICARE,11.55,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,AETNA,ALL COMMERCIAL AETNA,95.00,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTEHM MEDICAID,26.45,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.45 from Fee Schedule WIMCD_THX for Rev 420 Proc 97016 * Qty 1 = $26.45 at 100% = $26.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,11.55,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM POS/HMO,95.00,,,,,,,11.5500,95.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $331.00 per Visit = $331.00 (Limited to $95.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM PPO,95.00,,,,,,,11.5500,95.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $331.00 per Visit = $331.00 (Limited to $95.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,95.00,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,CENPATICO,ALL MEDICAID CENPATICO,95.00,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,80.75,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,CIGNA,ALL COMMERCIAL CIGNA,66.50,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $66.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,COFINITY,COFINITY,95.00,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,26.45,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.45 from Fee Schedule WIMCD_THX for Rev 420 Proc 97016 * Qty 1 = $26.45 at 100% = $26.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,26.45,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.45 from Fee Schedule WIMCD_THX for Rev 420 Proc 97016 * Qty 1 = $26.45 at 100% = $26.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,90.25,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $90.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,79.80,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,67.45,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $67.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,69.35,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,46.17,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $46.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,80.75,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE HMO,60.33,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $60.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE PPO,80.75,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,11.55,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA NATIIONAL POS HMO,60.33,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $60.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,69.35,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,95.00,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,26.45,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.45 from Fee Schedule WIMCD_THX for Rev 420 Proc 97016 * Qty 1 = $26.45 at 100% = $26.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.55,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,26.45,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.45 from Fee Schedule WIMCD_THX for Rev 420 Proc 97016 * Qty 1 = $26.45 at 100% = $26.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,28.04,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $26.45 from Fee Schedule WIMCD_THX for Rev 420 Proc 97016 * Qty 1 = $26.45 at 100% = $26.45... $26.45 at 106% = $28.04 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,11.55,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,47.50,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $47.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,79.80,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,25.99,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,71.25,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,87.40,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $87.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,95.00,,,,,,,11.5500,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,95.00,,,,,,,11.5500,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360,95.00,,,,,,,11.5500,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,95.00,,,,,,,11.5500,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,60.64,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $60.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,11.67,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,68.40,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97016 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,95.00,,,,,,,11.5500,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,95.00,,,,,,,11.5500,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,11.55,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,95.00,,,,,,,11.5500,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97016 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,UNITY HEALTH PLAN,UNITY HOSPICE,11.55,,,,,,,11.5500,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,68.40,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.90,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $58.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,68.40,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,68.40,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC APPLY VASOPNEUMATIC DEVICE,97016,CPT,420,RC,42000010,CDM,,,,both,,,95.0000,62.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,57.00,,,,,,,11.5500,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $95.00 in Billed Charges for Rev 420 Proc 97016 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA HSHS,61.37,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA MEDICARE,14.21,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,AETNA,ALL COMMERCIAL AETNA,95.00,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTEHM MEDICAID,23.50,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.50 from Fee Schedule WIMCD_THX for Rev 420 Proc 97032 * Qty 1 = $23.50 at 100% = $23.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,14.21,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM POS/HMO,95.00,,,,,,,14.2100,95.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $331.00 per Visit = $331.00 (Limited to $95.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM PPO,95.00,,,,,,,14.2100,95.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $331.00 per Visit = $331.00 (Limited to $95.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,95.00,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,CENPATICO,ALL MEDICAID CENPATICO,95.00,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,80.75,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,CIGNA,ALL COMMERCIAL CIGNA,66.50,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $66.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,COFINITY,COFINITY,95.00,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,23.50,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.50 from Fee Schedule WIMCD_THX for Rev 420 Proc 97032 * Qty 1 = $23.50 at 100% = $23.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,23.50,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.50 from Fee Schedule WIMCD_THX for Rev 420 Proc 97032 * Qty 1 = $23.50 at 100% = $23.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,90.25,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $90.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,79.80,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,67.45,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $67.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,69.35,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,46.17,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $46.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,80.75,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE HMO,60.33,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $60.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE PPO,80.75,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,14.21,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA NATIIONAL POS HMO,60.33,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $60.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,69.35,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,95.00,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,23.50,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.50 from Fee Schedule WIMCD_THX for Rev 420 Proc 97032 * Qty 1 = $23.50 at 100% = $23.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.21,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,23.50,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.50 from Fee Schedule WIMCD_THX for Rev 420 Proc 97032 * Qty 1 = $23.50 at 100% = $23.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,24.91,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.50 from Fee Schedule WIMCD_THX for Rev 420 Proc 97032 * Qty 1 = $23.50 at 100% = $23.50... $23.50 at 106% = $24.91 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,14.21,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,47.50,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $47.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,79.80,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,31.97,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,71.25,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,87.40,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $87.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,95.00,,,,,,,14.2100,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,95.00,,,,,,,14.2100,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360,95.00,,,,,,,14.2100,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,95.00,,,,,,,14.2100,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,60.64,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $60.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,14.35,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,68.40,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97032 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,95.00,,,,,,,14.2100,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,95.00,,,,,,,14.2100,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,14.21,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,95.00,,,,,,,14.2100,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97032 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,UNITY HEALTH PLAN,UNITY HOSPICE,14.21,,,,,,,14.2100,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,68.40,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.90,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $58.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,68.40,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,68.40,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APPL MODALITY 1+ESTIM EA 15,97032,CPT,420,RC,42000025,CDM,,,,both,,,95.0000,62.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,57.00,,,,,,,14.2100,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $95.00 in Billed Charges for Rev 420 Proc 97032 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA HSHS,75.58,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $75.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,AETNA,AETNA MEDICARE,18.39,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,AETNA,ALL COMMERCIAL AETNA,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTEHM MEDICAID,23.51,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.51 from Fee Schedule WIMCD_THX for Rev 420 Proc 97033 * Qty 1 = $23.51 at 100% = $23.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,18.39,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM POS/HMO,117.00,,,,,,,14.7100,117.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $331.00 per Visit = $331.00 (Limited to $117.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,ANTHEM,ANTHEM PPO,117.00,,,,,,,14.7100,117.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $331.00 per Visit = $331.00 (Limited to $117.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,CENPATICO,ALL MEDICAID CENPATICO,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,99.45,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,CIGNA,ALL COMMERCIAL CIGNA,81.90,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $81.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,COFINITY,COFINITY,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,23.51,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.51 from Fee Schedule WIMCD_THX for Rev 420 Proc 97033 * Qty 1 = $23.51 at 100% = $23.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,23.51,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.51 from Fee Schedule WIMCD_THX for Rev 420 Proc 97033 * Qty 1 = $23.51 at 100% = $23.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,111.15,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $111.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,98.28,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,83.07,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $83.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,85.41,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,56.86,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $56.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,99.45,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE HMO,74.30,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA CHOICE CARE PPO,99.45,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $99.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA MEDICARE ADVANTAGE,18.39,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,HUMANA,HUMANA NATIIONAL POS HMO,74.30,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,85.41,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $85.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,117.00,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,23.51,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.51 from Fee Schedule WIMCD_THX for Rev 420 Proc 97033 * Qty 1 = $23.51 at 100% = $23.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,18.39,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,23.51,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.51 from Fee Schedule WIMCD_THX for Rev 420 Proc 97033 * Qty 1 = $23.51 at 100% = $23.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICAID,24.92,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $23.51 from Fee Schedule WIMCD_THX for Rev 420 Proc 97033 * Qty 1 = $23.51 at 100% = $23.51... $23.51 at 106% = $24.92 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE,MOLINA MEDICARE,18.39,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,58.50,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $58.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,98.28,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $98.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,NAPHCARE,ALL COMMERICAL NAPHCARE,41.38,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,87.75,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $87.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,107.64,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $107.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,74.68,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $74.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,18.57,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,84.24,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97033 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,18.39,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,117.00,,,,,,,14.7100,117.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97033 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $117.00, claim capped at $117.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,UNITY HEALTH PLAN,UNITY HOSPICE,18.39,,,,,,,14.7100,117.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,84.24,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,72.54,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $72.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,84.24,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,84.24,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $84.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,42000031,CDM,,,,both,,,117.0000,77.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,70.20,,,,,,,14.7100,117.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $117.00 in Billed Charges for Rev 420 Proc 97033 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA HSHS,61.37,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,AETNA,AETNA MEDICARE,13.84,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,AETNA,ALL COMMERCIAL AETNA,95.00,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTEHM MEDICAID,19.41,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.41 from Fee Schedule WIMCD_THX for Rev 420 Proc 97035 * Qty 1 = $19.41 at 100% = $19.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.84,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM POS/HMO,95.00,,,,,,,13.8400,95.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $331.00 per Visit = $331.00 (Limited to $95.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,ANTHEM,ANTHEM PPO,95.00,,,,,,,13.8400,95.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $331.00 per Visit = $331.00 (Limited to $95.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,95.00,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,CENPATICO,ALL MEDICAID CENPATICO,95.00,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,80.75,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,CIGNA,ALL COMMERCIAL CIGNA,66.50,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $66.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,COFINITY,COFINITY,95.00,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,19.41,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.41 from Fee Schedule WIMCD_THX for Rev 420 Proc 97035 * Qty 1 = $19.41 at 100% = $19.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,19.41,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.41 from Fee Schedule WIMCD_THX for Rev 420 Proc 97035 * Qty 1 = $19.41 at 100% = $19.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,90.25,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $90.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,79.80,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,67.45,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $67.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,69.35,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,46.17,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $46.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,80.75,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE HMO,60.33,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $60.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA CHOICE CARE PPO,80.75,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,13.84,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,HUMANA,HUMANA NATIIONAL POS HMO,60.33,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $60.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,69.35,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $69.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,95.00,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,19.41,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.41 from Fee Schedule WIMCD_THX for Rev 420 Proc 97035 * Qty 1 = $19.41 at 100% = $19.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.84,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,19.41,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.41 from Fee Schedule WIMCD_THX for Rev 420 Proc 97035 * Qty 1 = $19.41 at 100% = $19.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,20.57,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $19.41 from Fee Schedule WIMCD_THX for Rev 420 Proc 97035 * Qty 1 = $19.41 at 100% = $19.41... $19.41 at 106% = $20.57 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,13.84,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,47.50,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $47.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,79.80,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $79.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,31.14,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,71.25,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $71.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,87.40,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $87.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,95.00,,,,,,,13.8400,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,95.00,,,,,,,13.8400,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360,95.00,,,,,,,13.8400,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,95.00,,,,,,,13.8400,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,60.64,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $60.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.98,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,68.40,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,TRIOLOGY,TRILOGY MEDICAID,14.71,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00493 Proc 97035 at $125.60 (Base Rate) * 0.1105 (Relative Weight) = $13.88 (Total Line Payment) at 106% = $14.71. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,95.00,,,,,,,13.8400,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,95.00,,,,,,,13.8400,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.84,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,95.00,,,,,,,13.8400,95.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97035 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $95.00, claim capped at $95.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,UNITY HEALTH PLAN,UNITY HOSPICE,13.84,,,,,,,13.8400,95.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,68.40,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.90,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $58.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,68.40,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,68.40,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $68.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ULTRASOUND EA 15MIN,97035,CPT,420,RC,42000033,CDM,,,,both,,,95.0000,62.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,57.00,,,,,,,13.8400,95.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $95.00 in Billed Charges for Rev 420 Proc 97035 = $57.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,AETNA,AETNA HSHS,78.81,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $78.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,AETNA,AETNA MEDICARE,28.25,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,AETNA,ALL COMMERCIAL AETNA,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTEHM MEDICAID,31.38,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $31.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97110 * Qty 1 = $31.38 at 100% = $31.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,28.25,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM POS/HMO,122.00,,,,,,,17.5100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,ANTHEM,ANTHEM PPO,122.00,,,,,,,17.5100,122.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $331.00 per Visit = $331.00 (Limited to $122.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,CENPATICO,ALL MEDICAID CENPATICO,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,CIGNA,ALL COMMERCIAL CIGNA,85.40,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $85.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,COFINITY,COFINITY,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,31.38,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $31.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97110 * Qty 1 = $31.38 at 100% = $31.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,31.38,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $31.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97110 * Qty 1 = $31.38 at 100% = $31.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,115.90,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $115.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,102.48,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,86.62,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $86.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.06,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,59.29,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $59.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE HMO,77.47,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA CHOICE CARE PPO,103.70,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,28.25,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,HUMANA,HUMANA NATIIONAL POS HMO,77.47,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $77.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.06,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $89.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,122.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $122.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,31.38,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $31.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97110 * Qty 1 = $31.38 at 100% = $31.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,28.25,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,31.38,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $31.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97110 * Qty 1 = $31.38 at 100% = $31.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,33.26,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $31.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97110 * Qty 1 = $31.38 at 100% = $31.38... $31.38 at 106% = $33.26 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,28.25,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.00,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $61.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,102.48,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $102.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,63.56,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,91.50,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $91.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,112.24,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $112.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,77.87,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $77.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,28.53,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,TRIOLOGY,TRILOGY MEDICAID,17.51,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00269 Proc 97110 at $125.60 (Base Rate) * 0.1315 (Relative Weight) = $16.52 (Total Line Payment) at 106% = $17.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,28.25,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,122.00,,,,,,,17.5100,122.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97110 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $122.00, claim capped at $122.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,UNITY HEALTH PLAN,UNITY HOSPICE,28.25,,,,,,,17.5100,122.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,75.64,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $75.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,87.84,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $87.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC THERA EXER; EA 15 MIN,97110,CPT,420,RC,42000037,CDM,,,,both,,,122.0000,80.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.20,,,,,,,17.5100,122.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $122.00 in Billed Charges for Rev 420 Proc 97110 = $73.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,AETNA,AETNA MEDICARE,17.47,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTEHM MEDICAID,6.38,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97150 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,17.47,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,106.00,,,,,,,6.3800,106.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $331.00 per Visit = $331.00 (Limited to $106.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,ANTHEM,ANTHEM PPO,106.00,,,,,,,6.3800,106.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $331.00 per Visit = $331.00 (Limited to $106.00 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,6.38,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97150 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,6.38,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97150 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,67.31,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,17.47,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,67.31,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,6.38,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97150 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.47,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,6.38,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97150 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,6.76,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule WIMCD_THX for Rev 420 Proc 97150 * Qty 1 = $6.38 at 100% = $6.38... $6.38 at 106% = $6.76 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,17.47,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,39.31,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,106.00,,,,,,,6.3800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,106.00,,,,,,,6.3800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,106.00,,,,,,,6.3800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,106.00,,,,,,,6.3800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $259.68 per Visit = $259.68 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,17.64,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,TRIOLOGY,TRILOGY MEDICAID,17.51,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00269 Proc 97150 at $125.60 (Base Rate) * 0.1315 (Relative Weight) = $16.52 (Total Line Payment) at 106% = $17.51. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,106.00,,,,,,,6.3800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,106.00,,,,,,,6.3800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,17.47,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,106.00,,,,,,,6.3800,106.0000,other,"ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97150 1 Visit at $266.90 per Visit = $266.90 (Service Line reduced to $106.00, claim capped at $106.00 in billed charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,UNITY HEALTH PLAN,UNITY HOSPICE,17.47,,,,,,,6.3800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GROUP THERAPEUTIC PROCEDURES,97150,CPT,420,RC,42000063,CDM,,,,both,,,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,6.3800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 420 Proc 97150 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,AETNA,AETNA HSHS,355.95,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $355.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,AETNA,AETNA MEDICARE,97.24,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,AETNA,ALL COMMERCIAL AETNA,551.00,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,ANTHEM,ANTEHM MEDICAID,42.35,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,97.24,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,ANTHEM,ANTHEM POS/HMO,331.00,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $331.00 per Visit = $331.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,ANTHEM,ANTHEM PPO,331.00,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $331.00 per Visit = $331.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,551.00,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,CENPATICO,ALL MEDICAID CENPATICO,551.00,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,468.35,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $468.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,CIGNA,ALL COMMERCIAL CIGNA,385.70,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $385.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,COFINITY,COFINITY,551.00,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,42.35,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,42.35,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,523.45,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $523.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,462.84,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $462.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,391.21,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $391.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,402.23,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $402.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,267.79,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $267.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,468.35,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $468.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HUMANA,HUMANA CHOICE CARE HMO,349.89,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $349.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HUMANA,HUMANA CHOICE CARE PPO,468.35,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $468.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,97.24,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,HUMANA,HUMANA NATIIONAL POS HMO,349.89,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $349.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,402.23,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $402.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,551.00,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $551.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,42.35,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,97.24,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,42.35,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,MOLINA HEALTHCARE,MOLINA MEDICAID,44.89,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35... $42.35 at 106% = $44.89 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,97.24,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,275.50,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $275.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,462.84,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $462.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,218.79,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,413.25,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $413.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,506.92,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $506.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,259.68,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $259.68 per Visit = $259.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,259.68,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $259.68 per Visit = $259.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,PREVEA HEALTH NETWORK,PREVEA360,259.68,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $259.68 per Visit = $259.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,259.68,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $259.68 per Visit = $259.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,351.70,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $351.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,98.21,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,396.72,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $396.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,TRIOLOGY,TRILOGY MEDICAID,88.56,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00016 Proc 97597 at $125.60 (Base Rate) * 0.6652 (Relative Weight) = $83.55 (Total Line Payment) at 106% = $88.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,266.90,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $266.90 per Visit = $266.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,266.90,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $266.90 per Visit = $266.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,97.24,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,266.90,,,,,,,42.3500,551.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $266.90 per Visit = $266.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,UNITY HEALTH PLAN,UNITY HOSPICE,97.24,,,,,,,42.3500,551.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,396.72,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $396.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,341.62,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $341.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,396.72,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $396.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,396.72,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $396.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,420,RC,42000068,CDM,,,,both,,,551.0000,363.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,330.60,,,,,,,42.3500,551.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $551.00 in Billed Charges for Rev 420 Proc 97597 = $330.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,AETNA,AETNA HSHS,602.72,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $602.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,AETNA,AETNA MEDICARE,97.24,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,AETNA,ALL COMMERCIAL AETNA,933.00,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,ANTHEM,ANTEHM MEDICAID,42.35,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,97.24,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,ANTHEM,ANTHEM POS/HMO,331.00,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $331.00 per Visit = $331.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,ANTHEM,ANTHEM PPO,331.00,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $331.00 per Visit = $331.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,933.00,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,CENPATICO,ALL MEDICAID CENPATICO,933.00,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,793.05,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $793.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,CIGNA,ALL COMMERCIAL CIGNA,653.10,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $653.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,COFINITY,COFINITY,933.00,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,42.35,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,42.35,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,886.35,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $886.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,783.72,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $783.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,662.43,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $662.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,681.09,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $681.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,453.44,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $453.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,793.05,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $793.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HUMANA,HUMANA CHOICE CARE HMO,592.46,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $592.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HUMANA,HUMANA CHOICE CARE PPO,793.05,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $793.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HUMANA,HUMANA MEDICARE ADVANTAGE,97.24,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,HUMANA,HUMANA NATIIONAL POS HMO,592.46,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $592.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,681.09,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $681.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,933.00,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $933.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,42.35,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,97.24,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,42.35,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,MOLINA HEALTHCARE,MOLINA MEDICAID,44.89,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $42.35 from Fee Schedule WIMCD_THX for Rev 420 Proc 97597 * Qty 1 = $42.35 at 100% = $42.35... $42.35 at 106% = $44.89 Final Expected The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,MOLINA HEALTHCARE,MOLINA MEDICARE,97.24,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,466.50,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $466.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,783.72,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $783.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,NAPHCARE,ALL COMMERICAL NAPHCARE,218.79,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,699.75,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $699.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,858.36,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $858.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,259.68,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $259.68 per Visit = $259.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,259.68,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $259.68 per Visit = $259.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,PREVEA HEALTH NETWORK,PREVEA360,259.68,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $259.68 per Visit = $259.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,259.68,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $259.68 per Visit = $259.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,595.53,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $595.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,98.21,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,671.76,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $671.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,TRIOLOGY,TRILOGY MEDICAID,88.56,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00016 Proc 97597 at $125.60 (Base Rate) * 0.6652 (Relative Weight) = $83.55 (Total Line Payment) at 106% = $88.56. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,266.90,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $266.90 per Visit = $266.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,266.90,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $266.90 per Visit = $266.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,97.24,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,266.90,,,,,,,42.3500,933.0000,other,ST VINCENT HOSPITAL (ACU). Rev 420 Proc 97597 1 Visit at $266.90 per Visit = $266.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,UNITY HEALTH PLAN,UNITY HOSPICE,97.24,,,,,,,42.3500,933.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,671.76,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $671.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,578.46,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $578.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,671.76,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $671.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,671.76,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $671.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC NEG PRESS/SEL DEBRD <=20CM INT,97597,CPT,420,RC,42000069,CDM,,,,both,,,933.0000,615.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,559.80,,,,,,,42.3500,933.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $933.00 in Billed Charges for Rev 420 Proc 97597 = $559.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,AETNA,AETNA HSHS,2.94,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $2.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,AETNA,AETNA MEDICARE,1.49,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,AETNA,ALL COMMERCIAL AETNA,4.55,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,ANTHEM,ANTEHM MEDICAID,4.55,,,,,,,1.4900,4.8200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J7187 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $4.55, claim capped at $4.55 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1.49,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,ANTHEM,ANTHEM POS/HMO,2.53,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7187 * Qty 1 = $1.49 at 170% = $2.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,ANTHEM,ANTHEM PPO,3.13,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7187 * Qty 1 = $1.49 at 210% = $3.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4.55,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,CENPATICO,ALL MEDICAID CENPATICO,4.55,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3.87,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,CIGNA,ALL COMMERCIAL CIGNA,3.19,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,COFINITY,COFINITY,4.55,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,4.55,,,,,,,1.4900,4.8200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J7187 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $4.55, claim capped at $4.55 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,4.55,,,,,,,1.4900,4.8200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J7187 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $4.55, claim capped at $4.55 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4.32,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $4.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,3.82,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.23,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.32,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,2.21,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $2.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3.87,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HUMANA,HUMANA CHOICE CARE HMO,2.37,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.37 from Fee Schedule 005543_170 for Rev 636 Proc J7187 * Qty 1 = $2.37 at 100% = $2.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HUMANA,HUMANA CHOICE CARE PPO,3.87,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HUMANA,HUMANA MEDICARE ADVANTAGE,1.49,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,HUMANA,HUMANA NATIIONAL POS HMO,2.37,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.37 from Fee Schedule 005543_170 for Rev 636 Proc J7187 * Qty 1 = $2.37 at 100% = $2.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.32,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,4.55,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,4.55,,,,,,,1.4900,4.8200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J7187 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $4.55, claim capped at $4.55 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1.49,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,4.55,,,,,,,1.4900,4.8200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J7187 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $4.55, claim capped at $4.55 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,MOLINA HEALTHCARE,MOLINA MEDICAID,4.82,,,,,,,1.4900,4.8200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J7187 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $4.55, claim capped at $4.55 in billed charges)... $4.55 at 106% = $4.82 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,MOLINA HEALTHCARE,MOLINA MEDICARE,1.49,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.28,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $2.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3.82,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,NAPHCARE,ALL COMMERICAL NAPHCARE,3.35,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.41,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4.19,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $4.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.67,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7187 * Qty 1 = $1.49 at 179% = $2.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.67,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7187 * Qty 1 = $1.49 at 179% = $2.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,PREVEA HEALTH NETWORK,PREVEA360,2.67,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7187 * Qty 1 = $1.49 at 179% = $2.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.67,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.49 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7187 * Qty 1 = $1.49 at 179% = $2.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2.90,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $2.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1.50,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.28,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,TRIOLOGY,TRILOGY MEDICAID,4.55,,,,,,,1.4900,4.8200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J7187 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 106% = $1,730.10 (Service Line reduced to $4.55, claim capped at $4.55 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.46,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.46 from Fee Schedule UHC_31190C for Rev 636 Proc J7187 * Qty 1 = $2.46 at 100% = $2.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,2.46,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.46 from Fee Schedule UHC_31190C for Rev 636 Proc J7187 * Qty 1 = $2.46 at 100% = $2.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1.49,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,2.46,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.46 from Fee Schedule UHC_31190C for Rev 636 Proc J7187 * Qty 1 = $2.46 at 100% = $2.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,UNITY HEALTH PLAN,UNITY HOSPICE,1.49,,,,,,,1.4900,4.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.28,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2.82,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $2.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.28,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.28,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $3.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANTIHEMOPHILIC FACTOR VIII-VWF 500-1200 UNITS SOLR per 1 VWF:RCo Units,J7187,HCPCS,636,RC,63833-616-02,CDM,,,,both,1.000000,UN,4.5500,3.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.73,,,,,,,1.4900,4.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.55 in Billed Charges for Rev 636 Proc J7187 = $2.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,AETNA,AETNA HSHS,0.63,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,AETNA,ALL COMMERCIAL AETNA,0.98,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.98,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,CENPATICO,ALL MEDICAID CENPATICO,0.98,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.83,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,CIGNA,ALL COMMERCIAL CIGNA,0.69,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,COFINITY,COFINITY,0.98,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.93,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,0.82,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.70,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.72,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,0.48,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.83,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,HUMANA,HUMANA CHOICE CARE PPO,0.83,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.72,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.98,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.49,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.82,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.74,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.90,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.63,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.71,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.71,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.61,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.71,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.71,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE (PF) 0.25 % SOLN 30 ML VIAL per 0.5 mg,J0665,HCPCS,636,RC,0409-1159-19,CDM,,,,both,0.500000,ME,0.9800,0.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.59,,,,,,,0.0200,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.98 in Billed Charges for Rev 636 Proc J0665 = $0.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,AETNA,AETNA HSHS,0.32,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,AETNA,ALL COMMERCIAL AETNA,0.49,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.49,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,CENPATICO,ALL MEDICAID CENPATICO,0.49,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.42,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,CIGNA,ALL COMMERCIAL CIGNA,0.34,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,COFINITY,COFINITY,0.49,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.47,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,0.41,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.35,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.36,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,0.24,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.42,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HUMANA,HUMANA CHOICE CARE PPO,0.42,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.36,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.49,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.25,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.41,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.37,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.45,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.31,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.35,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.4900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.35,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.30,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.35,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.35,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, BUPIVACAINE, NOS, 0.5MG",J0665,HCPCS,636,RC,0409-1560-10,CDM,,,,both,0.500000,ME,0.4900,0.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.29,,,,,,,0.0200,0.4900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.49 in Billed Charges for Rev 636 Proc J0665 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,AETNA,AETNA HSHS,1.38,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,AETNA,ALL COMMERCIAL AETNA,2.13,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $2.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2.13,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $2.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,CENPATICO,ALL MEDICAID CENPATICO,2.13,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $2.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1.81,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,CIGNA,ALL COMMERCIAL CIGNA,1.49,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,COFINITY,COFINITY,2.13,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $2.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2.02,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $2.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,1.79,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1.51,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1.55,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,1.04,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1.81,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,HUMANA,HUMANA CHOICE CARE HMO,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,HUMANA,HUMANA CHOICE CARE PPO,1.81,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,HUMANA,HUMANA NATIIONAL POS HMO,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule 005543_170 for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1.55,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,2.13,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $2.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.07,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1.79,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1.60,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1.96,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0665 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.36,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1.53,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,2.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J0665 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1.53,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.32,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1.53,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1.53,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75-8.25 % SOLN per 0.5 mg,J0665,HCPCS,636,RC,0409-3613-11,CDM,,,,both,0.500000,ME,2.1300,1.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1.28,,,,,,,0.0200,2.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $2.13 in Billed Charges for Rev 636 Proc J0665 = $1.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,AETNA,AETNA HSHS,19.33,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $19.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,AETNA,ALL COMMERCIAL AETNA,29.93,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,ANTHEM,ANTHEM POS/HMO,20.35,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0574 $29.93 in Billed Charges at 68% = $20.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,ANTHEM,ANTHEM PPO,20.35,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0574 $29.93 in Billed Charges at 68% = $20.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,29.93,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,CENPATICO,ALL MEDICAID CENPATICO,29.93,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,25.44,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $25.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,CIGNA,ALL COMMERCIAL CIGNA,20.95,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $20.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,COFINITY,COFINITY,29.93,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,28.43,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $28.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,25.14,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $25.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,21.25,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,21.85,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $21.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,14.55,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $14.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,25.44,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $25.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,HUMANA,HUMANA CHOICE CARE HMO,11.54,,,,,,,11.5400,29.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $11.54 from Fee Schedule 005543_170 for Rev 636 Proc J0574 * Qty 1 = $11.54 at 100% = $11.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,HUMANA,HUMANA CHOICE CARE PPO,25.44,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $25.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,HUMANA,HUMANA NATIIONAL POS HMO,11.54,,,,,,,11.5400,29.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $11.54 from Fee Schedule 005543_170 for Rev 636 Proc J0574 * Qty 1 = $11.54 at 100% = $11.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,21.85,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $21.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,29.93,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,14.97,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $14.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,25.14,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $25.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,22.45,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $22.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,27.54,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $27.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.96,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0574 $29.93 in Billed Charges at 60% = $17.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.96,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0574 $29.93 in Billed Charges at 60% = $17.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,PREVEA HEALTH NETWORK,PREVEA360,17.96,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0574 $29.93 in Billed Charges at 60% = $17.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.96,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0574 $29.93 in Billed Charges at 60% = $17.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,19.10,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $19.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,21.55,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.48,,,,,,,11.5400,29.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.48 from Fee Schedule UHC_31190C for Rev 636 Proc J0574 * Qty 1 = $15.48 at 100% = $15.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,UNITED HEALTHCARE,UHC ONEIDA NATION,15.48,,,,,,,11.5400,29.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.48 from Fee Schedule UHC_31190C for Rev 636 Proc J0574 * Qty 1 = $15.48 at 100% = $15.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,UNITED HEALTHCARE,UNITED HEALTHCARE,15.48,,,,,,,11.5400,29.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.48 from Fee Schedule UHC_31190C for Rev 636 Proc J0574 * Qty 1 = $15.48 at 100% = $15.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,21.55,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,18.56,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $18.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,21.55,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,21.55,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE-NALOXONE 8-2 MG FILM per 1 Film,J0574,HCPCS,636,RC,43598-582-01,CDM,,,,both,1.000000,EA,29.9300,19.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,17.96,,,,,,,11.5400,29.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.93 in Billed Charges for Rev 636 Proc J0574 = $17.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,AETNA,AETNA HSHS,3.69,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $3.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,AETNA,AETNA MEDICARE,0.83,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,AETNA,ALL COMMERCIAL AETNA,5.71,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $5.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,0.83,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,ANTHEM,ANTHEM POS/HMO,3.88,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.71 in Billed Charges at 68% = $3.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,ANTHEM,ANTHEM PPO,3.88,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.71 in Billed Charges at 68% = $3.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.71,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $5.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,CENPATICO,ALL MEDICAID CENPATICO,5.71,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $5.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.85,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,CIGNA,ALL COMMERCIAL CIGNA,4.00,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,COFINITY,COFINITY,5.71,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $5.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.42,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $5.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,4.80,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.05,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.17,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,2.78,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $2.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.85,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HUMANA,HUMANA CHOICE CARE HMO,3.63,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.71 in Billed Charges at 63.5% = $3.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HUMANA,HUMANA CHOICE CARE PPO,4.85,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HUMANA,HUMANA MEDICARE ADVANTAGE,0.83,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,HUMANA,HUMANA NATIIONAL POS HMO,3.63,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.71 in Billed Charges at 63.5% = $3.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.17,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.71,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $5.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,0.83,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,MOLINA HEALTHCARE,MOLINA MEDICARE,0.83,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.86,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $2.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.80,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,NAPHCARE,ALL COMMERICAL NAPHCARE,1.86,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.28,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.25,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.43,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.71 in Billed Charges at 60% = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.43,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.71 in Billed Charges at 60% = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,PREVEA HEALTH NETWORK,PREVEA360,3.43,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.71 in Billed Charges at 60% = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.43,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0668 $5.71 in Billed Charges at 60% = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.64,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $3.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,0.84,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.11,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.37,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0668 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,UNITED HEALTHCARE,UHC ONEIDA NATION,1.37,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0668 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,0.83,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,UNITED HEALTHCARE,UNITED HEALTHCARE,1.37,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.37 from Fee Schedule UHC_31190C for Rev 636 Proc J0668 * Qty 1 = $1.37 at 100% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,UNITY HEALTH PLAN,UNITY HOSPICE,0.83,,,,,,,0.8300,5.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.11,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.54,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $3.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.11,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.11,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $4.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML SOLN per 1 mg,J0668,HCPCS,636,RC,47426-501-02,CDM,,,,both,1.000000,ME,5.7100,3.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.43,,,,,,,0.8300,5.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.71 in Billed Charges for Rev 636 Proc J0668 = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,AETNA,AETNA HSHS,148.99,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $148.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,AETNA,ALL COMMERCIAL AETNA,230.63,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $230.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,ANTHEM,ANTHEM POS/HMO,23.49,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $13.82 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0515 * Qty 1 = $13.82 at 170% = $23.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,ANTHEM,ANTHEM PPO,29.02,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $13.82 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0515 * Qty 1 = $13.82 at 210% = $29.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,230.63,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $230.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,CENPATICO,ALL MEDICAID CENPATICO,230.63,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $230.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,196.04,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $196.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,CIGNA,ALL COMMERCIAL CIGNA,161.44,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $161.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,COFINITY,COFINITY,230.63,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $230.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,219.10,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $219.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,193.73,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $193.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,163.75,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $163.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,168.36,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $168.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,112.09,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $112.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,196.04,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $196.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,HUMANA,HUMANA CHOICE CARE HMO,27.69,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $27.69 from Fee Schedule 005543_170 for Rev 636 Proc J0515 * Qty 1 = $27.69 at 100% = $27.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,HUMANA,HUMANA CHOICE CARE PPO,196.04,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $196.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,HUMANA,HUMANA NATIIONAL POS HMO,27.69,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $27.69 from Fee Schedule 005543_170 for Rev 636 Proc J0515 * Qty 1 = $27.69 at 100% = $27.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,168.36,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $168.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,230.63,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $230.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,115.32,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $115.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,193.73,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $193.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,172.97,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $172.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,212.18,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $212.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,24.74,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $13.82 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0515 * Qty 1 = $13.82 at 179% = $24.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,24.74,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $13.82 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0515 * Qty 1 = $13.82 at 179% = $24.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,PREVEA HEALTH NETWORK,PREVEA360,24.74,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $13.82 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0515 * Qty 1 = $13.82 at 179% = $24.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,24.74,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $13.82 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0515 * Qty 1 = $13.82 at 179% = $24.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,147.21,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $147.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,166.05,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $166.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,22.80,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $22.80 from Fee Schedule UHC_31190C for Rev 636 Proc J0515 * Qty 1 = $22.80 at 100% = $22.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,22.80,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $22.80 from Fee Schedule UHC_31190C for Rev 636 Proc J0515 * Qty 1 = $22.80 at 100% = $22.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,22.80,,,,,,,22.8000,230.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $22.80 from Fee Schedule UHC_31190C for Rev 636 Proc J0515 * Qty 1 = $22.80 at 100% = $22.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,166.05,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $166.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,142.99,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $142.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,166.05,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $166.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,166.05,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $166.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZTROPINE MESYLATE 1 MG/ML SOLN per 1 mg,J0515,HCPCS,636,RC,0143-9729-01,CDM,,,,both,1.000000,ME,230.6300,152.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,138.38,,,,,,,22.8000,230.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $230.63 in Billed Charges for Rev 636 Proc J0515 = $138.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,AETNA,AETNA HSHS,5.28,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,AETNA,ALL COMMERCIAL AETNA,8.17,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,ANTHEM,ANTHEM POS/HMO,0.61,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 170% = $0.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,ANTHEM,ANTHEM PPO,0.76,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 210% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.17,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,CENPATICO,ALL MEDICAID CENPATICO,8.17,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.94,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,CIGNA,ALL COMMERCIAL CIGNA,5.72,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,COFINITY,COFINITY,8.17,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.76,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $7.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,6.86,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.80,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.96,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,3.97,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $3.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.94,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,HUMANA,HUMANA CHOICE CARE HMO,1.05,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.05 from Fee Schedule 005543_170 for Rev 636 Proc J1939 * Qty 1 = $1.05 at 100% = $1.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,HUMANA,HUMANA CHOICE CARE PPO,6.94,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,HUMANA,HUMANA NATIIONAL POS HMO,1.05,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.05 from Fee Schedule 005543_170 for Rev 636 Proc J1939 * Qty 1 = $1.05 at 100% = $1.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.96,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.17,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.09,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $4.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.86,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.13,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.52,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $7.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.64,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.64,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA360,0.64,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.64,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.36 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1939 * Qty 1 = $0.36 at 179% = $0.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.21,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.88,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.59,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.59,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.59,,,,,,,0.5900,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule UHC_31190C for Rev 636 Proc J1939 * Qty 1 = $0.59 at 100% = $0.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.88,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.07,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.88,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.88,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUMETANIDE 0.25 MG/ML SOLN per 0.5 mg,J1939,HCPCS,636,RC,65219-572-01,CDM,,,,both,0.500000,ME,8.1700,5.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.90,,,,,,,0.5900,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.17 in Billed Charges for Rev 636 Proc J1939 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,AETNA,AETNA HSHS,26.58,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $26.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,AETNA,ALL COMMERCIAL AETNA,41.15,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,ANTHEM,ANTHEM POS/HMO,4.98,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 170% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,ANTHEM,ANTHEM PPO,6.15,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 210% = $6.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,41.15,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,CENPATICO,ALL MEDICAID CENPATICO,41.15,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,34.98,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $34.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,CIGNA,ALL COMMERCIAL CIGNA,28.81,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $28.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,COFINITY,COFINITY,41.15,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,39.09,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $39.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,34.57,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $34.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.22,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $29.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,30.04,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $30.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,20.00,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $20.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,34.98,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $34.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,HUMANA,HUMANA CHOICE CARE HMO,6.27,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.27 from Fee Schedule 005543_170 for Rev 636 Proc J9045 * Qty 1 = $6.27 at 100% = $6.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,HUMANA,HUMANA CHOICE CARE PPO,34.98,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $34.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,HUMANA,HUMANA NATIIONAL POS HMO,6.27,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $6.27 from Fee Schedule 005543_170 for Rev 636 Proc J9045 * Qty 1 = $6.27 at 100% = $6.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,30.04,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $30.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,41.15,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,20.58,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,34.57,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $34.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,30.86,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $30.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,37.86,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $37.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.24,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.24,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,PREVEA HEALTH NETWORK,PREVEA360,5.24,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.24,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.27,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $26.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,29.63,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $29.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.83,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,4.83,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,4.83,,,,,,,4.8300,41.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,29.63,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $29.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,25.51,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $25.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,29.63,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $29.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,29.63,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $29.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,0703-4248-01,CDM,,,,both,50.000000,ME,41.1500,27.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,24.69,,,,,,,4.8300,41.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.15 in Billed Charges for Rev 636 Proc J9045 = $24.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,AETNA,AETNA HSHS,24.52,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $24.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,AETNA,ALL COMMERCIAL AETNA,37.96,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,ANTHEM,ANTHEM POS/HMO,4.98,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 170% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,ANTHEM,ANTHEM PPO,6.15,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 210% = $6.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,37.96,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,CENPATICO,ALL MEDICAID CENPATICO,37.96,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,32.27,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $32.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,CIGNA,ALL COMMERCIAL CIGNA,26.57,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $26.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,COFINITY,COFINITY,37.96,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,36.06,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $36.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,31.89,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $31.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,26.95,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $26.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,27.71,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $27.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,18.45,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $18.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,32.27,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $32.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,HUMANA,HUMANA CHOICE CARE HMO,6.27,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $6.27 from Fee Schedule 005543_170 for Rev 636 Proc J9045 * Qty 1 = $6.27 at 100% = $6.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,HUMANA,HUMANA CHOICE CARE PPO,32.27,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $32.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,HUMANA,HUMANA NATIIONAL POS HMO,6.27,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $6.27 from Fee Schedule 005543_170 for Rev 636 Proc J9045 * Qty 1 = $6.27 at 100% = $6.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,27.71,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $27.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,37.96,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $37.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,18.98,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $18.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,31.89,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $31.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,28.47,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $28.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,34.92,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $34.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.24,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.24,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,PREVEA HEALTH NETWORK,PREVEA360,5.24,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.24,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,24.23,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $24.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,27.33,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $27.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.83,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,UNITED HEALTHCARE,UHC ONEIDA NATION,4.83,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,UNITED HEALTHCARE,UNITED HEALTHCARE,4.83,,,,,,,4.8300,37.9600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,27.33,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $27.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,23.54,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $23.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,27.33,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $27.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,27.33,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $27.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,16729-295-34,CDM,,,,both,50.000000,ME,37.9600,25.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,22.78,,,,,,,4.8300,37.9600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $37.96 in Billed Charges for Rev 636 Proc J9045 = $22.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,AETNA,AETNA HSHS,21.51,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $21.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,AETNA,ALL COMMERCIAL AETNA,33.29,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $33.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,ANTHEM,ANTHEM POS/HMO,4.98,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 170% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,ANTHEM,ANTHEM PPO,6.15,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 210% = $6.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,33.29,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $33.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,CENPATICO,ALL MEDICAID CENPATICO,33.29,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $33.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,28.30,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $28.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,CIGNA,ALL COMMERCIAL CIGNA,23.30,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $23.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,COFINITY,COFINITY,33.29,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $33.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,31.63,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $31.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,27.96,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $27.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,23.64,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $23.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,24.30,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $24.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,16.18,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $16.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,28.30,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $28.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,HUMANA,HUMANA CHOICE CARE HMO,6.27,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $6.27 from Fee Schedule 005543_170 for Rev 636 Proc J9045 * Qty 1 = $6.27 at 100% = $6.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,HUMANA,HUMANA CHOICE CARE PPO,28.30,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $28.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,HUMANA,HUMANA NATIIONAL POS HMO,6.27,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $6.27 from Fee Schedule 005543_170 for Rev 636 Proc J9045 * Qty 1 = $6.27 at 100% = $6.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,24.30,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $24.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,33.29,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $33.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.65,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $16.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,27.96,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $27.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,24.97,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $24.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,30.63,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $30.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.24,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.24,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,PREVEA HEALTH NETWORK,PREVEA360,5.24,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.24,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $2.93 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9045 * Qty 1 = $2.93 at 179% = $5.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,21.25,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,23.97,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $23.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.83,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,UNITED HEALTHCARE,UHC ONEIDA NATION,4.83,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,UNITED HEALTHCARE,UNITED HEALTHCARE,4.83,,,,,,,4.8300,33.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.83 from Fee Schedule UHC_31190C for Rev 636 Proc J9045 * Qty 1 = $4.83 at 100% = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,23.97,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $23.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,20.64,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $20.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,23.97,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $23.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,23.97,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $23.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPLATIN 450 MG/45ML SOLN 45 ML VIAL per 50 mg,J9045,HCPCS,636,RC,61703-339-50,CDM,,,,both,50.000000,ME,33.2900,21.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,19.97,,,,,,,4.8300,33.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.29 in Billed Charges for Rev 636 Proc J9045 = $19.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,AETNA,AETNA HSHS,325.60,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $325.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,AETNA,AETNA MEDICARE,13.70,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,AETNA,ALL COMMERCIAL AETNA,504.02,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $504.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,13.70,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,ANTHEM,ANTHEM POS/HMO,342.73,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $504.02 in Billed Charges at 68% = $342.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,ANTHEM,ANTHEM PPO,342.73,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $504.02 in Billed Charges at 68% = $342.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,504.02,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $504.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,CENPATICO,ALL MEDICAID CENPATICO,504.02,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $504.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,428.42,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $428.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,CIGNA,ALL COMMERCIAL CIGNA,352.81,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $352.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,COFINITY,COFINITY,504.02,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $504.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,478.82,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $478.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,423.38,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $423.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,357.85,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $357.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,367.93,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $367.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,244.95,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $244.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,428.42,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $428.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HUMANA,HUMANA CHOICE CARE HMO,320.05,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $504.02 in Billed Charges at 63.5% = $320.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HUMANA,HUMANA CHOICE CARE PPO,428.42,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $428.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HUMANA,HUMANA MEDICARE ADVANTAGE,13.70,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,HUMANA,HUMANA NATIIONAL POS HMO,320.05,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $504.02 in Billed Charges at 63.5% = $320.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,367.93,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $367.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,504.02,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $504.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.70,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,MOLINA HEALTHCARE,MOLINA MEDICARE,13.70,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,252.01,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $252.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,423.38,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $423.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,NAPHCARE,ALL COMMERICAL NAPHCARE,30.83,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,378.02,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $378.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,463.70,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $463.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,302.41,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $504.02 in Billed Charges at 60% = $302.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,302.41,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $504.02 in Billed Charges at 60% = $302.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,PREVEA HEALTH NETWORK,PREVEA360,302.41,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $504.02 in Billed Charges at 60% = $302.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,302.41,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0675 $504.02 in Billed Charges at 60% = $302.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,321.72,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $321.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,13.84,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,362.89,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $362.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,22.61,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). $22.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0675 * Qty 1 = $22.61 at 100% = $22.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,UNITED HEALTHCARE,UHC ONEIDA NATION,22.61,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). $22.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0675 * Qty 1 = $22.61 at 100% = $22.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,13.70,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,UNITED HEALTHCARE,UNITED HEALTHCARE,22.61,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). $22.61 from Fee Schedule UHC_31190C for Rev 636 Proc J0675 * Qty 1 = $22.61 at 100% = $22.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,UNITY HEALTH PLAN,UNITY HOSPICE,13.70,,,,,,,13.7000,504.0200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,362.89,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $362.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,312.49,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $312.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,362.89,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $362.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,362.89,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $362.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBOPROST 250 MCG/ML SOLN PER .1 MG,J0675,HCPCS,636,RC,43598-698-11,CDM,,,,both,0.100000,ME,504.0200,332.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,302.41,,,,,,,13.7000,504.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $504.02 in Billed Charges for Rev 636 Proc J0675 = $302.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,AETNA,AETNA HSHS,108.87,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $108.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,AETNA,AETNA MEDICARE,55.61,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,AETNA,ALL COMMERCIAL AETNA,168.53,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $168.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,ANTHEM,ANTEHM MEDICAID,168.53,,,,,,,55.6100,178.6400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.53, claim capped at $168.53 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,55.61,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,ANTHEM,ANTHEM POS/HMO,94.54,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 170% = $94.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,ANTHEM,ANTHEM PPO,116.78,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 210% = $116.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,168.53,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $168.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,CENPATICO,ALL MEDICAID CENPATICO,168.53,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $168.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,143.25,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $143.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,CIGNA,ALL COMMERCIAL CIGNA,117.97,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $117.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,COFINITY,COFINITY,168.53,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $168.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,168.53,,,,,,,55.6100,178.6400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.53, claim capped at $168.53 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,168.53,,,,,,,55.6100,178.6400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.53, claim capped at $168.53 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,160.10,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $160.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,141.57,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $141.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,119.66,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $119.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,123.03,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $123.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,81.91,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $81.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,143.25,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $143.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HUMANA,HUMANA CHOICE CARE HMO,84.37,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $84.37 from Fee Schedule 005543_170 for Rev 636 Proc J9047 * Qty 1 = $84.37 at 100% = $84.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HUMANA,HUMANA CHOICE CARE PPO,143.25,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $143.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HUMANA,HUMANA MEDICARE ADVANTAGE,55.61,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,HUMANA,HUMANA NATIIONAL POS HMO,84.37,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $84.37 from Fee Schedule 005543_170 for Rev 636 Proc J9047 * Qty 1 = $84.37 at 100% = $84.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,123.03,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $123.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,168.53,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $168.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,168.53,,,,,,,55.6100,178.6400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.53, claim capped at $168.53 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,55.61,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,168.53,,,,,,,55.6100,178.6400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.53, claim capped at $168.53 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,MOLINA HEALTHCARE,MOLINA MEDICAID,178.64,,,,,,,55.6100,178.6400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01 (Service Line reduced to $168.53, claim capped at $168.53 in billed charges)... $168.53 at 106% = $178.64 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,MOLINA HEALTHCARE,MOLINA MEDICARE,55.61,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,84.27,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $84.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,141.57,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $141.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,NAPHCARE,ALL COMMERICAL NAPHCARE,125.12,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,126.40,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $126.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,155.05,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $155.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,99.54,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 179% = $99.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,99.54,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 179% = $99.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,PREVEA HEALTH NETWORK,PREVEA360,99.54,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 179% = $99.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,99.54,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $55.61 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9047 * Qty 1 = $55.61 at 179% = $99.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,107.57,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $107.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,56.17,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,121.34,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $121.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,TRIOLOGY,TRILOGY MEDICAID,168.53,,,,,,,55.6100,178.6400,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00460 Proc J9047 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 106% = $612.69 (Service Line reduced to $168.53, claim capped at $168.53 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,91.76,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $91.76 from Fee Schedule UHC_31190C for Rev 636 Proc J9047 * Qty 1 = $91.76 at 100% = $91.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,UNITED HEALTHCARE,UHC ONEIDA NATION,91.76,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $91.76 from Fee Schedule UHC_31190C for Rev 636 Proc J9047 * Qty 1 = $91.76 at 100% = $91.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,55.61,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,UNITED HEALTHCARE,UNITED HEALTHCARE,91.76,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). $91.76 from Fee Schedule UHC_31190C for Rev 636 Proc J9047 * Qty 1 = $91.76 at 100% = $91.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,UNITY HEALTH PLAN,UNITY HOSPICE,55.61,,,,,,,55.6100,178.6400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,121.34,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $121.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,104.49,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $104.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,121.34,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $121.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,121.34,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $121.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARFILZOMIB 60 MG SOLR 1 EACH VIAL per 1 mg,J9047,HCPCS,636,RC,76075-101-01,CDM,,,,both,1.000000,ME,168.5300,111.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,101.12,,,,,,,55.6100,178.6400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $168.53 in Billed Charges for Rev 636 Proc J9047 = $101.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,AETNA,AETNA HSHS,2449.63,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,449.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,AETNA,ALL COMMERCIAL AETNA,3792.00,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,ANTHEM,ANTEHM MEDICAID,578.01,,,,,,,578.0100,3792.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0630 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,ANTHEM,ANTHEM POS/HMO,1942.10,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,142.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0630 * Qty 1 = $1,142.41 at 170% = $1,942.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,ANTHEM,ANTHEM PPO,2399.06,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,142.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0630 * Qty 1 = $1,142.41 at 210% = $2,399.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3792.00,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,CENPATICO,ALL MEDICAID CENPATICO,3792.00,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3223.20,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,CIGNA,ALL COMMERCIAL CIGNA,2654.40,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,654.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,COFINITY,COFINITY,3792.00,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,578.01,,,,,,,578.0100,3792.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0630 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,578.01,,,,,,,578.0100,3792.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0630 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3602.40,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,602.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,3185.28,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,185.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2692.32,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,692.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2768.16,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,768.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,1842.91,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $1,842.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3223.20,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,HUMANA,HUMANA CHOICE CARE HMO,1822.35,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,822.35 from Fee Schedule 005543_170 for Rev 636 Proc J0630 * Qty 1 = $1,822.35 at 100% = $1,822.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,HUMANA,HUMANA CHOICE CARE PPO,3223.20,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,HUMANA,HUMANA NATIIONAL POS HMO,1822.35,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,822.35 from Fee Schedule 005543_170 for Rev 636 Proc J0630 * Qty 1 = $1,822.35 at 100% = $1,822.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2768.16,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,768.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,3792.00,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,792.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,578.01,,,,,,,578.0100,3792.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0630 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,578.01,,,,,,,578.0100,3792.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0630 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,MOLINA HEALTHCARE,MOLINA MEDICAID,612.69,,,,,,,578.0100,3792.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0630 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 100% = $578.01... $578.01 at 106% = $612.69 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1896.00,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $1,896.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3185.28,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,185.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2844.00,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,844.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3488.64,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $3,488.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2044.91,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,142.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0630 * Qty 1 = $1,142.41 at 179% = $2,044.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2044.91,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,142.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0630 * Qty 1 = $1,142.41 at 179% = $2,044.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,PREVEA HEALTH NETWORK,PREVEA360,2044.91,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,142.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0630 * Qty 1 = $1,142.41 at 179% = $2,044.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2044.91,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $1,142.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0630 * Qty 1 = $1,142.41 at 179% = $2,044.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2420.43,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,420.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2730.24,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,730.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,TRIOLOGY,TRILOGY MEDICAID,612.69,,,,,,,578.0100,3792.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00460 Proc J0630 at $125.60 (Base Rate) * 4.602 (Relative Weight) = $578.01 (Total Line Payment) at 106% = $612.69. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2364.78,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,364.78 from Fee Schedule UHC_31190C for Rev 636 Proc J0630 * Qty 1 = $2,364.78 at 100% = $2,364.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,2364.78,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,364.78 from Fee Schedule UHC_31190C for Rev 636 Proc J0630 * Qty 1 = $2,364.78 at 100% = $2,364.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,2364.78,,,,,,,578.0100,3792.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). $2,364.78 from Fee Schedule UHC_31190C for Rev 636 Proc J0630 * Qty 1 = $2,364.78 at 100% = $2,364.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2730.24,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,730.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2351.04,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,351.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2730.24,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,730.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2730.24,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,730.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCITONIN 200 UNIT/ML SOLN per 400 Units,J0630,HCPCS,636,RC,42023-205-01,CDM,,,,both,400.000000,UN,3792.0000,2502.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2275.20,,,,,,,578.0100,3792.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,792.00 in Billed Charges for Rev 636 Proc J0630 = $2,275.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,AETNA,AETNA HSHS,1.14,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,AETNA,ALL COMMERCIAL AETNA,1.77,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1.77,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,CENPATICO,ALL MEDICAID CENPATICO,1.77,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1.50,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,CIGNA,ALL COMMERCIAL CIGNA,1.24,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,COFINITY,COFINITY,1.77,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1.68,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,1.49,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1.26,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1.29,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,0.86,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $0.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1.50,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,HUMANA,HUMANA CHOICE CARE HMO,0.07,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,HUMANA,HUMANA CHOICE CARE PPO,1.50,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,HUMANA,HUMANA NATIIONAL POS HMO,0.07,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1.29,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1.77,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.89,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $0.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1.49,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1.33,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1.63,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.13,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1.27,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,1.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1.27,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.10,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1.27,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1.27,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 1 G 1-0.675 GM/50ML-% SOLN per 10 MG,J0612,HCPCS,636,RC,80830-2362-1,CDM,,,,both,10.000000,ME,1.7700,1.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1.06,,,,,,,0.0500,1.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $1.77 in Billed Charges for Rev 636 Proc J0612 = $1.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,AETNA,AETNA HSHS,0.48,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,AETNA,ALL COMMERCIAL AETNA,0.74,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.74,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,CENPATICO,ALL MEDICAID CENPATICO,0.74,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.63,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,CIGNA,ALL COMMERCIAL CIGNA,0.52,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,COFINITY,COFINITY,0.74,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.70,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,HEALTH CARE ALLIANCE,THE ALLIANCE,0.62,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.53,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.54,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,HSHS EMPLOYEES,HSHS EMPLOYEES,0.36,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.63,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,HUMANA,HUMANA CHOICE CARE HMO,0.07,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,HUMANA,HUMANA CHOICE CARE PPO,0.63,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,HUMANA,HUMANA NATIIONAL POS HMO,0.07,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.54,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.74,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.37,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.62,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.56,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.68,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.47,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.53,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.7400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.53,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.46,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.53,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.53,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CALCIUM GLUCONATE, NOS",J0612,HCPCS,636,RC,63323-360-19,CDM,,,,both,10.000000,ME,0.7400,0.4900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.44,,,,,,,0.0500,0.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.74 in Billed Charges for Rev 636 Proc J0612 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,AETNA,AETNA HSHS,0.28,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,AETNA,ALL COMMERCIAL AETNA,0.43,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.43,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,CENPATICO,ALL MEDICAID CENPATICO,0.43,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.37,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,CIGNA,ALL COMMERCIAL CIGNA,0.30,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,COFINITY,COFINITY,0.43,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.41,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,0.36,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.31,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.31,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,0.21,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.37,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,HUMANA,HUMANA CHOICE CARE HMO,0.07,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,HUMANA,HUMANA CHOICE CARE PPO,0.37,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,HUMANA,HUMANA NATIIONAL POS HMO,0.07,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule 005543_170 for Rev 636 Proc J0612 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.31,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.43,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.22,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.36,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.32,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.40,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0612 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.27,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.31,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0612 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.31,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.27,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.31,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.31,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 10 % SOLN 50 ML VIAL PER 10 MG,J0612,HCPCS,636,RC,70069-727-10,CDM,,,,both,10.000000,ME,0.4300,0.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.26,,,,,,,0.0500,0.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.43 in Billed Charges for Rev 636 Proc J0612 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,AETNA,AETNA HSHS,1.04,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,AETNA,ALL COMMERCIAL AETNA,1.61,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,ANTHEM,ANTHEM POS/HMO,0.15,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 170% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,ANTHEM,ANTHEM PPO,0.19,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 210% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1.61,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,CENPATICO,ALL MEDICAID CENPATICO,1.61,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1.37,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,CIGNA,ALL COMMERCIAL CIGNA,1.13,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,COFINITY,COFINITY,1.61,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1.53,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,1.35,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1.14,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1.18,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,0.78,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $0.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1.37,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,HUMANA,HUMANA CHOICE CARE HMO,0.15,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule 005543_170 for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,HUMANA,HUMANA CHOICE CARE PPO,1.37,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,HUMANA,HUMANA NATIIONAL POS HMO,0.15,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule 005543_170 for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1.18,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1.61,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.81,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $0.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1.35,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1.21,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1.48,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.16,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 179% = $0.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.16,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 179% = $0.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,PREVEA HEALTH NETWORK,PREVEA360,0.16,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 179% = $0.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.16,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.09 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0613 * Qty 1 = $0.09 at 179% = $0.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.03,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1.16,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.15,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.15,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.15,,,,,,,0.1500,1.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0613 * Qty 1 = $0.15 at 100% = $0.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1.16,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.00,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1.16,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1.16,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $1.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM GLUCONATE 2 G 2-0.675 GM/100ML-% SOLN per 10 mg,J0613,HCPCS,636,RC,44567-621-24,CDM,,,,both,10.000000,ME,1.6100,1.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.97,,,,,,,0.1500,1.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $1.61 in Billed Charges for Rev 636 Proc J0613 = $0.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,AETNA,AETNA HSHS,48.90,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $48.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,AETNA,AETNA MEDICARE,19.94,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,AETNA,ALL COMMERCIAL AETNA,75.69,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $75.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,ANTHEM,ANTEHM MEDICAID,75.69,,,,,,,19.9400,80.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc C9460 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $75.69, claim capped at $75.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,19.94,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,ANTHEM,ANTHEM POS/HMO,26.04,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.32 from Fee Schedule MEDCR_ASP for Rev 636 Proc C9460 * Qty 1 = $15.32 at 170% = $26.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,ANTHEM,ANTHEM PPO,32.17,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.32 from Fee Schedule MEDCR_ASP for Rev 636 Proc C9460 * Qty 1 = $15.32 at 210% = $32.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,75.69,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $75.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,CENPATICO,ALL MEDICAID CENPATICO,75.69,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $75.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,64.34,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $64.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,CIGNA,ALL COMMERCIAL CIGNA,52.98,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $52.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,COFINITY,COFINITY,75.69,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $75.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,75.69,,,,,,,19.9400,80.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc C9460 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $75.69, claim capped at $75.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,75.69,,,,,,,19.9400,80.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc C9460 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $75.69, claim capped at $75.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,71.91,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $71.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,63.58,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $63.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,53.74,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $53.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,55.25,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $55.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,36.79,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $36.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,64.34,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $64.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HUMANA,HUMANA CHOICE CARE HMO,48.06,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc C9460 $75.69 in Billed Charges at 63.5% = $48.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HUMANA,HUMANA CHOICE CARE PPO,64.34,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $64.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HUMANA,HUMANA MEDICARE ADVANTAGE,19.94,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,HUMANA,HUMANA NATIIONAL POS HMO,48.06,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc C9460 $75.69 in Billed Charges at 63.5% = $48.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,55.25,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $55.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,75.69,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $75.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,75.69,,,,,,,19.9400,80.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc C9460 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $75.69, claim capped at $75.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,19.94,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,75.69,,,,,,,19.9400,80.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc C9460 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $75.69, claim capped at $75.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,MOLINA HEALTHCARE,MOLINA MEDICAID,80.23,,,,,,,19.9400,80.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc C9460 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $75.69, claim capped at $75.69 in billed charges)... $75.69 at 106% = $80.23 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,MOLINA HEALTHCARE,MOLINA MEDICARE,19.94,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.85,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $37.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,63.58,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $63.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,NAPHCARE,ALL COMMERICAL NAPHCARE,44.86,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,56.77,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $56.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,69.63,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $69.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,27.42,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.32 from Fee Schedule MEDCR_ASP for Rev 636 Proc C9460 * Qty 1 = $15.32 at 179% = $27.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,27.42,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.32 from Fee Schedule MEDCR_ASP for Rev 636 Proc C9460 * Qty 1 = $15.32 at 179% = $27.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,PREVEA HEALTH NETWORK,PREVEA360,27.42,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.32 from Fee Schedule MEDCR_ASP for Rev 636 Proc C9460 * Qty 1 = $15.32 at 179% = $27.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,27.42,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.32 from Fee Schedule MEDCR_ASP for Rev 636 Proc C9460 * Qty 1 = $15.32 at 179% = $27.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,48.31,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $48.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,20.14,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,54.50,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $54.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,TRIOLOGY,TRILOGY MEDICAID,75.69,,,,,,,19.9400,80.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc C9460 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 106% = $220.74 (Service Line reduced to $75.69, claim capped at $75.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32.90,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $32.90 from Fee Schedule UHC_31190C for Rev 636 Proc C9460 * Qty 1 = $32.90 at 100% = $32.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,32.90,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $32.90 from Fee Schedule UHC_31190C for Rev 636 Proc C9460 * Qty 1 = $32.90 at 100% = $32.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,19.94,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,32.90,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $32.90 from Fee Schedule UHC_31190C for Rev 636 Proc C9460 * Qty 1 = $32.90 at 100% = $32.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,UNITY HEALTH PLAN,UNITY HOSPICE,19.94,,,,,,,19.9400,80.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,54.50,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $54.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,46.93,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $46.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,54.50,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $54.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,54.50,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $54.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CANGRELOR 50 MG SOLR 1 EACH VIAL per 1 mg,C9460,HCPCS,636,RC,10122-620-01,CDM,,,,both,1.000000,ME,75.6900,49.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,45.41,,,,,,,19.9400,80.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $75.69 in Billed Charges for Rev 636 Proc C9460 = $45.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,AETNA,AETNA HSHS,5.28,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,AETNA,ALL COMMERCIAL AETNA,8.17,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,ANTHEM,ANTHEM POS/HMO,1.50,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0687 * Qty 1 = $0.88 at 170% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,ANTHEM,ANTHEM PPO,1.85,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0687 * Qty 1 = $0.88 at 210% = $1.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.17,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,CENPATICO,ALL MEDICAID CENPATICO,8.17,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.94,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,CIGNA,ALL COMMERCIAL CIGNA,5.72,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,COFINITY,COFINITY,8.17,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.76,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $7.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,6.86,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.80,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.96,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,3.97,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $3.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.94,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,HUMANA,HUMANA CHOICE CARE HMO,5.19,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0687 $8.17 in Billed Charges at 63.5% = $5.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,HUMANA,HUMANA CHOICE CARE PPO,6.94,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,HUMANA,HUMANA NATIIONAL POS HMO,5.19,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0687 $8.17 in Billed Charges at 63.5% = $5.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.96,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.17,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.09,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $4.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.86,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.13,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.52,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $7.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.58,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0687 * Qty 1 = $0.88 at 179% = $1.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.58,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0687 * Qty 1 = $0.88 at 179% = $1.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA360,1.58,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0687 * Qty 1 = $0.88 at 179% = $1.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.58,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0687 * Qty 1 = $0.88 at 179% = $1.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.21,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.88,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.45,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.45 from Fee Schedule UHC_31190C for Rev 636 Proc J0687 * Qty 1 = $1.45 at 100% = $1.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,UNITED HEALTHCARE,UHC ONEIDA NATION,1.45,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.45 from Fee Schedule UHC_31190C for Rev 636 Proc J0687 * Qty 1 = $1.45 at 100% = $1.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,UNITED HEALTHCARE,UNITED HEALTHCARE,1.45,,,,,,,1.4500,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.45 from Fee Schedule UHC_31190C for Rev 636 Proc J0687 * Qty 1 = $1.45 at 100% = $1.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.88,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.07,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.88,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.88,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0687,HCPCS,636,RC,44567-845-01,CDM,,,,both,500.000000,ME,8.1700,5.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.90,,,,,,,1.4500,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.17 in Billed Charges for Rev 636 Proc J0687 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,AETNA,AETNA HSHS,6.98,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $6.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,AETNA,ALL COMMERCIAL AETNA,10.80,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,ANTHEM,ANTHEM POS/HMO,1.50,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0688 * Qty 1 = $0.88 at 170% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,ANTHEM,ANTHEM PPO,1.85,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0688 * Qty 1 = $0.88 at 210% = $1.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.80,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,CENPATICO,ALL MEDICAID CENPATICO,10.80,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.18,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,CIGNA,ALL COMMERCIAL CIGNA,7.56,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $7.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,COFINITY,COFINITY,10.80,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.26,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $10.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,HEALTH CARE ALLIANCE,THE ALLIANCE,9.07,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $9.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.67,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $7.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.88,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,HSHS EMPLOYEES,HSHS EMPLOYEES,5.25,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.18,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,HUMANA,HUMANA CHOICE CARE HMO,1.80,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.80 from Fee Schedule 005543_170 for Rev 636 Proc J0688 * Qty 1 = $1.80 at 100% = $1.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,HUMANA,HUMANA CHOICE CARE PPO,9.18,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,HUMANA,HUMANA NATIIONAL POS HMO,1.80,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.80 from Fee Schedule 005543_170 for Rev 636 Proc J0688 * Qty 1 = $1.80 at 100% = $1.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.88,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.80,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.40,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $5.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.07,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $9.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.10,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $8.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.94,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $9.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.58,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0688 * Qty 1 = $0.88 at 179% = $1.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.58,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0688 * Qty 1 = $0.88 at 179% = $1.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,PREVEA HEALTH NETWORK,PREVEA360,1.58,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0688 * Qty 1 = $0.88 at 179% = $1.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.58,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.88 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0688 * Qty 1 = $0.88 at 179% = $1.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.89,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $6.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.78,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.45,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.45 from Fee Schedule UHC_31190C for Rev 636 Proc J0688 * Qty 1 = $1.45 at 100% = $1.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,UNITED HEALTHCARE,UHC ONEIDA NATION,1.45,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.45 from Fee Schedule UHC_31190C for Rev 636 Proc J0688 * Qty 1 = $1.45 at 100% = $1.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,UNITED HEALTHCARE,UNITED HEALTHCARE,1.45,,,,,,,1.4500,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.45 from Fee Schedule UHC_31190C for Rev 636 Proc J0688 * Qty 1 = $1.45 at 100% = $1.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.78,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.70,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $6.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.78,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.78,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFAZOLIN 3 G SOLR 1 EACH VIAL per 500 mg,J0688,HCPCS,636,RC,0143-9140-01,CDM,,,,both,500.000000,ME,10.8000,7.1300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.48,,,,,,,1.4500,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.80 in Billed Charges for Rev 636 Proc J0688 = $6.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,AETNA,AETNA HSHS,142.66,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $142.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,AETNA,AETNA MEDICARE,82.08,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,AETNA,ALL COMMERCIAL AETNA,220.84,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $220.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,ANTHEM,ANTEHM MEDICAID,220.84,,,,,,,82.0800,234.0900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9118 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $220.84, claim capped at $220.84 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,82.08,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,ANTHEM,ANTHEM POS/HMO,139.54,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $82.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9118 * Qty 1 = $82.08 at 170% = $139.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,ANTHEM,ANTHEM PPO,172.37,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $82.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9118 * Qty 1 = $82.08 at 210% = $172.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,220.84,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $220.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,CENPATICO,ALL MEDICAID CENPATICO,220.84,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $220.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,187.71,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $187.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,CIGNA,ALL COMMERCIAL CIGNA,154.59,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $154.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,COFINITY,COFINITY,220.84,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $220.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,220.84,,,,,,,82.0800,234.0900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9118 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $220.84, claim capped at $220.84 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,220.84,,,,,,,82.0800,234.0900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9118 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $220.84, claim capped at $220.84 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,209.80,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $209.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,185.51,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $185.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,156.80,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $156.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,161.21,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $161.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,107.33,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $107.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,187.71,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $187.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HUMANA,HUMANA CHOICE CARE HMO,129.86,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $129.86 from Fee Schedule 005543_170 for Rev 636 Proc J9118 * Qty 1 = $129.86 at 100% = $129.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HUMANA,HUMANA CHOICE CARE PPO,187.71,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $187.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HUMANA,HUMANA MEDICARE ADVANTAGE,82.08,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,HUMANA,HUMANA NATIIONAL POS HMO,129.86,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $129.86 from Fee Schedule 005543_170 for Rev 636 Proc J9118 * Qty 1 = $129.86 at 100% = $129.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,161.21,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $161.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,220.84,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $220.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,220.84,,,,,,,82.0800,234.0900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9118 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $220.84, claim capped at $220.84 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,82.08,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,220.84,,,,,,,82.0800,234.0900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9118 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $220.84, claim capped at $220.84 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,MOLINA HEALTHCARE,MOLINA MEDICAID,234.09,,,,,,,82.0800,234.0900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9118 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $220.84, claim capped at $220.84 in billed charges)... $220.84 at 106% = $234.09 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,MOLINA HEALTHCARE,MOLINA MEDICARE,82.08,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,110.42,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $110.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,185.51,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $185.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,NAPHCARE,ALL COMMERICAL NAPHCARE,184.67,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,165.63,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $165.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,203.17,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $203.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,146.92,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $82.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9118 * Qty 1 = $82.08 at 179% = $146.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,146.92,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $82.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9118 * Qty 1 = $82.08 at 179% = $146.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,PREVEA HEALTH NETWORK,PREVEA360,146.92,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $82.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9118 * Qty 1 = $82.08 at 179% = $146.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,146.92,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $82.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9118 * Qty 1 = $82.08 at 179% = $146.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,140.96,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $140.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,82.90,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,159.00,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,TRIOLOGY,TRILOGY MEDICAID,220.84,,,,,,,82.0800,234.0900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9118 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 106% = $3,433.75 (Service Line reduced to $220.84, claim capped at $220.84 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,135.43,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $135.43 from Fee Schedule UHC_31190C for Rev 636 Proc J9118 * Qty 1 = $135.43 at 100% = $135.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,UNITED HEALTHCARE,UHC ONEIDA NATION,135.43,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $135.43 from Fee Schedule UHC_31190C for Rev 636 Proc J9118 * Qty 1 = $135.43 at 100% = $135.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,82.08,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,UNITED HEALTHCARE,UNITED HEALTHCARE,135.43,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $135.43 from Fee Schedule UHC_31190C for Rev 636 Proc J9118 * Qty 1 = $135.43 at 100% = $135.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,UNITY HEALTH PLAN,UNITY HOSPICE,82.08,,,,,,,82.0800,234.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,159.00,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,136.92,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $136.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,159.00,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,159.00,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $159.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML SOLN 5 ML VIAL per 10 Units,J9118,HCPCS,636,RC,72694-515-01,CDM,,,,both,10.000000,UN,220.8400,145.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,132.50,,,,,,,82.0800,234.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $220.84 in Billed Charges for Rev 636 Proc J9118 = $132.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,AETNA,AETNA HSHS,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,AETNA,ALL COMMERCIAL AETNA,0.16,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,ANTHEM,ANTHEM POS/HMO,0.11,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.16 in Billed Charges at 68% = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,ANTHEM,ANTHEM PPO,0.11,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.16 in Billed Charges at 68% = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.16,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,CENPATICO,ALL MEDICAID CENPATICO,0.16,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.14,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,CIGNA,ALL COMMERCIAL CIGNA,0.11,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,COFINITY,COFINITY,0.16,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.15,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,0.13,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.11,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.12,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,0.08,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.14,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,HUMANA,HUMANA CHOICE CARE HMO,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.16 in Billed Charges at 63.5% = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,HUMANA,HUMANA CHOICE CARE PPO,0.14,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,HUMANA,HUMANA NATIIONAL POS HMO,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.16 in Billed Charges at 63.5% = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.12,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.16,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.08,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.13,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.12,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.15,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.16 in Billed Charges at 60% = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.16 in Billed Charges at 60% = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,PREVEA HEALTH NETWORK,PREVEA360,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.16 in Billed Charges at 60% = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0618 $0.16 in Billed Charges at 60% = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.12,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0618 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0618 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.1600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0618 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.12,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.12,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.12,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CHLORIDE 10 % SOLN per 2 mg,J0618,HCPCS,636,RC,76329-3304-1,CDM,,,,both,2.000000,ME,0.1600,0.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.10,,,,,,,0.0500,0.1600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.16 in Billed Charges for Rev 636 Proc J0618 = $0.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,AETNA,AETNA HSHS,15.83,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,AETNA,ALL COMMERCIAL AETNA,24.50,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM POS/HMO,1.48,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 170% = $1.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM PPO,1.83,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 210% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.50,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,CENPATICO,ALL MEDICAID CENPATICO,24.50,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.83,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,CIGNA,ALL COMMERCIAL CIGNA,17.15,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,COFINITY,COFINITY,24.50,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.28,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $23.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,20.58,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.40,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.89,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,11.91,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $11.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.83,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE HMO,2.18,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.18 from Fee Schedule 005543_170 for Rev 636 Proc J0692 * Qty 1 = $2.18 at 100% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE PPO,20.83,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,HUMANA,HUMANA NATIIONAL POS HMO,2.18,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.18 from Fee Schedule 005543_170 for Rev 636 Proc J0692 * Qty 1 = $2.18 at 100% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.89,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.50,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.25,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.58,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.38,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $18.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.54,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $22.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.56,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.56,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360,1.56,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.56,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.64,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.64,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.44,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,1.44,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,1.44,,,,,,,1.4400,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.64,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.19,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $15.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.64,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.64,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 1 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-240-10,CDM,,,,both,500.000000,ME,24.5000,16.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.70,,,,,,,1.4400,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.50 in Billed Charges for Rev 636 Proc J0692 = $14.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,AETNA,AETNA HSHS,11.69,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,AETNA,ALL COMMERCIAL AETNA,18.09,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $18.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,ANTHEM,ANTHEM POS/HMO,1.48,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 170% = $1.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,ANTHEM,ANTHEM PPO,1.83,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 210% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,18.09,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $18.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,CENPATICO,ALL MEDICAID CENPATICO,18.09,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $18.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15.38,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $15.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,CIGNA,ALL COMMERCIAL CIGNA,12.66,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $12.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,COFINITY,COFINITY,18.09,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $18.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17.19,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $17.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,15.20,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $15.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12.84,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $12.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13.21,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $13.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,8.79,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15.38,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $15.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,HUMANA,HUMANA CHOICE CARE HMO,2.18,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $2.18 from Fee Schedule 005543_170 for Rev 636 Proc J0692 * Qty 1 = $2.18 at 100% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,HUMANA,HUMANA CHOICE CARE PPO,15.38,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $15.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,HUMANA,HUMANA NATIIONAL POS HMO,2.18,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $2.18 from Fee Schedule 005543_170 for Rev 636 Proc J0692 * Qty 1 = $2.18 at 100% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13.21,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $13.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,18.09,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $18.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.05,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $9.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15.20,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $15.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13.57,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $13.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,16.64,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $16.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.56,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.56,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,PREVEA HEALTH NETWORK,PREVEA360,1.56,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.56,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0692 * Qty 1 = $0.87 at 179% = $1.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.55,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $11.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.02,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $13.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.44,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,1.44,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,1.44,,,,,,,1.4400,18.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.44 from Fee Schedule UHC_31190C for Rev 636 Proc J0692 * Qty 1 = $1.44 at 100% = $1.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.02,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $13.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.22,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $11.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.02,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $13.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.02,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $13.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFEPIME 2 G SOLR 1 EACH VIAL per 500 mg,J0692,HCPCS,636,RC,44567-241-10,CDM,,,,both,500.000000,ME,18.0900,11.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.85,,,,,,,1.4400,18.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.09 in Billed Charges for Rev 636 Proc J0692 = $10.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,AETNA,AETNA HSHS,11.92,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,AETNA,AETNA MEDICARE,4.24,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,AETNA,ALL COMMERCIAL AETNA,18.45,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $18.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,ANTHEM,ANTEHM MEDICAID,18.45,,,,,,,4.2400,19.5600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0712 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $18.45, claim capped at $18.45 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,4.24,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,ANTHEM,ANTHEM POS/HMO,7.21,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.24 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0712 * Qty 1 = $4.24 at 170% = $7.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,ANTHEM,ANTHEM PPO,8.90,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.24 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0712 * Qty 1 = $4.24 at 210% = $8.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,18.45,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $18.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,CENPATICO,ALL MEDICAID CENPATICO,18.45,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $18.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15.68,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $15.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,CIGNA,ALL COMMERCIAL CIGNA,12.92,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $12.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,COFINITY,COFINITY,18.45,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $18.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,18.45,,,,,,,4.2400,19.5600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0712 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $18.45, claim capped at $18.45 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,18.45,,,,,,,4.2400,19.5600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0712 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $18.45, claim capped at $18.45 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17.53,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $17.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,15.50,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.10,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $13.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13.47,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $13.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,8.97,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $8.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15.68,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $15.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HUMANA,HUMANA CHOICE CARE HMO,6.85,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $6.85 from Fee Schedule 005543_170 for Rev 636 Proc J0712 * Qty 1 = $6.85 at 100% = $6.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HUMANA,HUMANA CHOICE CARE PPO,15.68,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $15.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HUMANA,HUMANA MEDICARE ADVANTAGE,4.24,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,HUMANA,HUMANA NATIIONAL POS HMO,6.85,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $6.85 from Fee Schedule 005543_170 for Rev 636 Proc J0712 * Qty 1 = $6.85 at 100% = $6.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13.47,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $13.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,18.45,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $18.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,18.45,,,,,,,4.2400,19.5600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0712 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $18.45, claim capped at $18.45 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,4.24,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,18.45,,,,,,,4.2400,19.5600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0712 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $18.45, claim capped at $18.45 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,MOLINA HEALTHCARE,MOLINA MEDICAID,19.56,,,,,,,4.2400,19.5600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0712 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10 (Service Line reduced to $18.45, claim capped at $18.45 in billed charges)... $18.45 at 106% = $19.56 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,MOLINA HEALTHCARE,MOLINA MEDICARE,4.24,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.23,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $9.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15.50,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $15.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,NAPHCARE,ALL COMMERICAL NAPHCARE,9.54,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13.84,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $13.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,16.97,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $16.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.59,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.24 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0712 * Qty 1 = $4.24 at 179% = $7.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.59,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.24 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0712 * Qty 1 = $4.24 at 179% = $7.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,PREVEA HEALTH NETWORK,PREVEA360,7.59,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.24 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0712 * Qty 1 = $4.24 at 179% = $7.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.59,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $4.24 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0712 * Qty 1 = $4.24 at 179% = $7.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.78,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $11.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,4.28,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.28,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,TRIOLOGY,TRILOGY MEDICAID,18.45,,,,,,,4.2400,19.5600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0712 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 106% = $56.29 (Service Line reduced to $18.45, claim capped at $18.45 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.00,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.00 from Fee Schedule UHC_31190C for Rev 636 Proc J0712 * Qty 1 = $7.00 at 100% = $7.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,7.00,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.00 from Fee Schedule UHC_31190C for Rev 636 Proc J0712 * Qty 1 = $7.00 at 100% = $7.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,4.24,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,7.00,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.00 from Fee Schedule UHC_31190C for Rev 636 Proc J0712 * Qty 1 = $7.00 at 100% = $7.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,UNITY HEALTH PLAN,UNITY HOSPICE,4.24,,,,,,,4.2400,19.5600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.28,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.44,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $11.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.28,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.28,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAROLINE 600 MG SOLR 1 EACH VIAL per 10 mg,J0712,HCPCS,636,RC,0456-0600-01,CDM,,,,both,10.000000,ME,18.4500,12.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.07,,,,,,,4.2400,19.5600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.45 in Billed Charges for Rev 636 Proc J0712 = $11.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,AETNA,AETNA HSHS,317.97,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $317.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,AETNA,AETNA MEDICARE,104.71,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,AETNA,ALL COMMERCIAL AETNA,492.21,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $492.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,ANTHEM,ANTEHM MEDICAID,86.29,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc J0714 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,104.71,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,ANTHEM,ANTHEM POS/HMO,178.01,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $104.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0714 * Qty 1 = $104.71 at 170% = $178.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,ANTHEM,ANTHEM PPO,219.89,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $104.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0714 * Qty 1 = $104.71 at 210% = $219.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,492.21,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $492.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,CENPATICO,ALL MEDICAID CENPATICO,492.21,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $492.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,418.38,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $418.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,CIGNA,ALL COMMERCIAL CIGNA,344.55,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $344.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,COFINITY,COFINITY,492.21,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $492.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,86.29,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc J0714 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,86.29,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc J0714 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,467.60,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $467.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,413.46,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $413.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,349.47,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $349.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,359.31,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $359.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,239.21,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $239.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,418.38,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $418.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HUMANA,HUMANA CHOICE CARE HMO,170.34,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $170.34 from Fee Schedule 005543_170 for Rev 636 Proc J0714 * Qty 1 = $170.34 at 100% = $170.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HUMANA,HUMANA CHOICE CARE PPO,418.38,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $418.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HUMANA,HUMANA MEDICARE ADVANTAGE,104.71,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,HUMANA,HUMANA NATIIONAL POS HMO,170.34,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $170.34 from Fee Schedule 005543_170 for Rev 636 Proc J0714 * Qty 1 = $170.34 at 100% = $170.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,359.31,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $359.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,492.21,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $492.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,86.29,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc J0714 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,104.71,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,86.29,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc J0714 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,MOLINA HEALTHCARE,MOLINA MEDICAID,91.47,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc J0714 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29... $86.29 at 106% = $91.47 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,MOLINA HEALTHCARE,MOLINA MEDICARE,104.71,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,246.11,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $246.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,413.46,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $413.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,NAPHCARE,ALL COMMERICAL NAPHCARE,235.60,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,369.16,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $369.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,452.83,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $452.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,187.43,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $104.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0714 * Qty 1 = $104.71 at 179% = $187.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,187.43,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $104.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0714 * Qty 1 = $104.71 at 179% = $187.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,PREVEA HEALTH NETWORK,PREVEA360,187.43,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $104.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0714 * Qty 1 = $104.71 at 179% = $187.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,187.43,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $104.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0714 * Qty 1 = $104.71 at 179% = $187.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,314.18,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $314.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,105.76,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,354.39,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $354.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,TRIOLOGY,TRILOGY MEDICAID,91.46,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc J0714 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 106% = $91.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,172.77,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $172.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0714 * Qty 1 = $172.77 at 100% = $172.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,172.77,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $172.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0714 * Qty 1 = $172.77 at 100% = $172.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,104.71,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,172.77,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). $172.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0714 * Qty 1 = $172.77 at 100% = $172.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,UNITY HEALTH PLAN,UNITY HOSPICE,104.71,,,,,,,86.2900,492.2100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,354.39,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $354.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,305.17,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $305.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,354.39,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $354.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,354.39,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $354.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL per 0.625 g,J0714,HCPCS,636,RC,0456-2700-01,CDM,,,,both,0.625000,GM,492.2100,324.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,295.33,,,,,,,86.2900,492.2100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $492.21 in Billed Charges for Rev 636 Proc J0714 = $295.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,AETNA,AETNA HSHS,45.64,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $45.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,AETNA,ALL COMMERCIAL AETNA,70.65,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $70.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,ANTHEM,ANTHEM POS/HMO,0.78,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 170% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,ANTHEM,ANTHEM PPO,0.97,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 210% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,70.65,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $70.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,CENPATICO,ALL MEDICAID CENPATICO,70.65,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $70.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,60.05,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $60.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,CIGNA,ALL COMMERCIAL CIGNA,49.46,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $49.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,COFINITY,COFINITY,70.65,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $70.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,67.12,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $67.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,HEALTH CARE ALLIANCE,THE ALLIANCE,59.35,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $59.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,50.16,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $50.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,51.57,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $51.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,HSHS EMPLOYEES,HSHS EMPLOYEES,34.34,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $34.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,60.05,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $60.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,HUMANA,HUMANA CHOICE CARE HMO,0.78,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,HUMANA,HUMANA CHOICE CARE PPO,60.05,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $60.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,HUMANA,HUMANA NATIIONAL POS HMO,0.78,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,51.57,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $51.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,LIVE360,LIVE360 HSHS HEALTHY PLAN,70.65,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $70.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35.33,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $35.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,59.35,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $59.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,52.99,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $52.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,65.00,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $65.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.82,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.82,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,PREVEA HEALTH NETWORK,PREVEA360,0.82,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.82,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,45.10,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $45.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,50.87,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $50.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.76,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.76,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.76,,,,,,,0.7600,70.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,50.87,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $50.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,43.80,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $43.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,50.87,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $50.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,50.87,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $50.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 1 G/10 ML SOLR 1 EACH VIAL per 250 mg,J0696,HCPCS,636,RC,60505-6148-0,CDM,,,,both,250.000000,ME,70.6500,46.6300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42.39,,,,,,,0.7600,70.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.65 in Billed Charges for Rev 636 Proc J0696 = $42.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,AETNA,AETNA HSHS,45.35,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $45.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,AETNA,ALL COMMERCIAL AETNA,70.20,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,ANTHEM,ANTHEM POS/HMO,0.78,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 170% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,ANTHEM,ANTHEM PPO,0.97,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 210% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,70.20,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,CENPATICO,ALL MEDICAID CENPATICO,70.20,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,59.67,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $59.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,CIGNA,ALL COMMERCIAL CIGNA,49.14,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $49.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,COFINITY,COFINITY,70.20,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,66.69,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $66.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,58.97,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $58.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,49.84,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $49.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,51.25,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $51.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,34.12,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $34.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,59.67,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $59.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,HUMANA,HUMANA CHOICE CARE HMO,0.78,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,HUMANA,HUMANA CHOICE CARE PPO,59.67,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $59.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,HUMANA,HUMANA NATIIONAL POS HMO,0.78,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.78 from Fee Schedule 005543_170 for Rev 636 Proc J0696 * Qty 1 = $0.78 at 100% = $0.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,51.25,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $51.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,70.20,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $70.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35.10,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $35.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,58.97,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $58.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,52.65,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $52.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,64.58,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $64.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.82,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.82,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,PREVEA HEALTH NETWORK,PREVEA360,0.82,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.82,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.46 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0696 * Qty 1 = $0.46 at 179% = $0.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44.81,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $44.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,50.54,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.76,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.76,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.76,,,,,,,0.7600,70.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.76 from Fee Schedule UHC_31190C for Rev 636 Proc J0696 * Qty 1 = $0.76 at 100% = $0.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,50.54,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,43.52,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $43.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,50.54,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,50.54,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFTRIAXONE 40 MG/ML SOLN per 250 mg,J0696,HCPCS,636,RC,60505-6149-0,CDM,,,,both,250.000000,ME,70.2000,46.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42.12,,,,,,,0.7600,70.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.20 in Billed Charges for Rev 636 Proc J0696 = $42.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,AETNA,AETNA HSHS,15.83,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,AETNA,ALL COMMERCIAL AETNA,24.50,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM POS/HMO,3.49,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0697 * Qty 1 = $2.05 at 170% = $3.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM PPO,4.31,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0697 * Qty 1 = $2.05 at 210% = $4.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.50,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,CENPATICO,ALL MEDICAID CENPATICO,24.50,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.83,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,CIGNA,ALL COMMERCIAL CIGNA,17.15,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,COFINITY,COFINITY,24.50,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.28,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $23.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,20.58,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.40,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.89,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,11.91,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $11.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.83,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE HMO,3.18,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.18 from Fee Schedule 005543_170 for Rev 636 Proc J0697 * Qty 1 = $3.18 at 100% = $3.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE PPO,20.83,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,HUMANA,HUMANA NATIIONAL POS HMO,3.18,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.18 from Fee Schedule 005543_170 for Rev 636 Proc J0697 * Qty 1 = $3.18 at 100% = $3.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.89,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.50,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.25,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.58,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.38,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $18.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.54,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $22.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.67,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0697 * Qty 1 = $2.05 at 179% = $3.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.67,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0697 * Qty 1 = $2.05 at 179% = $3.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360,3.67,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0697 * Qty 1 = $2.05 at 179% = $3.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.67,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.05 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0697 * Qty 1 = $2.05 at 179% = $3.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.64,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.64,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.38,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.38 from Fee Schedule UHC_31190C for Rev 636 Proc J0697 * Qty 1 = $3.38 at 100% = $3.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,3.38,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.38 from Fee Schedule UHC_31190C for Rev 636 Proc J0697 * Qty 1 = $3.38 at 100% = $3.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,3.38,,,,,,,3.1800,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.38 from Fee Schedule UHC_31190C for Rev 636 Proc J0697 * Qty 1 = $3.38 at 100% = $3.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.64,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.19,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $15.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.64,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.64,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
STERILE CEFUROXIME INJECTION,J0697,HCPCS,636,RC,0143-9977-90,CDM,,,,both,750.000000,ME,24.5000,16.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.70,,,,,,,3.1800,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.50 in Billed Charges for Rev 636 Proc J0697 = $14.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,AETNA,AETNA HSHS,39.49,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $39.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,AETNA,ALL COMMERCIAL AETNA,61.13,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $61.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,ANTHEM,ANTHEM POS/HMO,3.25,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 170% = $3.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,ANTHEM,ANTHEM PPO,4.01,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 210% = $4.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,61.13,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $61.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,CENPATICO,ALL MEDICAID CENPATICO,61.13,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $61.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,51.96,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $51.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,CIGNA,ALL COMMERCIAL CIGNA,42.79,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $42.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,COFINITY,COFINITY,61.13,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $61.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,58.07,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $58.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,51.35,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $51.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,43.40,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $43.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,44.62,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $44.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,29.71,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $29.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,51.96,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $51.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,HUMANA,HUMANA CHOICE CARE HMO,4.06,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.06 from Fee Schedule 005543_170 for Rev 636 Proc J0736 * Qty 1 = $4.06 at 100% = $4.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,HUMANA,HUMANA CHOICE CARE PPO,51.96,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $51.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,HUMANA,HUMANA NATIIONAL POS HMO,4.06,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.06 from Fee Schedule 005543_170 for Rev 636 Proc J0736 * Qty 1 = $4.06 at 100% = $4.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,44.62,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $44.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,61.13,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $61.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,30.57,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $30.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,51.35,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $51.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,45.85,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $45.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,56.24,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $56.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.42,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.42,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,PREVEA HEALTH NETWORK,PREVEA360,3.42,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.42,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,39.02,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $39.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,44.01,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $44.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.15,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,UNITED HEALTHCARE,UHC ONEIDA NATION,3.15,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,UNITED HEALTHCARE,UNITED HEALTHCARE,3.15,,,,,,,3.1500,61.1300,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,44.01,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $44.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,37.90,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $37.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,44.01,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $44.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,44.01,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $44.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 600 MG/50ML SOLN per 300 mg,J0736,HCPCS,636,RC,0781-3289-91,CDM,,,,both,300.000000,ME,61.1300,40.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,36.68,,,,,,,3.1500,61.1300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $61.13 in Billed Charges for Rev 636 Proc J0736 = $36.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,AETNA,AETNA HSHS,4.22,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,AETNA,ALL COMMERCIAL AETNA,6.54,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,ANTHEM,ANTHEM POS/HMO,1.43,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 170% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,ANTHEM,ANTHEM PPO,1.76,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 210% = $1.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6.54,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,CENPATICO,ALL MEDICAID CENPATICO,6.54,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.56,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $5.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,CIGNA,ALL COMMERCIAL CIGNA,4.58,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,COFINITY,COFINITY,6.54,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6.21,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $6.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,5.49,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $5.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.64,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.77,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,3.18,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $3.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.56,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $5.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,HUMANA,HUMANA CHOICE CARE HMO,1.29,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $1.29 from Fee Schedule 005543_170 for Rev 636 Proc J9100 * Qty 1 = $1.29 at 100% = $1.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,HUMANA,HUMANA CHOICE CARE PPO,5.56,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $5.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,HUMANA,HUMANA NATIIONAL POS HMO,1.29,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $1.29 from Fee Schedule 005543_170 for Rev 636 Proc J9100 * Qty 1 = $1.29 at 100% = $1.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.77,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,6.54,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.27,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $3.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.49,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $5.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.91,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6.02,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $6.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.50,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.50,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,PREVEA HEALTH NETWORK,PREVEA360,1.50,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.50,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.17,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.71,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.39,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,1.39,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,1.39,,,,,,,1.2900,6.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.71,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.05,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.71,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.71,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,61703-319-22,CDM,,,,both,100.000000,ME,6.5400,4.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.92,,,,,,,1.2900,6.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $6.54 in Billed Charges for Rev 636 Proc J9100 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,AETNA,AETNA HSHS,3.99,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,AETNA,ALL COMMERCIAL AETNA,6.17,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,ANTHEM,ANTHEM POS/HMO,1.43,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 170% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,ANTHEM,ANTHEM PPO,1.76,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 210% = $1.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6.17,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,CENPATICO,ALL MEDICAID CENPATICO,6.17,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.24,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,CIGNA,ALL COMMERCIAL CIGNA,4.32,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,COFINITY,COFINITY,6.17,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.86,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $5.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,5.18,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.38,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.50,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,3.00,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $3.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.24,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,HUMANA,HUMANA CHOICE CARE HMO,1.29,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.29 from Fee Schedule 005543_170 for Rev 636 Proc J9100 * Qty 1 = $1.29 at 100% = $1.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,HUMANA,HUMANA CHOICE CARE PPO,5.24,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,HUMANA,HUMANA NATIIONAL POS HMO,1.29,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.29 from Fee Schedule 005543_170 for Rev 636 Proc J9100 * Qty 1 = $1.29 at 100% = $1.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.50,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,6.17,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.09,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $3.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.18,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.63,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.68,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.50,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.50,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,PREVEA HEALTH NETWORK,PREVEA360,1.50,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.50,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.94,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $3.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.44,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.39,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,UNITED HEALTHCARE,UHC ONEIDA NATION,1.39,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,UNITED HEALTHCARE,UNITED HEALTHCARE,1.39,,,,,,,1.2900,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.44,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.83,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $3.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.44,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.44,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE (PF) 100 MG/ML SOLN 20 ML VIAL per 100 mg,J9100,HCPCS,636,RC,63323-120-20,CDM,,,,both,100.000000,ME,6.1700,4.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.70,,,,,,,1.2900,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $6.17 in Billed Charges for Rev 636 Proc J9100 = $3.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,AETNA,AETNA HSHS,60.11,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $60.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,AETNA,ALL COMMERCIAL AETNA,93.05,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $93.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,ANTHEM,ANTHEM POS/HMO,1.43,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 170% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,ANTHEM,ANTHEM PPO,1.76,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 210% = $1.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,93.05,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $93.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,CENPATICO,ALL MEDICAID CENPATICO,93.05,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $93.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.09,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $79.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,CIGNA,ALL COMMERCIAL CIGNA,65.14,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $65.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,COFINITY,COFINITY,93.05,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $93.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,88.40,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,78.16,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $78.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.07,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $66.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,67.93,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $67.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,45.22,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $45.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.09,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $79.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,HUMANA,HUMANA CHOICE CARE HMO,1.29,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.29 from Fee Schedule 005543_170 for Rev 636 Proc J9100 * Qty 1 = $1.29 at 100% = $1.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,HUMANA,HUMANA CHOICE CARE PPO,79.09,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $79.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,HUMANA,HUMANA NATIIONAL POS HMO,1.29,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.29 from Fee Schedule 005543_170 for Rev 636 Proc J9100 * Qty 1 = $1.29 at 100% = $1.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,67.93,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $67.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,93.05,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $93.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.53,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $46.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.16,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $78.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,69.79,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $69.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,85.61,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $85.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.50,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.50,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,PREVEA HEALTH NETWORK,PREVEA360,1.50,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.50,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9100 * Qty 1 = $0.84 at 179% = $1.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,59.39,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $59.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,67.00,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.39,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,UNITED HEALTHCARE,UHC ONEIDA NATION,1.39,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,UNITED HEALTHCARE,UNITED HEALTHCARE,1.39,,,,,,,1.2900,93.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.39 from Fee Schedule UHC_31190C for Rev 636 Proc J9100 * Qty 1 = $1.39 at 100% = $1.39 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,67.00,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,57.69,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $57.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,67.00,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,67.00,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $67.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYTARABINE HCL 100 MG INJ,J9100,HCPCS,636,RC,61703-305-38,CDM,,,,both,100.000000,ME,93.0500,61.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.83,,,,,,,1.2900,93.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.05 in Billed Charges for Rev 636 Proc J9100 = $55.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,AETNA,AETNA HSHS,342.90,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $342.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,AETNA,ALL COMMERCIAL AETNA,530.80,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $530.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,ANTHEM,ANTHEM POS/HMO,35.11,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0834 * Qty 1 = $20.65 at 170% = $35.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,ANTHEM,ANTHEM PPO,43.37,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0834 * Qty 1 = $20.65 at 210% = $43.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,530.80,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $530.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,CENPATICO,ALL MEDICAID CENPATICO,530.80,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $530.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,451.18,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $451.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,CIGNA,ALL COMMERCIAL CIGNA,371.56,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $371.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,COFINITY,COFINITY,530.80,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $530.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,504.26,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $504.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,445.87,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $445.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,376.87,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $376.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,387.48,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $387.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,257.97,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $257.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,451.18,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $451.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,HUMANA,HUMANA CHOICE CARE HMO,36.94,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.94 from Fee Schedule 005543_170 for Rev 636 Proc J0834 * Qty 1 = $36.94 at 100% = $36.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,HUMANA,HUMANA CHOICE CARE PPO,451.18,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $451.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,HUMANA,HUMANA NATIIONAL POS HMO,36.94,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $36.94 from Fee Schedule 005543_170 for Rev 636 Proc J0834 * Qty 1 = $36.94 at 100% = $36.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,387.48,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $387.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,530.80,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $530.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,265.40,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $265.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,445.87,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $445.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,398.10,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $398.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,488.34,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $488.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,36.96,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0834 * Qty 1 = $20.65 at 179% = $36.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,36.96,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0834 * Qty 1 = $20.65 at 179% = $36.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,PREVEA HEALTH NETWORK,PREVEA360,36.96,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0834 * Qty 1 = $20.65 at 179% = $36.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,36.96,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $20.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0834 * Qty 1 = $20.65 at 179% = $36.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,338.81,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $338.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,382.18,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $382.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,34.07,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0834 * Qty 1 = $34.07 at 100% = $34.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,34.07,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0834 * Qty 1 = $34.07 at 100% = $34.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,34.07,,,,,,,34.0700,530.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0834 * Qty 1 = $34.07 at 100% = $34.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,382.18,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $382.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,329.10,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $329.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,382.18,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $382.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,382.18,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $382.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COSYNTROPIN 0.25 MG SOLR per 0.25 mg,J0834,HCPCS,636,RC,0548-5900-00,CDM,,,,both,0.250000,ME,530.8000,350.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,318.48,,,,,,,34.0700,530.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $530.80 in Billed Charges for Rev 636 Proc J0834 = $318.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,AETNA,AETNA HSHS,2.18,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,AETNA,ALL COMMERCIAL AETNA,3.37,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3.37,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,CENPATICO,ALL MEDICAID CENPATICO,3.37,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2.86,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,CIGNA,ALL COMMERCIAL CIGNA,2.36,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,COFINITY,COFINITY,3.37,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3.20,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $3.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,2.83,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2.39,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2.46,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,1.64,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $1.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2.86,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,HUMANA,HUMANA CHOICE CARE HMO,0.03,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,HUMANA,HUMANA CHOICE CARE PPO,2.86,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,HUMANA,HUMANA NATIIONAL POS HMO,0.03,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2.46,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,3.37,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $3.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.69,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $1.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2.83,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2.53,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3.10,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $3.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2.15,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2.43,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0300,3.3700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2.43,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2.09,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2.43,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2.43,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,60505-6229-4,CDM,,,,both,1.000000,ME,3.3700,2.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.02,,,,,,,0.0300,3.3700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $3.37 in Billed Charges for Rev 636 Proc J0878 = $2.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,AETNA,AETNA HSHS,0.81,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,AETNA,ALL COMMERCIAL AETNA,1.25,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1.25,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,CENPATICO,ALL MEDICAID CENPATICO,1.25,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1.06,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,CIGNA,ALL COMMERCIAL CIGNA,0.88,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,COFINITY,COFINITY,1.25,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1.19,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,1.05,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.89,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.91,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,0.61,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1.06,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,HUMANA,HUMANA CHOICE CARE HMO,0.03,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,HUMANA,HUMANA CHOICE CARE PPO,1.06,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,HUMANA,HUMANA NATIIONAL POS HMO,0.03,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule 005543_170 for Rev 636 Proc J0878 * Qty 1 = $0.03 at 100% = $0.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.91,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,1.25,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.63,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1.05,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.94,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1.15,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $1.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0878 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.80,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.90,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0300,1.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J0878 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.90,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.78,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.90,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.90,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DAPTOMYCIN INJECTION,J0878,HCPCS,636,RC,67457-813-50,CDM,,,,both,1.000000,ME,1.2500,0.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.75,,,,,,,0.0300,1.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $1.25 in Billed Charges for Rev 636 Proc J0878 = $0.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,AETNA,AETNA HSHS,108.35,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $108.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,AETNA,AETNA MEDICARE,55.06,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,AETNA,ALL COMMERCIAL AETNA,167.73,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $167.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,ANTHEM,ANTEHM MEDICAID,167.73,,,,,,,55.0600,177.7900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9144 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $167.73, claim capped at $167.73 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,55.06,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,ANTHEM,ANTHEM POS/HMO,93.60,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $55.06 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9144 * Qty 1 = $55.06 at 170% = $93.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,ANTHEM,ANTHEM PPO,115.63,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $55.06 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9144 * Qty 1 = $55.06 at 210% = $115.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,167.73,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $167.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,CENPATICO,ALL MEDICAID CENPATICO,167.73,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $167.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,142.57,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $142.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,CIGNA,ALL COMMERCIAL CIGNA,117.41,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $117.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,COFINITY,COFINITY,167.73,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $167.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,167.73,,,,,,,55.0600,177.7900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9144 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $167.73, claim capped at $167.73 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,167.73,,,,,,,55.0600,177.7900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9144 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $167.73, claim capped at $167.73 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,159.34,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $159.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,140.89,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $140.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,119.09,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $119.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,122.44,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $122.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,81.52,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $81.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,142.57,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $142.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HUMANA,HUMANA CHOICE CARE HMO,86.70,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $86.70 from Fee Schedule 005543_170 for Rev 636 Proc J9144 * Qty 1 = $86.70 at 100% = $86.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HUMANA,HUMANA CHOICE CARE PPO,142.57,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $142.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HUMANA,HUMANA MEDICARE ADVANTAGE,55.06,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,HUMANA,HUMANA NATIIONAL POS HMO,86.70,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $86.70 from Fee Schedule 005543_170 for Rev 636 Proc J9144 * Qty 1 = $86.70 at 100% = $86.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,122.44,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $122.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,167.73,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $167.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,167.73,,,,,,,55.0600,177.7900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9144 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $167.73, claim capped at $167.73 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,55.06,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,167.73,,,,,,,55.0600,177.7900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9144 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $167.73, claim capped at $167.73 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,MOLINA HEALTHCARE,MOLINA MEDICAID,177.79,,,,,,,55.0600,177.7900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9144 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $167.73, claim capped at $167.73 in billed charges)... $167.73 at 106% = $177.79 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,MOLINA HEALTHCARE,MOLINA MEDICARE,55.06,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,83.87,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $83.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,140.89,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $140.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,NAPHCARE,ALL COMMERICAL NAPHCARE,123.88,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,125.80,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $125.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,154.31,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $154.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,98.56,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $55.06 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9144 * Qty 1 = $55.06 at 179% = $98.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,98.56,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $55.06 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9144 * Qty 1 = $55.06 at 179% = $98.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,PREVEA HEALTH NETWORK,PREVEA360,98.56,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $55.06 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9144 * Qty 1 = $55.06 at 179% = $98.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,98.56,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $55.06 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9144 * Qty 1 = $55.06 at 179% = $98.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,107.06,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $107.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,55.61,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,120.77,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $120.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,TRIOLOGY,TRILOGY MEDICAID,167.73,,,,,,,55.0600,177.7900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9144 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 106% = $1,730.10 (Service Line reduced to $167.73, claim capped at $167.73 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,90.85,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $90.85 from Fee Schedule UHC_31190C for Rev 636 Proc J9144 * Qty 1 = $90.85 at 100% = $90.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,90.85,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $90.85 from Fee Schedule UHC_31190C for Rev 636 Proc J9144 * Qty 1 = $90.85 at 100% = $90.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,55.06,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,90.85,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). $90.85 from Fee Schedule UHC_31190C for Rev 636 Proc J9144 * Qty 1 = $90.85 at 100% = $90.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,UNITY HEALTH PLAN,UNITY HOSPICE,55.06,,,,,,,55.0600,177.7900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,120.77,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $120.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,103.99,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $103.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,120.77,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $120.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,120.77,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $120.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 1800 MG-HYALURONIDASE 30000 UNITS-FIHJ 1800-30000 MG-UT/15ML SOLN per 10 mg,J9144,HCPCS,636,RC,57894-503-01,CDM,,,,both,10.000000,ME,167.7300,110.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,100.64,,,,,,,55.0600,177.7900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $167.73 in Billed Charges for Rev 636 Proc J9144 = $100.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,AETNA,AETNA HSHS,219.80,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $219.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,AETNA,AETNA MEDICARE,70.79,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,AETNA,ALL COMMERCIAL AETNA,340.24,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $340.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,ANTHEM,ANTEHM MEDICAID,340.24,,,,,,,70.7900,360.6500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $340.24, claim capped at $340.24 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,70.79,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,ANTHEM,ANTHEM POS/HMO,120.34,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 170% = $120.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,ANTHEM,ANTHEM PPO,148.66,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 210% = $148.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,340.24,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $340.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,CENPATICO,ALL MEDICAID CENPATICO,340.24,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $340.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,289.20,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $289.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,CIGNA,ALL COMMERCIAL CIGNA,238.17,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $238.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,COFINITY,COFINITY,340.24,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $340.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,340.24,,,,,,,70.7900,360.6500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $340.24, claim capped at $340.24 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,340.24,,,,,,,70.7900,360.6500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $340.24, claim capped at $340.24 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,323.23,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $323.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,285.80,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $285.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,241.57,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $241.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,248.38,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $248.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,165.36,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $165.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,289.20,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $289.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HUMANA,HUMANA CHOICE CARE HMO,109.45,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $109.45 from Fee Schedule 005543_170 for Rev 636 Proc J9145 * Qty 1 = $109.45 at 100% = $109.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HUMANA,HUMANA CHOICE CARE PPO,289.20,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $289.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HUMANA,HUMANA MEDICARE ADVANTAGE,70.79,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,HUMANA,HUMANA NATIIONAL POS HMO,109.45,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $109.45 from Fee Schedule 005543_170 for Rev 636 Proc J9145 * Qty 1 = $109.45 at 100% = $109.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,248.38,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $248.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,340.24,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $340.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,340.24,,,,,,,70.7900,360.6500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $340.24, claim capped at $340.24 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,70.79,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,340.24,,,,,,,70.7900,360.6500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $340.24, claim capped at $340.24 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,MOLINA HEALTHCARE,MOLINA MEDICAID,360.65,,,,,,,70.7900,360.6500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 100% = $1,632.17 (Service Line reduced to $340.24, claim capped at $340.24 in billed charges)... $340.24 at 106% = $360.65 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,MOLINA HEALTHCARE,MOLINA MEDICARE,70.79,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,170.12,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $170.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,285.80,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $285.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,NAPHCARE,ALL COMMERICAL NAPHCARE,159.27,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,255.18,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $255.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,313.02,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $313.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,126.71,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 179% = $126.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,126.71,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 179% = $126.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,PREVEA HEALTH NETWORK,PREVEA360,126.71,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 179% = $126.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,126.71,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $70.79 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9145 * Qty 1 = $70.79 at 179% = $126.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,217.18,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $217.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,71.50,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,244.97,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $244.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,TRIOLOGY,TRILOGY MEDICAID,340.24,,,,,,,70.7900,360.6500,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00462 Proc J9145 at $125.60 (Base Rate) * 12.995 (Relative Weight) = $1,632.17 (Total Line Payment) at 106% = $1,730.10 (Service Line reduced to $340.24, claim capped at $340.24 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,116.80,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $116.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9145 * Qty 1 = $116.80 at 100% = $116.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,116.80,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $116.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9145 * Qty 1 = $116.80 at 100% = $116.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,70.79,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,116.80,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). $116.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9145 * Qty 1 = $116.80 at 100% = $116.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,UNITY HEALTH PLAN,UNITY HOSPICE,70.79,,,,,,,70.7900,360.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,244.97,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $244.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,210.95,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $210.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,244.97,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $244.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,244.97,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $244.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARATUMUMAB 400 MG/20ML SOLN per 10 mg,J9145,HCPCS,636,RC,57894-502-20,CDM,,,,both,10.000000,ME,340.2400,224.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,204.14,,,,,,,70.7900,360.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $340.24 in Billed Charges for Rev 636 Proc J9145 = $204.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,AETNA,AETNA HSHS,5670.07,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $5,670.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,AETNA,AETNA MEDICARE,3.02,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,AETNA,ALL COMMERCIAL AETNA,8777.20,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $8,777.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,ANTHEM,ANTEHM MEDICAID,208.24,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.02,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,ANTHEM,ANTHEM POS/HMO,5.13,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 170% = $5.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,ANTHEM,ANTHEM PPO,6.34,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 210% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8777.20,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $8,777.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,CENPATICO,ALL MEDICAID CENPATICO,8777.20,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $8,777.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7460.62,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $7,460.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,CIGNA,ALL COMMERCIAL CIGNA,6144.04,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,144.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,COFINITY,COFINITY,8777.20,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $8,777.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,208.24,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,208.24,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8338.34,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $8,338.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HEALTH CARE ALLIANCE,THE ALLIANCE,7372.85,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $7,372.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6231.81,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,231.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6407.36,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,407.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HSHS EMPLOYEES,HSHS EMPLOYEES,4265.72,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $4,265.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7460.62,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $7,460.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HUMANA,HUMANA CHOICE CARE HMO,5.20,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.20 from Fee Schedule 005543_170 for Rev 636 Proc J0881 * Qty 1 = $5.20 at 100% = $5.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HUMANA,HUMANA CHOICE CARE PPO,7460.62,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $7,460.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HUMANA,HUMANA MEDICARE ADVANTAGE,3.02,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,HUMANA,HUMANA NATIIONAL POS HMO,5.20,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $5.20 from Fee Schedule 005543_170 for Rev 636 Proc J0881 * Qty 1 = $5.20 at 100% = $5.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6407.36,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,407.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,LIVE360,LIVE360 HSHS HEALTHY PLAN,8777.20,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $8,777.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,208.24,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.02,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,208.24,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,MOLINA HEALTHCARE,MOLINA MEDICAID,220.73,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24... $208.24 at 106% = $220.73 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,MOLINA HEALTHCARE,MOLINA MEDICARE,3.02,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4388.60,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $4,388.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7372.85,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $7,372.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,NAPHCARE,ALL COMMERICAL NAPHCARE,6.80,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6582.90,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,582.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8075.02,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $8,075.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.41,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.41,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,PREVEA HEALTH NETWORK,PREVEA360,5.41,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.41,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0881 * Qty 1 = $3.02 at 179% = $5.41 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5602.49,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $5,602.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.05,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6319.58,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,319.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,TRIOLOGY,TRILOGY MEDICAID,220.74,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00439 Proc J0881 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 106% = $220.74. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.98,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,UNITED HEALTHCARE,UHC ONEIDA NATION,4.98,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.02,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,UNITED HEALTHCARE,UNITED HEALTHCARE,4.98,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.98 from Fee Schedule UHC_31190C for Rev 636 Proc J0881 * Qty 1 = $4.98 at 100% = $4.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,UNITY HEALTH PLAN,UNITY HOSPICE,3.02,,,,,,,3.0200,8777.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6319.58,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,319.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5441.86,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $5,441.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6319.58,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,319.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6319.58,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $6,319.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DARBEPOETIN ALFA 300 MCG/0.6ML SOSY per 1 mcg,J0881,HCPCS,636,RC,55513-111-01,CDM,,,,both,0.600000,ML,8777.2000,5792.9500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5266.32,,,,,,,3.0200,8777.2000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $8,777.20 in Billed Charges for Rev 636 Proc J0881 = $5,266.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,AETNA,AETNA HSHS,90.16,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $90.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,AETNA,AETNA MEDICARE,51.55,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,AETNA,ALL COMMERCIAL AETNA,139.57,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $139.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,51.55,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,ANTHEM,ANTHEM POS/HMO,87.64,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.55 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9011 * Qty 1 = $51.55 at 170% = $87.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,ANTHEM,ANTHEM PPO,108.26,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.55 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9011 * Qty 1 = $51.55 at 210% = $108.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,139.57,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $139.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,CENPATICO,ALL MEDICAID CENPATICO,139.57,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $139.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,118.63,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $118.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,CIGNA,ALL COMMERCIAL CIGNA,97.70,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $97.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,COFINITY,COFINITY,139.57,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $139.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,132.59,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $132.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,117.24,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $117.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,99.09,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $99.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,101.89,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $101.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,67.83,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $67.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,118.63,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $118.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HUMANA,HUMANA CHOICE CARE HMO,88.63,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9011 $139.57 in Billed Charges at 63.5% = $88.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HUMANA,HUMANA CHOICE CARE PPO,118.63,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $118.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HUMANA,HUMANA MEDICARE ADVANTAGE,51.55,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,HUMANA,HUMANA NATIIONAL POS HMO,88.63,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9011 $139.57 in Billed Charges at 63.5% = $88.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,101.89,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $101.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,139.57,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $139.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,51.55,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,MOLINA HEALTHCARE,MOLINA MEDICARE,51.55,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,69.79,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $69.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,117.24,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $117.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,NAPHCARE,ALL COMMERICAL NAPHCARE,115.99,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,104.68,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $104.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,128.40,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $128.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,92.27,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.55 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9011 * Qty 1 = $51.55 at 179% = $92.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,92.27,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.55 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9011 * Qty 1 = $51.55 at 179% = $92.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,PREVEA HEALTH NETWORK,PREVEA360,92.27,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.55 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9011 * Qty 1 = $51.55 at 179% = $92.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,92.27,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $51.55 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9011 * Qty 1 = $51.55 at 179% = $92.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,89.09,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $89.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,52.07,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,100.49,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $100.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,85.06,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $85.06 from Fee Schedule UHC_31190C for Rev 636 Proc J9011 * Qty 1 = $85.06 at 100% = $85.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,85.06,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $85.06 from Fee Schedule UHC_31190C for Rev 636 Proc J9011 * Qty 1 = $85.06 at 100% = $85.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,51.55,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,85.06,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $85.06 from Fee Schedule UHC_31190C for Rev 636 Proc J9011 * Qty 1 = $85.06 at 100% = $85.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,UNITY HEALTH PLAN,UNITY HOSPICE,51.55,,,,,,,51.5500,139.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,100.49,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $100.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,86.53,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $86.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,100.49,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $100.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,100.49,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $100.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DATOPOTAMAB DERUXTECAN-DLNK 100 MG SOLR 1 EACH VIAL per 1 mg,J9011,HCPCS,636,RC,65597-801-01,CDM,,,,both,1.000000,ME,139.5700,92.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,83.74,,,,,,,51.5500,139.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $139.57 in Billed Charges for Rev 636 Proc J9011 = $83.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,AETNA,AETNA HSHS,22.89,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $22.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,AETNA,ALL COMMERCIAL AETNA,35.44,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $35.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,ANTHEM,ANTEHM MEDICAID,16.45,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,ANTHEM,ANTHEM POS/HMO,1.11,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 170% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,ANTHEM,ANTHEM PPO,1.37,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 210% = $1.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,35.44,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $35.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,CENPATICO,ALL MEDICAID CENPATICO,35.44,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $35.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,30.12,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $30.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,CIGNA,ALL COMMERCIAL CIGNA,24.81,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $24.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,COFINITY,COFINITY,35.44,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $35.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.45,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.45,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,33.67,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $33.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,29.77,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $29.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,25.16,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $25.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,25.87,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $25.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,17.22,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $17.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,30.12,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $30.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,HUMANA,HUMANA CHOICE CARE HMO,2.43,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule 005543_170 for Rev 636 Proc J0894 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,HUMANA,HUMANA CHOICE CARE PPO,30.12,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $30.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,HUMANA,HUMANA NATIIONAL POS HMO,2.43,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $2.43 from Fee Schedule 005543_170 for Rev 636 Proc J0894 * Qty 1 = $2.43 at 100% = $2.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,25.87,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $25.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,35.44,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $35.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.45,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.45,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,MOLINA HEALTHCARE,MOLINA MEDICAID,17.44,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45... $16.45 at 106% = $17.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,17.72,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $17.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,29.77,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $29.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,26.58,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $26.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,32.60,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $32.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.16,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.16,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,PREVEA HEALTH NETWORK,PREVEA360,1.16,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.16,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.65 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0894 * Qty 1 = $0.65 at 179% = $1.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,22.62,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $22.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,25.52,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $25.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,TRIOLOGY,TRILOGY MEDICAID,17.44,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J0894 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 106% = $17.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.07,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0894 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,UNITED HEALTHCARE,UHC ONEIDA NATION,1.07,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0894 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,UNITED HEALTHCARE,UNITED HEALTHCARE,1.07,,,,,,,1.0700,35.4400,fee schedule,ST VINCENT HOSPITAL (ACU). $1.07 from Fee Schedule UHC_31190C for Rev 636 Proc J0894 * Qty 1 = $1.07 at 100% = $1.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,25.52,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $25.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,21.97,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $21.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,25.52,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $25.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,25.52,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $25.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DECITABINE 50 MG SOLR 1 EACH VIAL per 1 mg,J0894,HCPCS,636,RC,55111-556-10,CDM,,,,both,1.000000,ME,35.4400,23.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,21.26,,,,,,,1.0700,35.4400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.44 in Billed Charges for Rev 636 Proc J0894 = $21.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,AETNA,AETNA HSHS,6.01,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,AETNA,AETNA MEDICARE,4.45,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,AETNA,ALL COMMERCIAL AETNA,9.31,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,ANTHEM,ANTEHM MEDICAID,9.31,,,,,,,4.4500,10.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00433 Proc J9155 at $125.60 (Base Rate) * 1.0693 (Relative Weight) = $134.30 (Total Line Payment) at 100% = $134.30 (Service Line reduced to $9.31, claim capped at $9.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,4.45,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,ANTHEM,ANTHEM POS/HMO,7.57,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.45 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9155 * Qty 1 = $4.45 at 170% = $7.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,ANTHEM,ANTHEM PPO,9.31,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.45 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9155 * Qty 1 = $4.45 at 210% = $9.35 (Limited to $9.31 in Billed Charges) The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.31,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,CENPATICO,ALL MEDICAID CENPATICO,9.31,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.91,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,CIGNA,ALL COMMERCIAL CIGNA,6.52,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,COFINITY,COFINITY,9.31,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,9.31,,,,,,,4.4500,10.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00433 Proc J9155 at $125.60 (Base Rate) * 1.0693 (Relative Weight) = $134.30 (Total Line Payment) at 100% = $134.30 (Service Line reduced to $9.31, claim capped at $9.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,9.31,,,,,,,4.4500,10.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00433 Proc J9155 at $125.60 (Base Rate) * 1.0693 (Relative Weight) = $134.30 (Total Line Payment) at 100% = $134.30 (Service Line reduced to $9.31, claim capped at $9.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.84,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $8.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,7.82,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.61,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.80,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,4.52,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $4.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.91,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HUMANA,HUMANA CHOICE CARE HMO,7.26,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.26 from Fee Schedule 005543_170 for Rev 636 Proc J9155 * Qty 1 = $7.26 at 100% = $7.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HUMANA,HUMANA CHOICE CARE PPO,7.91,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HUMANA,HUMANA MEDICARE ADVANTAGE,4.45,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,HUMANA,HUMANA NATIIONAL POS HMO,7.26,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.26 from Fee Schedule 005543_170 for Rev 636 Proc J9155 * Qty 1 = $7.26 at 100% = $7.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.80,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.31,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,9.31,,,,,,,4.4500,10.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00433 Proc J9155 at $125.60 (Base Rate) * 1.0693 (Relative Weight) = $134.30 (Total Line Payment) at 100% = $134.30 (Service Line reduced to $9.31, claim capped at $9.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,4.45,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,9.31,,,,,,,4.4500,10.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00433 Proc J9155 at $125.60 (Base Rate) * 1.0693 (Relative Weight) = $134.30 (Total Line Payment) at 100% = $134.30 (Service Line reduced to $9.31, claim capped at $9.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,MOLINA HEALTHCARE,MOLINA MEDICAID,9.87,,,,,,,4.4500,10.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00433 Proc J9155 at $125.60 (Base Rate) * 1.0693 (Relative Weight) = $134.30 (Total Line Payment) at 100% = $134.30 (Service Line reduced to $9.31, claim capped at $9.31 in billed charges)... $9.31 at 106% = $9.87 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,MOLINA HEALTHCARE,MOLINA MEDICARE,4.45,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.66,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $4.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.82,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,NAPHCARE,ALL COMMERICAL NAPHCARE,10.01,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.98,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.57,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $8.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.97,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.45 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9155 * Qty 1 = $4.45 at 179% = $7.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.97,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.45 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9155 * Qty 1 = $4.45 at 179% = $7.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,PREVEA HEALTH NETWORK,PREVEA360,7.97,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.45 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9155 * Qty 1 = $4.45 at 179% = $7.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.97,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $4.45 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9155 * Qty 1 = $4.45 at 179% = $7.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.94,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $5.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,4.49,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.70,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,TRIOLOGY,TRILOGY MEDICAID,9.31,,,,,,,4.4500,10.0100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00433 Proc J9155 at $125.60 (Base Rate) * 1.0693 (Relative Weight) = $134.30 (Total Line Payment) at 106% = $142.36 (Service Line reduced to $9.31, claim capped at $9.31 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.34,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9155 * Qty 1 = $7.34 at 100% = $7.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,7.34,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9155 * Qty 1 = $7.34 at 100% = $7.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,4.45,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,7.34,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9155 * Qty 1 = $7.34 at 100% = $7.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,UNITY HEALTH PLAN,UNITY HOSPICE,4.45,,,,,,,4.4500,10.0100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.70,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.77,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $5.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.70,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.70,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $6.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEGARELIX ACETATE (LOADING DOSE) 120 MG/VIAL SOLR per 1 mg,J9155,HCPCS,636,RC,55566-8403-1,CDM,,,,both,1.000000,ME,9.3100,6.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.59,,,,,,,4.4500,10.0100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.31 in Billed Charges for Rev 636 Proc J9155 = $5.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,AETNA,AETNA HSHS,6.52,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $6.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,AETNA,AETNA MEDICARE,3.84,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,AETNA,ALL COMMERCIAL AETNA,10.09,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $10.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.84,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,ANTHEM,ANTHEM POS/HMO,6.53,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 170% = $6.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,ANTHEM,ANTHEM PPO,8.06,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 210% = $8.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.09,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $10.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,CENPATICO,ALL MEDICAID CENPATICO,10.09,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $10.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8.58,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,CIGNA,ALL COMMERCIAL CIGNA,7.06,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,COFINITY,COFINITY,10.09,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $10.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9.59,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $9.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,8.48,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $8.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.16,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.37,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,4.90,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8.58,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HUMANA,HUMANA CHOICE CARE HMO,6.41,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9074 $10.09 in Billed Charges at 63.5% = $6.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HUMANA,HUMANA CHOICE CARE PPO,8.58,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HUMANA,HUMANA MEDICARE ADVANTAGE,3.84,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,HUMANA,HUMANA NATIIONAL POS HMO,6.41,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9074 $10.09 in Billed Charges at 63.5% = $6.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.37,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.09,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $10.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.84,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,MOLINA HEALTHCARE,MOLINA MEDICARE,3.84,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.05,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $5.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8.48,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $8.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,NAPHCARE,ALL COMMERICAL NAPHCARE,8.64,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.57,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.28,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $9.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.87,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 179% = $6.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.87,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 179% = $6.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,PREVEA HEALTH NETWORK,PREVEA360,6.87,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 179% = $6.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.87,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $3.84 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9074 * Qty 1 = $3.84 at 179% = $6.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.44,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $6.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.88,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.26,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.34,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $6.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9074 * Qty 1 = $6.34 at 100% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,6.34,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $6.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9074 * Qty 1 = $6.34 at 100% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.84,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,6.34,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $6.34 from Fee Schedule UHC_31190C for Rev 636 Proc J9074 * Qty 1 = $6.34 at 100% = $6.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,UNITY HEALTH PLAN,UNITY HOSPICE,3.84,,,,,,,3.8400,10.0900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.26,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.26,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $6.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.26,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.26,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $7.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9074,HCPCS,636,RC,0781-3244-94,CDM,,,,both,5.000000,ME,10.0900,6.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.05,,,,,,,3.8400,10.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.09 in Billed Charges for Rev 636 Proc J9074 = $6.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,AETNA,AETNA HSHS,4.33,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,AETNA,AETNA MEDICARE,0.59,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,AETNA,ALL COMMERCIAL AETNA,6.71,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $6.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,0.59,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,ANTHEM,ANTHEM POS/HMO,1.00,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 170% = $1.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,ANTHEM,ANTHEM PPO,1.24,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 210% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6.71,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $6.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,CENPATICO,ALL MEDICAID CENPATICO,6.71,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $6.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.70,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $5.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,CIGNA,ALL COMMERCIAL CIGNA,4.70,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,COFINITY,COFINITY,6.71,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $6.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6.37,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $6.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,5.64,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $5.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.76,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.90,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,3.26,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $3.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.70,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $5.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HUMANA,HUMANA CHOICE CARE HMO,4.26,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $6.71 in Billed Charges at 63.5% = $4.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HUMANA,HUMANA CHOICE CARE PPO,5.70,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $5.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HUMANA,HUMANA MEDICARE ADVANTAGE,0.59,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,HUMANA,HUMANA NATIIONAL POS HMO,4.26,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $6.71 in Billed Charges at 63.5% = $4.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.90,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,6.71,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $6.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,0.59,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,MOLINA HEALTHCARE,MOLINA MEDICARE,0.59,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.36,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $3.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.64,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $5.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,NAPHCARE,ALL COMMERICAL NAPHCARE,1.32,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5.03,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $5.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6.17,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.06,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.06,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,PREVEA HEALTH NETWORK,PREVEA360,1.06,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.06,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.28,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,0.60,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.83,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.97,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.97,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,0.59,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.97,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,UNITY HEALTH PLAN,UNITY HOSPICE,0.59,,,,,,,0.5900,6.7100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.83,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.16,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.83,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.83,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 1 G SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,25021-248-51,CDM,,,,both,5.000000,ME,6.7100,4.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.03,,,,,,,0.5900,6.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $6.71 in Billed Charges for Rev 636 Proc J9075 = $4.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,AETNA,AETNA HSHS,10.22,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $10.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,AETNA,AETNA MEDICARE,0.59,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,AETNA,ALL COMMERCIAL AETNA,15.82,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $15.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,0.59,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,ANTHEM,ANTHEM POS/HMO,1.00,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 170% = $1.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,ANTHEM,ANTHEM PPO,1.24,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 210% = $1.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15.82,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $15.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,CENPATICO,ALL MEDICAID CENPATICO,15.82,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $15.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.45,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,CIGNA,ALL COMMERCIAL CIGNA,11.07,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,COFINITY,COFINITY,15.82,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $15.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.03,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $15.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,13.29,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $13.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.23,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.55,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,7.69,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $7.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.45,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HUMANA,HUMANA CHOICE CARE HMO,10.05,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $15.82 in Billed Charges at 63.5% = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HUMANA,HUMANA CHOICE CARE PPO,13.45,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HUMANA,HUMANA MEDICARE ADVANTAGE,0.59,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,HUMANA,HUMANA NATIIONAL POS HMO,10.05,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J9075 $15.82 in Billed Charges at 63.5% = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.55,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,15.82,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $15.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,0.59,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,MOLINA HEALTHCARE,MOLINA MEDICARE,0.59,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.91,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.29,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $13.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,NAPHCARE,ALL COMMERICAL NAPHCARE,1.32,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.87,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,14.55,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $14.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.06,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.06,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,PREVEA HEALTH NETWORK,PREVEA360,1.06,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.06,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.59 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9075 * Qty 1 = $0.59 at 179% = $1.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.10,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $10.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,0.60,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.39,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.97,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,0.97,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,0.59,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,0.97,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.97 from Fee Schedule UHC_31190C for Rev 636 Proc J9075 * Qty 1 = $0.97 at 100% = $0.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,UNITY HEALTH PLAN,UNITY HOSPICE,0.59,,,,,,,0.5900,15.8200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.39,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.81,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $9.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.39,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.39,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $11.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPHOSPHAMIDE 500 MG SOLR 1 EACH VIAL per 5 mg,J9075,HCPCS,636,RC,10019-955-01,CDM,,,,both,5.000000,ME,15.8200,10.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.49,,,,,,,0.5900,15.8200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.82 in Billed Charges for Rev 636 Proc J9075 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,AETNA,AETNA HSHS,12.08,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $12.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,AETNA,ALL COMMERCIAL AETNA,18.70,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,ANTHEM,ANTHEM POS/HMO,3.08,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.81 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7502 * Qty 1 = $1.81 at 170% = $3.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,ANTHEM,ANTHEM PPO,3.80,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.81 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7502 * Qty 1 = $1.81 at 210% = $3.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,18.70,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,CENPATICO,ALL MEDICAID CENPATICO,18.70,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15.90,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,CIGNA,ALL COMMERCIAL CIGNA,13.09,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $13.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,COFINITY,COFINITY,18.70,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17.77,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $17.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,15.71,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $15.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.28,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13.65,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $13.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,9.09,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $9.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15.90,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,HUMANA,HUMANA CHOICE CARE HMO,3.72,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.72 from Fee Schedule 005543_170 for Rev 636 Proc J7502 * Qty 1 = $3.72 at 100% = $3.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,HUMANA,HUMANA CHOICE CARE PPO,15.90,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,HUMANA,HUMANA NATIIONAL POS HMO,3.72,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.72 from Fee Schedule 005543_170 for Rev 636 Proc J7502 * Qty 1 = $3.72 at 100% = $3.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13.65,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $13.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,18.70,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.35,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $9.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15.71,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $15.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.03,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,17.20,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $17.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.24,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.81 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7502 * Qty 1 = $1.81 at 179% = $3.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.24,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.81 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7502 * Qty 1 = $1.81 at 179% = $3.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,PREVEA HEALTH NETWORK,PREVEA360,3.24,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.81 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7502 * Qty 1 = $1.81 at 179% = $3.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.24,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.81 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7502 * Qty 1 = $1.81 at 179% = $3.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.94,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $11.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.46,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.99,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.99 from Fee Schedule UHC_31190C for Rev 636 Proc J7502 * Qty 1 = $2.99 at 100% = $2.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,2.99,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.99 from Fee Schedule UHC_31190C for Rev 636 Proc J7502 * Qty 1 = $2.99 at 100% = $2.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,2.99,,,,,,,2.9900,18.7000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.99 from Fee Schedule UHC_31190C for Rev 636 Proc J7502 * Qty 1 = $2.99 at 100% = $2.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.46,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.59,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $11.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.46,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.46,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOSPORINE MODIFIED 100 MG CAPS per 100 mg,J7502,HCPCS,636,RC,60505-4632-3,CDM,,,,both,100.000000,ME,18.7000,12.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.22,,,,,,,2.9900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.70 in Billed Charges for Rev 636 Proc J7502 = $11.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,AETNA,AETNA HSHS,124.16,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $124.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,AETNA,ALL COMMERCIAL AETNA,192.20,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $192.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,ANTHEM,ANTHEM POS/HMO,29.29,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.23 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0735 * Qty 1 = $17.23 at 170% = $29.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,ANTHEM,ANTHEM PPO,36.18,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.23 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0735 * Qty 1 = $17.23 at 210% = $36.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,192.20,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $192.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,CENPATICO,ALL MEDICAID CENPATICO,192.20,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $192.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,163.37,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $163.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,CIGNA,ALL COMMERCIAL CIGNA,134.54,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $134.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,COFINITY,COFINITY,192.20,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $192.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,182.59,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $182.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,HEALTH CARE ALLIANCE,THE ALLIANCE,161.45,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $161.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,136.46,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $136.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,140.31,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $140.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,HSHS EMPLOYEES,HSHS EMPLOYEES,93.41,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $93.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,163.37,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $163.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,HUMANA,HUMANA CHOICE CARE HMO,29.53,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.53 from Fee Schedule 005543_170 for Rev 636 Proc J0735 * Qty 1 = $29.53 at 100% = $29.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,HUMANA,HUMANA CHOICE CARE PPO,163.37,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $163.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,HUMANA,HUMANA NATIIONAL POS HMO,29.53,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $29.53 from Fee Schedule 005543_170 for Rev 636 Proc J0735 * Qty 1 = $29.53 at 100% = $29.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,140.31,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $140.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,LIVE360,LIVE360 HSHS HEALTHY PLAN,192.20,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $192.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,96.10,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $96.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,161.45,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $161.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,144.15,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $144.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,176.82,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $176.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,30.84,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.23 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0735 * Qty 1 = $17.23 at 179% = $30.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,30.84,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.23 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0735 * Qty 1 = $17.23 at 179% = $30.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,PREVEA HEALTH NETWORK,PREVEA360,30.84,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.23 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0735 * Qty 1 = $17.23 at 179% = $30.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,30.84,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $17.23 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0735 * Qty 1 = $17.23 at 179% = $30.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,122.68,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $122.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,138.38,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $138.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,28.43,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0735 * Qty 1 = $28.43 at 100% = $28.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,UNITED HEALTHCARE,UHC ONEIDA NATION,28.43,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0735 * Qty 1 = $28.43 at 100% = $28.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,UNITED HEALTHCARE,UNITED HEALTHCARE,28.43,,,,,,,28.4300,192.2000,fee schedule,ST VINCENT HOSPITAL (ACU). $28.43 from Fee Schedule UHC_31190C for Rev 636 Proc J0735 * Qty 1 = $28.43 at 100% = $28.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,138.38,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $138.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,119.16,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $119.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,138.38,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $138.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,138.38,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $138.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 100 MCG/ML SOLN 10 ML VIAL per 1 mg,J0735,HCPCS,636,RC,39822-2000-1,CDM,,,,both,1.000000,ME,192.2000,126.8500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,115.32,,,,,,,28.4300,192.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $192.20 in Billed Charges for Rev 636 Proc J0735 = $115.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,AETNA,AETNA HSHS,10014.29,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $10,014.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,AETNA,AETNA MEDICARE,2.62,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,AETNA,ALL COMMERCIAL AETNA,15502.00,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $15,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,ANTHEM,ANTEHM MEDICAID,2032.07,,,,,,,2.6200,15502.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7189 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,2.62,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,ANTHEM,ANTHEM POS/HMO,4.45,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.62 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7189 * Qty 1 = $2.62 at 170% = $4.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,ANTHEM,ANTHEM PPO,5.50,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.62 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7189 * Qty 1 = $2.62 at 210% = $5.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15502.00,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $15,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,CENPATICO,ALL MEDICAID CENPATICO,15502.00,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $15,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13176.70,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $13,176.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,CIGNA,ALL COMMERCIAL CIGNA,10851.40,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $10,851.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,COFINITY,COFINITY,15502.00,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $15,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,2032.07,,,,,,,2.6200,15502.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7189 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,2032.07,,,,,,,2.6200,15502.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7189 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14726.90,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $14,726.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,13021.68,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $13,021.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11006.42,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $11,006.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11316.46,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $11,316.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,7533.97,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $7,533.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13176.70,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $13,176.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HUMANA,HUMANA CHOICE CARE HMO,4.32,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.32 from Fee Schedule 005543_170 for Rev 636 Proc J7189 * Qty 1 = $4.32 at 100% = $4.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HUMANA,HUMANA CHOICE CARE PPO,13176.70,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $13,176.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,2.62,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,HUMANA,HUMANA NATIIONAL POS HMO,4.32,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.32 from Fee Schedule 005543_170 for Rev 636 Proc J7189 * Qty 1 = $4.32 at 100% = $4.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11316.46,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $11,316.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,15502.00,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $15,502.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,2032.07,,,,,,,2.6200,15502.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7189 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2.62,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,2032.07,,,,,,,2.6200,15502.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7189 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,2153.99,,,,,,,2.6200,15502.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7189 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 100% = $2,032.07... $2,032.07 at 106% = $2,153.99 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,2.62,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7751.00,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $7,751.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13021.68,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $13,021.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,5.90,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11626.50,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $11,626.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,14261.84,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $14,261.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.69,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.62 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7189 * Qty 1 = $2.62 at 179% = $4.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.69,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.62 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7189 * Qty 1 = $2.62 at 179% = $4.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,PREVEA HEALTH NETWORK,PREVEA360,4.69,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.62 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7189 * Qty 1 = $2.62 at 179% = $4.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.69,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.62 from Fee Schedule MEDCR_ASP for Rev 636 Proc J7189 * Qty 1 = $2.62 at 179% = $4.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9894.93,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $9,894.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,2.65,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11161.44,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $11,161.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,TRIOLOGY,TRILOGY MEDICAID,2153.99,,,,,,,2.6200,15502.0000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00463 Proc J7189 at $125.60 (Base Rate) * 16.1789 (Relative Weight) = $2,032.07 (Total Line Payment) at 106% = $2,153.99. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.32,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.32 from Fee Schedule UHC_31190C for Rev 636 Proc J7189 * Qty 1 = $4.32 at 100% = $4.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,4.32,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.32 from Fee Schedule UHC_31190C for Rev 636 Proc J7189 * Qty 1 = $4.32 at 100% = $4.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,2.62,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,4.32,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.32 from Fee Schedule UHC_31190C for Rev 636 Proc J7189 * Qty 1 = $4.32 at 100% = $4.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,UNITY HEALTH PLAN,UNITY HOSPICE,2.62,,,,,,,2.6200,15502.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11161.44,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $11,161.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9611.24,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $9,611.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11161.44,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $11,161.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11161.44,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $11,161.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COAGULATION FACTOR VIIA RECOMB 2 MG SOLR per 1 mcg,J7189,HCPCS,636,RC,0169-7202-01,CDM,,,,both,2.000000,ME,15502.0000,10231.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9301.20,,,,,,,2.6200,15502.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $15,502.00 in Billed Charges for Rev 636 Proc J7189 = $9,301.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,AETNA,AETNA HSHS,18.35,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $18.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,AETNA,ALL COMMERCIAL AETNA,28.40,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $28.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,ANTHEM,ANTHEM POS/HMO,3.59,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 170% = $3.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,ANTHEM,ANTHEM PPO,4.43,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 210% = $4.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,28.40,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $28.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,CENPATICO,ALL MEDICAID CENPATICO,28.40,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $28.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,24.14,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $24.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,CIGNA,ALL COMMERCIAL CIGNA,19.88,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $19.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,COFINITY,COFINITY,28.40,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $28.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,26.98,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $26.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,23.86,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $23.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,20.16,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $20.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,20.73,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $20.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,13.80,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $13.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,24.14,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $24.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,HUMANA,HUMANA CHOICE CARE HMO,6.38,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule 005543_170 for Rev 636 Proc J9060 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,HUMANA,HUMANA CHOICE CARE PPO,24.14,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $24.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,HUMANA,HUMANA NATIIONAL POS HMO,6.38,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule 005543_170 for Rev 636 Proc J9060 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,20.73,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $20.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,28.40,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $28.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,14.20,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $14.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,23.86,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $23.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,21.30,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $21.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,26.13,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $26.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.78,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.78,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,PREVEA HEALTH NETWORK,PREVEA360,3.78,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.78,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,18.13,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $18.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,20.45,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $20.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.48,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,3.48,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,3.48,,,,,,,3.4800,28.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,20.45,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $20.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.61,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $17.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,20.45,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $20.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,20.45,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $20.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,0703-5747-11,CDM,,,,both,10.000000,ME,28.4000,18.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,17.04,,,,,,,3.4800,28.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $28.40 in Billed Charges for Rev 636 Proc J9060 = $17.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,AETNA,AETNA HSHS,25.79,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $25.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,AETNA,ALL COMMERCIAL AETNA,39.92,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $39.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,ANTHEM,ANTHEM POS/HMO,3.59,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 170% = $3.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,ANTHEM,ANTHEM PPO,4.43,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 210% = $4.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,39.92,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $39.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,CENPATICO,ALL MEDICAID CENPATICO,39.92,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $39.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,33.93,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $33.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,CIGNA,ALL COMMERCIAL CIGNA,27.94,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $27.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,COFINITY,COFINITY,39.92,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $39.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,37.92,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $37.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,33.53,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $33.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,28.34,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $28.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,29.14,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $29.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,19.40,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $19.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,33.93,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $33.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,HUMANA,HUMANA CHOICE CARE HMO,6.38,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule 005543_170 for Rev 636 Proc J9060 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,HUMANA,HUMANA CHOICE CARE PPO,33.93,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $33.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,HUMANA,HUMANA NATIIONAL POS HMO,6.38,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $6.38 from Fee Schedule 005543_170 for Rev 636 Proc J9060 * Qty 1 = $6.38 at 100% = $6.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,29.14,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $29.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,39.92,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $39.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.96,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $19.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,33.53,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $33.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,29.94,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $29.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,36.73,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $36.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.78,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.78,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,PREVEA HEALTH NETWORK,PREVEA360,3.78,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.78,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $2.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9060 * Qty 1 = $2.11 at 179% = $3.78 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,25.48,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $25.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,28.74,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $28.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.48,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,UNITED HEALTHCARE,UHC ONEIDA NATION,3.48,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,UNITED HEALTHCARE,UNITED HEALTHCARE,3.48,,,,,,,3.4800,39.9200,fee schedule,ST VINCENT HOSPITAL (ACU). $3.48 from Fee Schedule UHC_31190C for Rev 636 Proc J9060 * Qty 1 = $3.48 at 100% = $3.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,28.74,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $28.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,24.75,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,28.74,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $28.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,28.74,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $28.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISPLATIN 50 MG/50ML SOLN 50 ML VIAL per 10 mg,J9060,HCPCS,636,RC,25021-253-50,CDM,,,,both,10.000000,ME,39.9200,26.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,23.95,,,,,,,3.4800,39.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $39.92 in Billed Charges for Rev 636 Proc J9060 = $23.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,AETNA,AETNA HSHS,536.18,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $536.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,AETNA,ALL COMMERCIAL AETNA,830.00,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $830.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,ANTHEM,ANTHEM POS/HMO,98.82,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.13 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1205 * Qty 1 = $58.13 at 170% = $98.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,ANTHEM,ANTHEM PPO,122.07,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.13 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1205 * Qty 1 = $58.13 at 210% = $122.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,830.00,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $830.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,CENPATICO,ALL MEDICAID CENPATICO,830.00,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $830.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,705.50,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $705.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,CIGNA,ALL COMMERCIAL CIGNA,581.00,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $581.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,COFINITY,COFINITY,830.00,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $830.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,788.50,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $788.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,697.20,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $697.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,589.30,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $589.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,605.90,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $605.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,403.38,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $403.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,705.50,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $705.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,HUMANA,HUMANA CHOICE CARE HMO,108.44,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $108.44 from Fee Schedule 005543_170 for Rev 636 Proc J1205 * Qty 1 = $108.44 at 100% = $108.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,HUMANA,HUMANA CHOICE CARE PPO,705.50,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $705.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,HUMANA,HUMANA NATIIONAL POS HMO,108.44,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $108.44 from Fee Schedule 005543_170 for Rev 636 Proc J1205 * Qty 1 = $108.44 at 100% = $108.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,605.90,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $605.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,830.00,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $830.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,415.00,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $415.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,697.20,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $697.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,622.50,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $622.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,763.60,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $763.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,104.05,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.13 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1205 * Qty 1 = $58.13 at 179% = $104.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,104.05,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.13 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1205 * Qty 1 = $58.13 at 179% = $104.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,PREVEA HEALTH NETWORK,PREVEA360,104.05,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.13 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1205 * Qty 1 = $58.13 at 179% = $104.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,104.05,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.13 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1205 * Qty 1 = $58.13 at 179% = $104.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,529.79,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $529.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,597.60,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $597.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,95.91,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.91 from Fee Schedule UHC_31190C for Rev 636 Proc J1205 * Qty 1 = $95.91 at 100% = $95.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,95.91,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.91 from Fee Schedule UHC_31190C for Rev 636 Proc J1205 * Qty 1 = $95.91 at 100% = $95.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,95.91,,,,,,,95.9100,830.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.91 from Fee Schedule UHC_31190C for Rev 636 Proc J1205 * Qty 1 = $95.91 at 100% = $95.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,597.60,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $597.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,514.60,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $514.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,597.60,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $597.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,597.60,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $597.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL per 500 mg,J1205,HCPCS,636,RC,0517-1820-01,CDM,,,,both,500.000000,ME,830.0000,547.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,498.00,,,,,,,95.9100,830.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $830.00 in Billed Charges for Rev 636 Proc J1205 = $498.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,AETNA,AETNA HSHS,115.23,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $115.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,AETNA,AETNA MEDICARE,7.42,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,AETNA,ALL COMMERCIAL AETNA,178.38,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $178.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,ANTHEM,ANTEHM MEDICAID,56.96,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9065 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.42,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,ANTHEM,ANTHEM POS/HMO,12.61,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $7.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9065 * Qty 1 = $7.42 at 170% = $12.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,ANTHEM,ANTHEM PPO,15.58,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $7.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9065 * Qty 1 = $7.42 at 210% = $15.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,178.38,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $178.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,CENPATICO,ALL MEDICAID CENPATICO,178.38,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $178.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,151.62,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $151.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,CIGNA,ALL COMMERCIAL CIGNA,124.87,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $124.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,COFINITY,COFINITY,178.38,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $178.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,56.96,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9065 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,56.96,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9065 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,169.46,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $169.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,149.84,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $149.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,126.65,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $126.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,130.22,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $130.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,86.69,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $86.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,151.62,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $151.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HUMANA,HUMANA CHOICE CARE HMO,22.58,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $22.58 from Fee Schedule 005543_170 for Rev 636 Proc J9065 * Qty 1 = $22.58 at 100% = $22.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HUMANA,HUMANA CHOICE CARE PPO,151.62,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $151.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HUMANA,HUMANA MEDICARE ADVANTAGE,7.42,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,HUMANA,HUMANA NATIIONAL POS HMO,22.58,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $22.58 from Fee Schedule 005543_170 for Rev 636 Proc J9065 * Qty 1 = $22.58 at 100% = $22.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,130.22,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $130.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,178.38,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $178.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,56.96,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9065 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.42,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,56.96,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9065 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,MOLINA HEALTHCARE,MOLINA MEDICAID,60.38,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9065 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 100% = $56.96... $56.96 at 106% = $60.38 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,MOLINA HEALTHCARE,MOLINA MEDICARE,7.42,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,89.19,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $89.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,149.84,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $149.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,NAPHCARE,ALL COMMERICAL NAPHCARE,16.69,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,133.79,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $133.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,164.11,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $164.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.28,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $7.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9065 * Qty 1 = $7.42 at 179% = $13.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.28,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $7.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9065 * Qty 1 = $7.42 at 179% = $13.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,PREVEA HEALTH NETWORK,PREVEA360,13.28,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $7.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9065 * Qty 1 = $7.42 at 179% = $13.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.28,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $7.42 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9065 * Qty 1 = $7.42 at 179% = $13.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,113.86,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $113.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.49,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,128.43,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,TRIOLOGY,TRILOGY MEDICAID,60.38,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00432 Proc J9065 at $125.60 (Base Rate) * 0.4535 (Relative Weight) = $56.96 (Total Line Payment) at 106% = $60.38. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.24,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $12.24 from Fee Schedule UHC_31190C for Rev 636 Proc J9065 * Qty 1 = $12.24 at 100% = $12.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,UNITED HEALTHCARE,UHC ONEIDA NATION,12.24,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $12.24 from Fee Schedule UHC_31190C for Rev 636 Proc J9065 * Qty 1 = $12.24 at 100% = $12.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.42,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,UNITED HEALTHCARE,UNITED HEALTHCARE,12.24,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $12.24 from Fee Schedule UHC_31190C for Rev 636 Proc J9065 * Qty 1 = $12.24 at 100% = $12.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,UNITY HEALTH PLAN,UNITY HOSPICE,7.42,,,,,,,7.4200,178.3800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,128.43,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,110.60,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $110.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,128.43,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,128.43,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLADRIBINE 10 MG/10ML SOLN 10 ML VIAL per 1 mg,J9065,HCPCS,636,RC,0143-9871-01,CDM,,,,both,1.000000,ME,178.3800,117.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,107.03,,,,,,,7.4200,178.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $178.38 in Billed Charges for Rev 636 Proc J9065 = $107.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,AETNA,AETNA HSHS,30.63,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $30.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,AETNA,ALL COMMERCIAL AETNA,47.42,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $47.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,ANTHEM,ANTHEM POS/HMO,3.25,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 170% = $3.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,ANTHEM,ANTHEM PPO,4.01,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 210% = $4.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,47.42,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $47.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,CENPATICO,ALL MEDICAID CENPATICO,47.42,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $47.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,40.31,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $40.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,CIGNA,ALL COMMERCIAL CIGNA,33.19,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $33.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,COFINITY,COFINITY,47.42,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $47.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,45.05,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $45.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,39.83,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $39.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,33.67,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $33.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,34.62,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $34.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,23.05,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $23.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,40.31,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $40.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,HUMANA,HUMANA CHOICE CARE HMO,4.06,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $4.06 from Fee Schedule 005543_170 for Rev 636 Proc J0736 * Qty 1 = $4.06 at 100% = $4.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,HUMANA,HUMANA CHOICE CARE PPO,40.31,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $40.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,HUMANA,HUMANA NATIIONAL POS HMO,4.06,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $4.06 from Fee Schedule 005543_170 for Rev 636 Proc J0736 * Qty 1 = $4.06 at 100% = $4.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,34.62,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $34.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,47.42,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $47.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,23.71,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $23.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,39.83,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $39.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,35.57,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $35.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,43.63,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $43.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.42,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.42,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,PREVEA HEALTH NETWORK,PREVEA360,3.42,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.42,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.91 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0736 * Qty 1 = $1.91 at 179% = $3.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,30.27,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $30.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,34.14,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $34.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.15,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,3.15,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,3.15,,,,,,,3.1500,47.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $3.15 from Fee Schedule UHC_31190C for Rev 636 Proc J0736 * Qty 1 = $3.15 at 100% = $3.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,34.14,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $34.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,29.40,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,34.14,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $34.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,34.14,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $34.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, CLINDAMYCIN PHOSP 300MG",J0736,HCPCS,636,RC,0781-3290-09,CDM,,,,both,300.000000,ME,47.4200,31.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,28.45,,,,,,,3.1500,47.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $47.42 in Billed Charges for Rev 636 Proc J0736 = $28.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,AETNA,AETNA HSHS,0.63,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,AETNA,ALL COMMERCIAL AETNA,0.98,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.98,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,CENPATICO,ALL MEDICAID CENPATICO,0.98,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.83,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,CIGNA,ALL COMMERCIAL CIGNA,0.69,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,COFINITY,COFINITY,0.98,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.93,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,0.82,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.70,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.72,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,0.48,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.83,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,HUMANA,HUMANA CHOICE CARE HMO,0.62,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1163 $0.98 in Billed Charges at 63.5% = $0.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,HUMANA,HUMANA CHOICE CARE PPO,0.83,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,HUMANA,HUMANA NATIIONAL POS HMO,0.62,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1163 $0.98 in Billed Charges at 63.5% = $0.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.72,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.98,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.49,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.82,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.74,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.90,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.63,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.71,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.9800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.71,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.61,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.71,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.71,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6013-01,CDM,,,,both,0.500000,ME,0.9800,0.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.59,,,,,,,0.0500,0.9800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.98 in Billed Charges for Rev 636 Proc J1163 = $0.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,AETNA,AETNA HSHS,2.25,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,AETNA,ALL COMMERCIAL AETNA,3.48,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,ANTHEM,ANTEHM MEDICAID,3.48,,,,,,,0.1000,3.6900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00436 Proc J0604 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45 (Service Line reduced to $3.48, claim capped at $3.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,ANTHEM,ANTHEM POS/HMO,2.37,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0604 $3.48 in Billed Charges at 68% = $2.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,ANTHEM,ANTHEM PPO,2.37,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0604 $3.48 in Billed Charges at 68% = $2.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3.48,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,CENPATICO,ALL MEDICAID CENPATICO,3.48,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2.96,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,CIGNA,ALL COMMERCIAL CIGNA,2.44,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,COFINITY,COFINITY,3.48,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,3.48,,,,,,,0.1000,3.6900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00436 Proc J0604 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45 (Service Line reduced to $3.48, claim capped at $3.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,3.48,,,,,,,0.1000,3.6900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00436 Proc J0604 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45 (Service Line reduced to $3.48, claim capped at $3.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3.31,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $3.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,2.92,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2.47,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2.54,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,1.69,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $1.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2.96,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,HUMANA,HUMANA CHOICE CARE HMO,0.10,,,,,,,0.1000,3.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.10 from Fee Schedule 005543_170 for Rev 636 Proc J0604 * Qty 1 = $0.10 at 100% = $0.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,HUMANA,HUMANA CHOICE CARE PPO,2.96,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,HUMANA,HUMANA NATIIONAL POS HMO,0.10,,,,,,,0.1000,3.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.10 from Fee Schedule 005543_170 for Rev 636 Proc J0604 * Qty 1 = $0.10 at 100% = $0.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2.54,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,3.48,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,3.48,,,,,,,0.1000,3.6900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00436 Proc J0604 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45 (Service Line reduced to $3.48, claim capped at $3.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,3.48,,,,,,,0.1000,3.6900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00436 Proc J0604 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45 (Service Line reduced to $3.48, claim capped at $3.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,MOLINA HEALTHCARE,MOLINA MEDICAID,3.69,,,,,,,0.1000,3.6900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00436 Proc J0604 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 100% = $44.45 (Service Line reduced to $3.48, claim capped at $3.48 in billed charges)... $3.48 at 106% = $3.69 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.74,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $1.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2.92,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2.61,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3.20,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $3.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.09,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0604 $3.48 in Billed Charges at 60% = $2.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.09,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0604 $3.48 in Billed Charges at 60% = $2.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,PREVEA HEALTH NETWORK,PREVEA360,2.09,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0604 $3.48 in Billed Charges at 60% = $2.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.09,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0604 $3.48 in Billed Charges at 60% = $2.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2.22,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2.51,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,TRIOLOGY,TRILOGY MEDICAID,3.48,,,,,,,0.1000,3.6900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00436 Proc J0604 at $125.60 (Base Rate) * 0.3539 (Relative Weight) = $44.45 (Total Line Payment) at 106% = $47.12 (Service Line reduced to $3.48, claim capped at $3.48 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.63,,,,,,,0.1000,3.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.63 from Fee Schedule UHC_31190C for Rev 636 Proc J0604 * Qty 1 = $1.63 at 100% = $1.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,1.63,,,,,,,0.1000,3.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.63 from Fee Schedule UHC_31190C for Rev 636 Proc J0604 * Qty 1 = $1.63 at 100% = $1.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,1.63,,,,,,,0.1000,3.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.63 from Fee Schedule UHC_31190C for Rev 636 Proc J0604 * Qty 1 = $1.63 at 100% = $1.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2.51,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2.16,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2.51,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2.51,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS per 1 mg,J0604,HCPCS,636,RC,64380-883-04,CDM,,,,both,1.000000,ME,3.4800,2.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.09,,,,,,,0.1000,3.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $3.48 in Billed Charges for Rev 636 Proc J0604 = $2.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,AETNA,AETNA HSHS,6.56,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $6.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,AETNA,ALL COMMERCIAL AETNA,10.15,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $10.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,ANTHEM,ANTHEM POS/HMO,5.10,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0168 * Qty 1 = $3.00 at 170% = $5.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,ANTHEM,ANTHEM PPO,6.30,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0168 * Qty 1 = $3.00 at 210% = $6.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.15,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $10.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,CENPATICO,ALL MEDICAID CENPATICO,10.15,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $10.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8.63,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $8.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,CIGNA,ALL COMMERCIAL CIGNA,7.11,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,COFINITY,COFINITY,10.15,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $10.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9.64,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $9.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,8.53,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $8.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.21,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.41,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,4.93,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $4.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8.63,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $8.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,HUMANA,HUMANA CHOICE CARE HMO,6.45,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0168 $10.15 in Billed Charges at 63.5% = $6.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,HUMANA,HUMANA CHOICE CARE PPO,8.63,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $8.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,HUMANA,HUMANA NATIIONAL POS HMO,6.45,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0168 $10.15 in Billed Charges at 63.5% = $6.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.41,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.15,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $10.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.08,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8.53,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $8.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.61,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.34,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $9.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.37,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0168 * Qty 1 = $3.00 at 179% = $5.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.37,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0168 * Qty 1 = $3.00 at 179% = $5.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,PREVEA HEALTH NETWORK,PREVEA360,5.37,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0168 * Qty 1 = $3.00 at 179% = $5.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.37,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.00 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0168 * Qty 1 = $3.00 at 179% = $5.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.48,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $6.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.31,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.95,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.95 from Fee Schedule UHC_31190C for Rev 636 Proc J0168 * Qty 1 = $4.95 at 100% = $4.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,4.95,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.95 from Fee Schedule UHC_31190C for Rev 636 Proc J0168 * Qty 1 = $4.95 at 100% = $4.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,4.95,,,,,,,4.9300,10.1500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.95 from Fee Schedule UHC_31190C for Rev 636 Proc J0168 * Qty 1 = $4.95 at 100% = $4.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.31,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.29,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $6.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.31,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.31,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $7.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOLN per 0.1 mg,J0168,HCPCS,636,RC,76329-3318-1,CDM,,,,both,0.100000,ME,10.1500,6.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.09,,,,,,,4.9300,10.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.15 in Billed Charges for Rev 636 Proc J0168 = $6.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,71266-9180-1,CDM,,,,both,0.100000,ME,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,1.4300,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 636 Proc J3010 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,AETNA,AETNA HSHS,5.25,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,AETNA,ALL COMMERCIAL AETNA,8.12,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $8.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.12,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $8.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,CENPATICO,ALL MEDICAID CENPATICO,8.12,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $8.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.90,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $6.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,CIGNA,ALL COMMERCIAL CIGNA,5.68,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,COFINITY,COFINITY,8.12,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $8.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.71,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,HEALTH CARE ALLIANCE,THE ALLIANCE,6.82,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $6.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.77,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.93,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,HSHS EMPLOYEES,HSHS EMPLOYEES,3.95,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $3.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.90,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $6.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,HUMANA,HUMANA CHOICE CARE PPO,6.90,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $6.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.93,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.12,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $8.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.06,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $4.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.82,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $6.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.09,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $6.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.47,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $7.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.18,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.85,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,8.1200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.85,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.03,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.85,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.85,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0641-6029-01,CDM,,,,both,0.100000,ME,8.1200,5.3600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.87,,,,,,,1.4300,8.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.12 in Billed Charges for Rev 636 Proc J3010 = $4.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,AETNA,AETNA HSHS,7.55,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $7.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,AETNA,ALL COMMERCIAL AETNA,11.69,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11.69,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,CENPATICO,ALL MEDICAID CENPATICO,11.69,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.94,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $9.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,CIGNA,ALL COMMERCIAL CIGNA,8.18,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,COFINITY,COFINITY,11.69,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.11,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $11.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,9.82,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $9.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.30,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.53,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,5.68,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.94,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $9.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,HUMANA,HUMANA CHOICE CARE PPO,9.94,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $9.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.53,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,11.69,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.85,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.82,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $9.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.77,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.75,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $10.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.46,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $7.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.42,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,11.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.42,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.25,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $7.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.42,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.42,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/250ML NS SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-5010-1,CDM,,,,both,0.100000,ME,11.6900,7.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.01,,,,,,,1.4300,11.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.69 in Billed Charges for Rev 636 Proc J3010 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,AETNA,AETNA HSHS,5.98,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $5.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,AETNA,ALL COMMERCIAL AETNA,9.25,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.25,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,CENPATICO,ALL MEDICAID CENPATICO,9.25,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.86,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $7.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,CIGNA,ALL COMMERCIAL CIGNA,6.48,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,COFINITY,COFINITY,9.25,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.79,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,7.77,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $7.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.57,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.75,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,4.50,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $4.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.86,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $7.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,HUMANA,HUMANA CHOICE CARE PPO,7.86,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $7.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.75,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.25,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.63,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.77,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $7.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.94,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.51,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $8.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.90,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $5.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.66,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,9.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.66,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.74,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $5.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.66,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.66,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $6.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-41,CDM,,,,both,0.100000,ME,9.2500,6.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.55,,,,,,,1.4300,9.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.25 in Billed Charges for Rev 636 Proc J3010 = $5.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,AETNA,AETNA HSHS,15.83,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,AETNA,ALL COMMERCIAL AETNA,24.50,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.50,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,CENPATICO,ALL MEDICAID CENPATICO,24.50,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.83,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,CIGNA,ALL COMMERCIAL CIGNA,17.15,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,COFINITY,COFINITY,24.50,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.28,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $23.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,20.58,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.40,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.89,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,11.91,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $11.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.83,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE PPO,20.83,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.89,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.50,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.25,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.58,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.38,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $18.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.54,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $22.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.64,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.64,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.64,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.19,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $15.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.64,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.64,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 2500 MCG/50ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,72572-172-01,CDM,,,,both,0.100000,ME,24.5000,16.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.70,,,,,,,1.4300,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.50 in Billed Charges for Rev 636 Proc J3010 = $14.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,AETNA,AETNA HSHS,4.06,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,AETNA,ALL COMMERCIAL AETNA,6.28,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $6.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6.28,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $6.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,CENPATICO,ALL MEDICAID CENPATICO,6.28,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $6.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.34,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $5.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,CIGNA,ALL COMMERCIAL CIGNA,4.40,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,COFINITY,COFINITY,6.28,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $6.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.97,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $5.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,5.28,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $5.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.46,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.58,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,3.05,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $3.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.34,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $5.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,HUMANA,HUMANA CHOICE CARE PPO,5.34,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $5.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.58,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,6.28,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $6.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.14,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $3.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.28,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $5.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.71,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.78,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.01,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.52,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,6.2800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.52,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.89,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.52,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.52,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $4.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 1000 MCG/20ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,63323-806-14,CDM,,,,both,0.100000,ME,6.2800,4.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.77,,,,,,,1.4300,6.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $6.28 in Billed Charges for Rev 636 Proc J3010 = $3.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,AETNA,AETNA HSHS,12.98,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $12.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,AETNA,ALL COMMERCIAL AETNA,20.09,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.09,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,CENPATICO,ALL MEDICAID CENPATICO,20.09,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.08,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $17.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,CIGNA,ALL COMMERCIAL CIGNA,14.06,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $14.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,COFINITY,COFINITY,20.09,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.09,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $19.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,16.88,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $16.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.26,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $14.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.67,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $14.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,9.76,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $9.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.08,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $17.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,HUMANA,HUMANA CHOICE CARE PPO,17.08,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $17.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.67,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $14.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.09,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.05,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,16.88,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $16.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.07,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $15.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.48,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $18.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.82,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $12.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.46,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $14.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,20.0900,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.46,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $14.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.46,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $12.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.46,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $14.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.46,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $14.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71266-9170-5,CDM,,,,both,0.100000,ME,20.0900,13.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.05,,,,,,,1.4300,20.0900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.09 in Billed Charges for Rev 636 Proc J3010 = $12.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,AETNA,AETNA HSHS,12.77,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $12.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,AETNA,ALL COMMERCIAL AETNA,19.77,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $19.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,19.77,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $19.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,CENPATICO,ALL MEDICAID CENPATICO,19.77,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $19.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,16.80,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $16.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,CIGNA,ALL COMMERCIAL CIGNA,13.84,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $13.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,COFINITY,COFINITY,19.77,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $19.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,18.78,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $18.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,16.61,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $16.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.04,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $14.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.43,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $14.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,9.61,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $9.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,16.80,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $16.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,HUMANA,HUMANA CHOICE CARE PPO,16.80,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $16.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.43,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $14.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,19.77,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $19.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.89,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $9.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,16.61,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $16.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.83,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $14.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.19,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $18.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.62,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $12.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.23,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $14.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,19.7700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.23,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $14.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.26,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $12.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.23,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $14.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.23,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $14.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,71449-013-32,CDM,,,,both,0.100000,ME,19.7700,13.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.86,,,,,,,1.4300,19.7700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.77 in Billed Charges for Rev 636 Proc J3010 = $11.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,AETNA,AETNA HSHS,4.75,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $4.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,AETNA,ALL COMMERCIAL AETNA,7.35,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,ANTHEM,ANTHEM POS/HMO,1.77,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 170% = $1.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,ANTHEM,ANTHEM PPO,2.18,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 210% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7.35,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,CENPATICO,ALL MEDICAID CENPATICO,7.35,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.25,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $6.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,CIGNA,ALL COMMERCIAL CIGNA,5.15,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,COFINITY,COFINITY,7.35,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6.98,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $6.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,HEALTH CARE ALLIANCE,THE ALLIANCE,6.17,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.22,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.37,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,HSHS EMPLOYEES,HSHS EMPLOYEES,3.57,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $3.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.25,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $6.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,HUMANA,HUMANA CHOICE CARE HMO,1.92,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,HUMANA,HUMANA CHOICE CARE PPO,6.25,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $6.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,HUMANA,HUMANA NATIIONAL POS HMO,1.92,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.37,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,LIVE360,LIVE360 HSHS HEALTHY PLAN,7.35,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.68,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $3.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.17,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5.51,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6.76,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $6.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.86,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.86,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,PREVEA HEALTH NETWORK,PREVEA360,1.86,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.86,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.69,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $4.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.29,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.72,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,UNITED HEALTHCARE,UHC ONEIDA NATION,1.72,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,UNITED HEALTHCARE,UNITED HEALTHCARE,1.72,,,,,,,1.7200,7.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.29,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.56,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $4.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.29,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.29,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $5.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-22,CDM,,,,both,10.000000,ME,7.3500,4.8500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.41,,,,,,,1.7200,7.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $7.35 in Billed Charges for Rev 636 Proc J9181 = $4.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,AETNA,AETNA HSHS,0.39,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,AETNA,ALL COMMERCIAL AETNA,0.61,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1308 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1308 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.61,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,CENPATICO,ALL MEDICAID CENPATICO,0.61,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.52,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,CIGNA,ALL COMMERCIAL CIGNA,0.43,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,COFINITY,COFINITY,0.61,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.58,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,0.51,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.43,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.45,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,0.30,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.52,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,HUMANA,HUMANA CHOICE CARE HMO,0.39,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1308 $0.61 in Billed Charges at 63.5% = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,HUMANA,HUMANA CHOICE CARE PPO,0.52,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,HUMANA,HUMANA NATIIONAL POS HMO,0.39,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1308 $0.61 in Billed Charges at 63.5% = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.45,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.61,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.31,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.51,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.46,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.56,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1308 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1308 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1308 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1308 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.39,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.44,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J1308 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J1308 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.6100,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J1308 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.44,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.38,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.44,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.44,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, FAMOTIDINE, 0.25 MG",J1308,HCPCS,636,RC,63323-739-11,CDM,,,,both,0.250000,ME,0.6100,0.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.37,,,,,,,0.0200,0.6100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.61 in Billed Charges for Rev 636 Proc J1308 = $0.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,AETNA,AETNA HSHS,3.99,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,AETNA,ALL COMMERCIAL AETNA,6.17,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,ANTHEM,ANTHEM POS/HMO,2.35,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 170% = $2.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,ANTHEM,ANTHEM PPO,2.90,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 210% = $2.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6.17,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,CENPATICO,ALL MEDICAID CENPATICO,6.17,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.24,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,CIGNA,ALL COMMERCIAL CIGNA,4.32,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,COFINITY,COFINITY,6.17,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.86,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $5.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,5.18,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.38,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.50,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,3.00,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $3.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.24,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,HUMANA,HUMANA CHOICE CARE HMO,3.92,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0169 $6.17 in Billed Charges at 63.5% = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,HUMANA,HUMANA CHOICE CARE PPO,5.24,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,HUMANA,HUMANA NATIIONAL POS HMO,3.92,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0169 $6.17 in Billed Charges at 63.5% = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.50,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,6.17,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.09,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $3.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.18,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.63,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.68,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.47,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 179% = $2.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.47,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 179% = $2.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,PREVEA HEALTH NETWORK,PREVEA360,2.47,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 179% = $2.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.47,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 179% = $2.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.94,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $3.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.44,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.28,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.28 from Fee Schedule UHC_31190C for Rev 636 Proc J0169 * Qty 1 = $2.28 at 100% = $2.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,UNITED HEALTHCARE,UHC ONEIDA NATION,2.28,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.28 from Fee Schedule UHC_31190C for Rev 636 Proc J0169 * Qty 1 = $2.28 at 100% = $2.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,UNITED HEALTHCARE,UNITED HEALTHCARE,2.28,,,,,,,2.2800,6.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $2.28 from Fee Schedule UHC_31190C for Rev 636 Proc J0169 * Qty 1 = $2.28 at 100% = $2.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.44,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.83,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $3.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.44,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.44,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-168-01,CDM,,,,both,0.100000,ME,6.1700,4.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.70,,,,,,,2.2800,6.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $6.17 in Billed Charges for Rev 636 Proc J0169 = $3.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,AETNA,AETNA HSHS,10.55,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,AETNA,ALL COMMERCIAL AETNA,16.33,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,ANTHEM,ANTHEM POS/HMO,0.73,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.43 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0165 * Qty 1 = $0.43 at 170% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,ANTHEM,ANTHEM PPO,0.90,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.43 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0165 * Qty 1 = $0.43 at 210% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.33,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,CENPATICO,ALL MEDICAID CENPATICO,16.33,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.88,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,CIGNA,ALL COMMERCIAL CIGNA,11.43,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,COFINITY,COFINITY,16.33,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.51,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,13.72,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.59,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $11.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.92,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,7.94,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $7.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.88,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,HUMANA,HUMANA CHOICE CARE HMO,10.37,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0165 $16.33 in Billed Charges at 63.5% = $10.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,HUMANA,HUMANA CHOICE CARE PPO,13.88,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,HUMANA,HUMANA NATIIONAL POS HMO,10.37,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0165 $16.33 in Billed Charges at 63.5% = $10.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.92,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.33,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.17,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.72,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.25,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.02,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $15.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.77,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.43 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0165 * Qty 1 = $0.43 at 179% = $0.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.77,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.43 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0165 * Qty 1 = $0.43 at 179% = $0.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA360,0.77,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.43 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0165 * Qty 1 = $0.43 at 179% = $0.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.77,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.43 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0165 * Qty 1 = $0.43 at 179% = $0.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.42,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $10.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.76,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.71,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule UHC_31190C for Rev 636 Proc J0165 * Qty 1 = $0.71 at 100% = $0.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,0.71,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule UHC_31190C for Rev 636 Proc J0165 * Qty 1 = $0.71 at 100% = $0.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,0.71,,,,,,,0.7100,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule UHC_31190C for Rev 636 Proc J0165 * Qty 1 = $0.71 at 100% = $0.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.76,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.12,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $10.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.76,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.76,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN per 0.1 mg,J0165,HCPCS,636,RC,76329-9060-0,CDM,,,,both,0.100000,ME,16.3300,10.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.80,,,,,,,0.7100,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.33 in Billed Charges for Rev 636 Proc J0165 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,AETNA,AETNA HSHS,6.95,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $6.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,AETNA,ALL COMMERCIAL AETNA,10.76,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $10.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,ANTHEM,ANTHEM POS/HMO,1.89,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 170% = $1.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,ANTHEM,ANTHEM PPO,2.33,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 210% = $2.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.76,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $10.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,CENPATICO,ALL MEDICAID CENPATICO,10.76,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $10.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.15,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $9.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,CIGNA,ALL COMMERCIAL CIGNA,7.53,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $7.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,COFINITY,COFINITY,10.76,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $10.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.22,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $10.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,9.04,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $9.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.64,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $7.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.85,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,5.23,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $5.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.15,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $9.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,HUMANA,HUMANA CHOICE CARE HMO,6.83,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0166 $10.76 in Billed Charges at 63.5% = $6.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,HUMANA,HUMANA CHOICE CARE PPO,9.15,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $9.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,HUMANA,HUMANA NATIIONAL POS HMO,6.83,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0166 $10.76 in Billed Charges at 63.5% = $6.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.85,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.76,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $10.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.38,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $5.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.04,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $9.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.07,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.90,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $9.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.99,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 179% = $1.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.99,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 179% = $1.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,PREVEA HEALTH NETWORK,PREVEA360,1.99,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 179% = $1.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.99,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 179% = $1.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.87,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $6.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.75,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.83,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.83 from Fee Schedule UHC_31190C for Rev 636 Proc J0166 * Qty 1 = $1.83 at 100% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,1.83,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.83 from Fee Schedule UHC_31190C for Rev 636 Proc J0166 * Qty 1 = $1.83 at 100% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,1.83,,,,,,,1.8300,10.7600,fee schedule,ST VINCENT HOSPITAL (ACU). $1.83 from Fee Schedule UHC_31190C for Rev 636 Proc J0166 * Qty 1 = $1.83 at 100% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.75,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.67,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $6.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.75,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.75,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE per 0.1 mg,J0166,HCPCS,636,RC,54288-103-10,CDM,,,,both,0.100000,ME,10.7600,7.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.46,,,,,,,1.8300,10.7600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.76 in Billed Charges for Rev 636 Proc J0166 = $6.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,AETNA,AETNA HSHS,114.62,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $114.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,AETNA,AETNA MEDICARE,45.03,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,AETNA,ALL COMMERCIAL AETNA,177.43,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $177.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,45.03,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,ANTHEM,ANTHEM POS/HMO,76.55,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $45.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1299 * Qty 1 = $45.03 at 170% = $76.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,ANTHEM,ANTHEM PPO,94.56,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $45.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1299 * Qty 1 = $45.03 at 210% = $94.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,177.43,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $177.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,CENPATICO,ALL MEDICAID CENPATICO,177.43,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $177.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,150.82,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $150.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,CIGNA,ALL COMMERCIAL CIGNA,124.20,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $124.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,COFINITY,COFINITY,177.43,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $177.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,168.56,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $168.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,149.04,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $149.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,125.98,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $125.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,129.52,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $129.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,86.23,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $86.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,150.82,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $150.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HUMANA,HUMANA CHOICE CARE HMO,112.67,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1299 $177.43 in Billed Charges at 63.5% = $112.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HUMANA,HUMANA CHOICE CARE PPO,150.82,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $150.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HUMANA,HUMANA MEDICARE ADVANTAGE,45.03,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,HUMANA,HUMANA NATIIONAL POS HMO,112.67,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1299 $177.43 in Billed Charges at 63.5% = $112.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,129.52,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $129.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,177.43,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $177.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,45.03,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,MOLINA HEALTHCARE,MOLINA MEDICARE,45.03,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,88.72,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $88.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,149.04,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $149.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,NAPHCARE,ALL COMMERICAL NAPHCARE,101.31,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,133.07,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $133.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,163.24,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $163.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,80.60,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $45.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1299 * Qty 1 = $45.03 at 179% = $80.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,80.60,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $45.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1299 * Qty 1 = $45.03 at 179% = $80.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,PREVEA HEALTH NETWORK,PREVEA360,80.60,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $45.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1299 * Qty 1 = $45.03 at 179% = $80.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,80.60,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $45.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1299 * Qty 1 = $45.03 at 179% = $80.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,113.25,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $113.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,45.48,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,127.75,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $127.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,74.30,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $74.30 from Fee Schedule UHC_31190C for Rev 636 Proc J1299 * Qty 1 = $74.30 at 100% = $74.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,74.30,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $74.30 from Fee Schedule UHC_31190C for Rev 636 Proc J1299 * Qty 1 = $74.30 at 100% = $74.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,45.03,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,74.30,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). $74.30 from Fee Schedule UHC_31190C for Rev 636 Proc J1299 * Qty 1 = $74.30 at 100% = $74.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,UNITY HEALTH PLAN,UNITY HOSPICE,45.03,,,,,,,45.0300,177.4300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,127.75,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $127.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,110.01,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $110.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,127.75,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $127.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,127.75,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $127.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ECULIZUMAB 300 MG/30ML SOLN 30 ML VIAL per 2 mg,J1299,HCPCS,636,RC,25682-001-01,CDM,,,,both,2.000000,ME,177.4300,117.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,106.46,,,,,,,45.0300,177.4300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $177.43 in Billed Charges for Rev 636 Proc J1299 = $106.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,AETNA,AETNA HSHS,60.63,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $60.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,AETNA,AETNA MEDICARE,34.12,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,AETNA,ALL COMMERCIAL AETNA,93.85,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $93.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,ANTHEM,ANTEHM MEDICAID,93.85,,,,,,,34.1200,99.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9334 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $93.85, claim capped at $93.85 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,34.12,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,ANTHEM,ANTHEM POS/HMO,58.00,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $34.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9334 * Qty 1 = $34.12 at 170% = $58.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,ANTHEM,ANTHEM PPO,71.65,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $34.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9334 * Qty 1 = $34.12 at 210% = $71.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,93.85,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $93.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,CENPATICO,ALL MEDICAID CENPATICO,93.85,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $93.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.77,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $79.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,CIGNA,ALL COMMERCIAL CIGNA,65.70,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $65.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,COFINITY,COFINITY,93.85,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $93.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,93.85,,,,,,,34.1200,99.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9334 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $93.85, claim capped at $93.85 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,93.85,,,,,,,34.1200,99.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9334 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $93.85, claim capped at $93.85 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,89.16,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $89.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,78.83,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $78.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.63,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $66.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,68.51,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $68.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,45.61,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $45.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.77,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $79.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HUMANA,HUMANA CHOICE CARE HMO,56.32,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $56.32 from Fee Schedule 005543_170 for Rev 636 Proc J9334 * Qty 1 = $56.32 at 100% = $56.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HUMANA,HUMANA CHOICE CARE PPO,79.77,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $79.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,34.12,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,HUMANA,HUMANA NATIIONAL POS HMO,56.32,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $56.32 from Fee Schedule 005543_170 for Rev 636 Proc J9334 * Qty 1 = $56.32 at 100% = $56.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,68.51,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $68.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,93.85,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $93.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,93.85,,,,,,,34.1200,99.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9334 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $93.85, claim capped at $93.85 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,34.12,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,93.85,,,,,,,34.1200,99.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9334 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $93.85, claim capped at $93.85 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,99.48,,,,,,,34.1200,99.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9334 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $93.85, claim capped at $93.85 in billed charges)... $93.85 at 106% = $99.48 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,34.12,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.93,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $46.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.83,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $78.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,76.76,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,70.39,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $70.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,86.34,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $86.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,61.07,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $34.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9334 * Qty 1 = $34.12 at 179% = $61.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,61.07,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $34.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9334 * Qty 1 = $34.12 at 179% = $61.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,PREVEA HEALTH NETWORK,PREVEA360,61.07,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $34.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9334 * Qty 1 = $34.12 at 179% = $61.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,61.07,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $34.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9334 * Qty 1 = $34.12 at 179% = $61.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,59.90,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $59.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,34.46,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,67.57,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $67.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,TRIOLOGY,TRILOGY MEDICAID,93.85,,,,,,,34.1200,99.4800,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9334 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 106% = $3,433.75 (Service Line reduced to $93.85, claim capped at $93.85 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,56.30,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $56.30 from Fee Schedule UHC_31190C for Rev 636 Proc J9334 * Qty 1 = $56.30 at 100% = $56.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,56.30,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $56.30 from Fee Schedule UHC_31190C for Rev 636 Proc J9334 * Qty 1 = $56.30 at 100% = $56.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,34.12,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,56.30,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). $56.30 from Fee Schedule UHC_31190C for Rev 636 Proc J9334 * Qty 1 = $56.30 at 100% = $56.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,UNITY HEALTH PLAN,UNITY HOSPICE,34.12,,,,,,,34.1200,99.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,67.57,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $67.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,58.19,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $58.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,67.57,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $67.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,67.57,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $67.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC 180-2000 MG-UNIT/ML SOLN per 2 mg,J9334,HCPCS,636,RC,73475-3102-3,CDM,,,,both,2.000000,ME,93.8500,61.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,56.31,,,,,,,34.1200,99.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.85 in Billed Charges for Rev 636 Proc J9334 = $56.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,AETNA,AETNA MEDICARE,1.34,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1.34,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,2.28,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0750 * Qty 1 = $1.34 at 170% = $2.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,ANTHEM,ANTHEM PPO,2.81,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0750 * Qty 1 = $1.34 at 210% = $2.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,1.79,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.79 from Fee Schedule 005543_170 for Rev 636 Proc J0750 * Qty 1 = $1.79 at 100% = $1.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA MEDICARE ADVANTAGE,1.34,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,1.79,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.79 from Fee Schedule 005543_170 for Rev 636 Proc J0750 * Qty 1 = $1.79 at 100% = $1.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1.34,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,MOLINA HEALTHCARE,MOLINA MEDICARE,1.34,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,NAPHCARE,ALL COMMERICAL NAPHCARE,3.02,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.40,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0750 * Qty 1 = $1.34 at 179% = $2.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.40,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0750 * Qty 1 = $1.34 at 179% = $2.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,2.40,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0750 * Qty 1 = $1.34 at 179% = $2.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.40,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0750 * Qty 1 = $1.34 at 179% = $2.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1.35,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.21,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule UHC_31190C for Rev 636 Proc J0750 * Qty 1 = $2.21 at 100% = $2.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,2.21,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule UHC_31190C for Rev 636 Proc J0750 * Qty 1 = $2.21 at 100% = $2.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1.34,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,2.21,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule UHC_31190C for Rev 636 Proc J0750 * Qty 1 = $2.21 at 100% = $2.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,UNITY HEALTH PLAN,UNITY HOSPICE,1.34,,,,,,,1.3400,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EMTRICITABINE-TENOFOVIR 200-300 MG TABS per 1 each,J0750,HCPCS,636,RC,60687-719-95,CDM,,,,both,1.000000,EA,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,1.3400,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 636 Proc J0750 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,AETNA,AETNA HSHS,7.91,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,AETNA,ALL COMMERCIAL AETNA,12.25,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM POS/HMO,0.36,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 170% = $0.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM PPO,0.44,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 210% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.25,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,CENPATICO,ALL MEDICAID CENPATICO,12.25,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.41,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,CIGNA,ALL COMMERCIAL CIGNA,8.58,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,COFINITY,COFINITY,12.25,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.64,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $11.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,10.29,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.70,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.94,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.95,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.41,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE HMO,0.44,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE PPO,10.41,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,HUMANA,HUMANA NATIIONAL POS HMO,0.44,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.94,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.25,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.13,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.29,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.19,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $9.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.27,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.38,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.38,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360,0.38,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.38,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.82,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.82,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.35,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.35,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.35,,,,,,,0.3500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.82,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.60,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.82,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.82,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 100 MG/10ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-120-39,CDM,,,,both,10.000000,ME,12.2500,8.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.35,,,,,,,0.3500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 636 Proc J1805 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,AETNA,AETNA HSHS,15.83,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $15.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,AETNA,ALL COMMERCIAL AETNA,24.50,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM POS/HMO,0.36,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 170% = $0.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,ANTHEM,ANTHEM PPO,0.44,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 210% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.50,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,CENPATICO,ALL MEDICAID CENPATICO,24.50,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.83,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,CIGNA,ALL COMMERCIAL CIGNA,17.15,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,COFINITY,COFINITY,24.50,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.28,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $23.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,20.58,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.40,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.89,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,11.91,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $11.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.83,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE HMO,0.44,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,HUMANA,HUMANA CHOICE CARE PPO,20.83,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $20.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,HUMANA,HUMANA NATIIONAL POS HMO,0.44,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.89,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.50,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.25,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.58,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $20.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.38,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $18.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.54,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $22.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.38,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.38,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360,0.38,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.38,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.64,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.64,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.35,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.35,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.35,,,,,,,0.3500,24.5000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.64,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.19,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $15.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.64,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.64,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, ESMOLOL HCL, 10MG",J1805,HCPCS,636,RC,67457-182-00,CDM,,,,both,10.000000,ME,24.5000,16.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.70,,,,,,,0.3500,24.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.50 in Billed Charges for Rev 636 Proc J1805 = $14.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,AETNA,AETNA HSHS,3.68,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $3.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,AETNA,ALL COMMERCIAL AETNA,5.69,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $5.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,ANTHEM,ANTHEM POS/HMO,0.36,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 170% = $0.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,ANTHEM,ANTHEM PPO,0.44,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 210% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.69,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $5.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,CENPATICO,ALL MEDICAID CENPATICO,5.69,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $5.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.84,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,CIGNA,ALL COMMERCIAL CIGNA,3.98,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $3.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,COFINITY,COFINITY,5.69,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $5.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.41,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $5.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,4.78,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.04,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.15,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,2.77,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $2.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.84,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,HUMANA,HUMANA CHOICE CARE HMO,0.44,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,HUMANA,HUMANA CHOICE CARE PPO,4.84,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,HUMANA,HUMANA NATIIONAL POS HMO,0.44,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.15,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.69,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $5.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.85,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $2.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.78,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.27,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.23,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $5.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.38,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.38,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,PREVEA HEALTH NETWORK,PREVEA360,0.38,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.38,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.63,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $3.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.10,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.35,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.35,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.35,,,,,,,0.3500,5.6900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.10,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.53,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $3.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.10,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.10,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-309-82,CDM,,,,both,10.000000,ME,5.6900,3.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.41,,,,,,,0.3500,5.6900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.69 in Billed Charges for Rev 636 Proc J1805 = $3.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,AETNA,AETNA HSHS,1.85,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $1.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,AETNA,ALL COMMERCIAL AETNA,2.87,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,ANTHEM,ANTHEM POS/HMO,0.70,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 170% = $0.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,ANTHEM,ANTHEM PPO,0.86,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 210% = $0.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2.87,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,CENPATICO,ALL MEDICAID CENPATICO,2.87,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2.44,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,CIGNA,ALL COMMERCIAL CIGNA,2.01,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,COFINITY,COFINITY,2.87,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2.73,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,HEALTH CARE ALLIANCE,THE ALLIANCE,2.41,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2.04,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2.10,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,HSHS EMPLOYEES,HSHS EMPLOYEES,1.39,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $1.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2.44,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,HUMANA,HUMANA CHOICE CARE HMO,0.68,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule 005543_170 for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,HUMANA,HUMANA CHOICE CARE PPO,2.44,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,HUMANA,HUMANA NATIIONAL POS HMO,0.68,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule 005543_170 for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2.10,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,LIVE360,LIVE360 HSHS HEALTHY PLAN,2.87,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.44,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $1.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2.41,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2.15,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2.64,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.73,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 179% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.73,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 179% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,PREVEA HEALTH NETWORK,PREVEA360,0.73,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 179% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.73,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 179% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.83,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $1.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2.07,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.68,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule UHC_31190C for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.68,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule UHC_31190C for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.68,,,,,,,0.6800,2.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule UHC_31190C for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2.07,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.78,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $1.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2.07,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2.07,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $2.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-450-01,CDM,,,,both,10.000000,ME,2.8700,1.8900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1.72,,,,,,,0.6800,2.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $2.87 in Billed Charges for Rev 636 Proc J1806 = $1.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,AETNA,AETNA HSHS,119.25,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $119.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,AETNA,ALL COMMERCIAL AETNA,184.60,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $184.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,ANTHEM,ANTHEM POS/HMO,125.53,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $184.60 in Billed Charges at 68% = $125.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,ANTHEM,ANTHEM PPO,125.53,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $184.60 in Billed Charges at 68% = $125.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,184.60,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $184.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,CENPATICO,ALL MEDICAID CENPATICO,184.60,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $184.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,156.91,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $156.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,CIGNA,ALL COMMERCIAL CIGNA,129.22,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $129.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,COFINITY,COFINITY,184.60,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $184.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,175.37,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $175.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,155.06,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $155.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,131.07,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $131.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,134.76,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $134.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,89.72,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $89.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,156.91,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $156.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,HUMANA,HUMANA CHOICE CARE PPO,156.91,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $156.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,134.76,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $134.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,184.60,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $184.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,92.30,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $92.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,155.06,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $155.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,138.45,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $138.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,169.83,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $169.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,110.76,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $184.60 in Billed Charges at 60% = $110.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,110.76,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $184.60 in Billed Charges at 60% = $110.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,PREVEA HEALTH NETWORK,PREVEA360,110.76,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $184.60 in Billed Charges at 60% = $110.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,110.76,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $184.60 in Billed Charges at 60% = $110.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,117.83,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $117.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,132.91,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $132.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,132.91,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $132.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,114.45,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $114.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,132.91,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $132.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,132.91,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $132.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,0641-6238-25,CDM,,,,both,50.000000,ME,184.6000,121.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,110.76,,,,,,,89.7200,184.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $184.60 in Billed Charges for Rev 636 Proc J3490 = $110.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,AETNA,AETNA HSHS,138.47,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $138.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,AETNA,ALL COMMERCIAL AETNA,214.35,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $214.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,ANTHEM,ANTHEM POS/HMO,145.76,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $214.35 in Billed Charges at 68% = $145.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,ANTHEM,ANTHEM PPO,145.76,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $214.35 in Billed Charges at 68% = $145.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,214.35,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $214.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,CENPATICO,ALL MEDICAID CENPATICO,214.35,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $214.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,182.20,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $182.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,CIGNA,ALL COMMERCIAL CIGNA,150.05,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $150.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,COFINITY,COFINITY,214.35,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $214.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,203.63,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $203.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,180.05,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $180.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,152.19,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $152.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,156.48,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $156.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,104.17,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $104.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,182.20,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $182.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,HUMANA,HUMANA CHOICE CARE PPO,182.20,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $182.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,156.48,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $156.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,214.35,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $214.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,107.18,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $107.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,180.05,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $180.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,160.76,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $160.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,197.20,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $197.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,128.61,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $214.35 in Billed Charges at 60% = $128.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,128.61,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $214.35 in Billed Charges at 60% = $128.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,PREVEA HEALTH NETWORK,PREVEA360,128.61,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $214.35 in Billed Charges at 60% = $128.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,128.61,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $214.35 in Billed Charges at 60% = $128.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,136.82,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $136.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,154.33,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $154.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,154.33,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $154.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,132.90,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $132.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,154.33,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $154.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,154.33,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $154.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,42023-216-25,CDM,,,,both,50.000000,ME,214.3500,141.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,128.61,,,,,,,104.1700,214.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $214.35 in Billed Charges for Rev 636 Proc J3490 = $128.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,AETNA,AETNA HSHS,3.35,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,AETNA,ALL COMMERCIAL AETNA,5.18,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,ANTHEM,ANTHEM POS/HMO,0.90,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 170% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,ANTHEM,ANTHEM PPO,1.11,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 210% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.18,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,CENPATICO,ALL MEDICAID CENPATICO,5.18,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.40,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $4.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,CIGNA,ALL COMMERCIAL CIGNA,3.63,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,COFINITY,COFINITY,5.18,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4.92,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,4.35,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $4.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.68,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.78,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,2.52,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $2.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.40,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $4.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,HUMANA,HUMANA CHOICE CARE HMO,0.99,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,HUMANA,HUMANA CHOICE CARE PPO,4.40,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $4.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,HUMANA,HUMANA NATIIONAL POS HMO,0.99,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.78,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.18,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.59,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $2.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.35,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $4.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.89,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4.77,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $4.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.95,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.95,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,PREVEA HEALTH NETWORK,PREVEA360,0.95,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.95,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.31,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.73,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.87,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,0.87,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,0.87,,,,,,,0.8700,5.1800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.73,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.21,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.73,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.73,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 100 MG/ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-91,CDM,,,,both,10.000000,ME,5.1800,3.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.11,,,,,,,0.8700,5.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.18 in Billed Charges for Rev 636 Proc J1650 = $3.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,AETNA,AETNA HSHS,4.41,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,AETNA,ALL COMMERCIAL AETNA,6.83,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $6.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,ANTHEM,ANTHEM POS/HMO,0.90,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 170% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,ANTHEM,ANTHEM PPO,1.11,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 210% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6.83,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $6.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,CENPATICO,ALL MEDICAID CENPATICO,6.83,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $6.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.81,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $5.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,CIGNA,ALL COMMERCIAL CIGNA,4.78,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,COFINITY,COFINITY,6.83,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $6.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6.49,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $6.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,5.74,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $5.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.85,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.99,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,3.32,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $3.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.81,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $5.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,HUMANA,HUMANA CHOICE CARE HMO,0.99,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,HUMANA,HUMANA CHOICE CARE PPO,5.81,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $5.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,HUMANA,HUMANA NATIIONAL POS HMO,0.99,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.99,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,6.83,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $6.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.42,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $3.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.74,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $5.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5.12,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $5.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6.28,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $6.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.95,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.95,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,PREVEA HEALTH NETWORK,PREVEA360,0.95,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.95,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.36,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.92,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.87,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,UNITED HEALTHCARE,UHC ONEIDA NATION,0.87,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,UNITED HEALTHCARE,UNITED HEALTHCARE,0.87,,,,,,,0.8700,6.8300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.92,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.23,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.92,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.92,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-437-91,CDM,,,,both,10.000000,ME,6.8300,4.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.10,,,,,,,0.8700,6.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $6.83 in Billed Charges for Rev 636 Proc J1650 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,AETNA,AETNA HSHS,10.55,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,AETNA,ALL COMMERCIAL AETNA,16.33,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,ANTHEM,ANTHEM POS/HMO,0.90,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 170% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,ANTHEM,ANTHEM PPO,1.11,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 210% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.33,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,CENPATICO,ALL MEDICAID CENPATICO,16.33,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.88,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,CIGNA,ALL COMMERCIAL CIGNA,11.43,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,COFINITY,COFINITY,16.33,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.51,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,13.72,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.59,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $11.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.92,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,7.94,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $7.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.88,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,HUMANA,HUMANA CHOICE CARE HMO,0.99,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,HUMANA,HUMANA CHOICE CARE PPO,13.88,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,HUMANA,HUMANA NATIIONAL POS HMO,0.99,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.92,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.33,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.17,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.72,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.25,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.02,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $15.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.95,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.95,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA360,0.95,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.95,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.42,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $10.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.76,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.87,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,0.87,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,0.87,,,,,,,0.8700,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.76,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.12,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $10.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.76,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.76,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ ENOXAPARIN SODIUM,J1650,HCPCS,636,RC,71288-410-81,CDM,,,,both,10.000000,ME,16.3300,10.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.80,,,,,,,0.8700,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.33 in Billed Charges for Rev 636 Proc J1650 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,AETNA,AETNA HSHS,7.91,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,AETNA,ALL COMMERCIAL AETNA,12.25,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM POS/HMO,0.90,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 170% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM PPO,1.11,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 210% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.25,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,CENPATICO,ALL MEDICAID CENPATICO,12.25,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.41,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,CIGNA,ALL COMMERCIAL CIGNA,8.58,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,COFINITY,COFINITY,12.25,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.64,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $11.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,10.29,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.70,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.94,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.95,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.41,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE HMO,0.99,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE PPO,10.41,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,HUMANA,HUMANA NATIIONAL POS HMO,0.99,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.94,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.25,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.13,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.29,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.19,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $9.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.27,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.95,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.95,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360,0.95,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.95,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.82,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.82,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.87,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.87,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.87,,,,,,,0.8700,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.82,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.60,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.82,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.82,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 40 MG/0.4ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-433-91,CDM,,,,both,10.000000,ME,12.2500,8.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.35,,,,,,,0.8700,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 636 Proc J1650 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,AETNA,AETNA HSHS,5.28,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,AETNA,ALL COMMERCIAL AETNA,8.17,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,ANTHEM,ANTHEM POS/HMO,0.90,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 170% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,ANTHEM,ANTHEM PPO,1.11,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 210% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.17,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,CENPATICO,ALL MEDICAID CENPATICO,8.17,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.94,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,CIGNA,ALL COMMERCIAL CIGNA,5.72,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,COFINITY,COFINITY,8.17,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.76,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $7.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,6.86,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.80,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.96,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,3.97,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $3.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.94,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,HUMANA,HUMANA CHOICE CARE HMO,0.99,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,HUMANA,HUMANA CHOICE CARE PPO,6.94,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $6.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,HUMANA,HUMANA NATIIONAL POS HMO,0.99,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.96,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.17,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.09,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $4.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.86,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.13,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.52,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $7.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.95,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.95,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA360,0.95,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.95,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.21,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.88,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.87,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.87,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.87,,,,,,,0.8700,8.1700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.88,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.07,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.88,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.88,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 60 MG/0.6ML SOSY 0.6 ML SYRINGE per 10 mg,J1650,HCPCS,636,RC,71288-434-84,CDM,,,,both,10.000000,ME,8.1700,5.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.90,,,,,,,0.8700,8.1700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.17 in Billed Charges for Rev 636 Proc J1650 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,AETNA,AETNA HSHS,4.44,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,AETNA,ALL COMMERCIAL AETNA,6.88,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $6.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,ANTHEM,ANTHEM POS/HMO,0.90,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 170% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,ANTHEM,ANTHEM PPO,1.11,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 210% = $1.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6.88,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $6.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,CENPATICO,ALL MEDICAID CENPATICO,6.88,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $6.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5.85,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,CIGNA,ALL COMMERCIAL CIGNA,4.82,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,COFINITY,COFINITY,6.88,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $6.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,6.54,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,HEALTH CARE ALLIANCE,THE ALLIANCE,5.78,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4.88,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.02,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $5.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,HSHS EMPLOYEES,HSHS EMPLOYEES,3.34,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $3.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5.85,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,HUMANA,HUMANA CHOICE CARE HMO,0.99,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,HUMANA,HUMANA CHOICE CARE PPO,5.85,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,HUMANA,HUMANA NATIIONAL POS HMO,0.99,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.99 from Fee Schedule 005543_170 for Rev 636 Proc J1650 * Qty 1 = $0.99 at 100% = $0.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.02,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $5.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,LIVE360,LIVE360 HSHS HEALTHY PLAN,6.88,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $6.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.44,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $3.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5.78,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5.16,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $5.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6.33,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $6.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.95,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.95,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,PREVEA HEALTH NETWORK,PREVEA360,0.95,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.95,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.53 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1650 * Qty 1 = $0.53 at 179% = $0.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.39,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4.95,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.87,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,UNITED HEALTHCARE,UHC ONEIDA NATION,0.87,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,UNITED HEALTHCARE,UNITED HEALTHCARE,0.87,,,,,,,0.8700,6.8800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.87 from Fee Schedule UHC_31190C for Rev 636 Proc J1650 * Qty 1 = $0.87 at 100% = $0.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4.95,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.27,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4.95,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4.95,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENOXAPARIN 80 MG/0.8 ML SOSY per 10 mg,J1650,HCPCS,636,RC,71288-436-88,CDM,,,,both,10.000000,ME,6.8800,4.5400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.13,,,,,,,0.8700,6.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $6.88 in Billed Charges for Rev 636 Proc J1650 = $4.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,AETNA,AETNA HSHS,35.48,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $35.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,AETNA,AETNA MEDICARE,7.57,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,AETNA,ALL COMMERCIAL AETNA,54.93,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $54.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,ANTHEM,ANTEHM MEDICAID,54.93,,,,,,,7.5700,58.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $54.93, claim capped at $54.93 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.57,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,ANTHEM,ANTHEM POS/HMO,12.87,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 170% = $12.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,ANTHEM,ANTHEM PPO,15.90,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 210% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,54.93,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $54.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,CENPATICO,ALL MEDICAID CENPATICO,54.93,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $54.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,46.69,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $46.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,CIGNA,ALL COMMERCIAL CIGNA,38.45,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $38.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,COFINITY,COFINITY,54.93,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $54.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,54.93,,,,,,,7.5700,58.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $54.93, claim capped at $54.93 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,54.93,,,,,,,7.5700,58.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $54.93, claim capped at $54.93 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,52.18,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $52.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HEALTH CARE ALLIANCE,THE ALLIANCE,46.14,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $46.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,39.00,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $39.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,40.10,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $40.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HSHS EMPLOYEES,HSHS EMPLOYEES,26.70,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $26.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,46.69,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $46.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HUMANA,HUMANA CHOICE CARE HMO,11.59,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HUMANA,HUMANA CHOICE CARE PPO,46.69,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $46.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HUMANA,HUMANA MEDICARE ADVANTAGE,7.57,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,HUMANA,HUMANA NATIIONAL POS HMO,11.59,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,40.10,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $40.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,LIVE360,LIVE360 HSHS HEALTHY PLAN,54.93,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $54.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,54.93,,,,,,,7.5700,58.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $54.93, claim capped at $54.93 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.57,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,54.93,,,,,,,7.5700,58.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $54.93, claim capped at $54.93 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,MOLINA HEALTHCARE,MOLINA MEDICAID,58.23,,,,,,,7.5700,58.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $54.93, claim capped at $54.93 in billed charges)... $54.93 at 106% = $58.23 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,MOLINA HEALTHCARE,MOLINA MEDICARE,7.57,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27.47,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $27.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,46.14,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $46.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,NAPHCARE,ALL COMMERICAL NAPHCARE,17.03,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,41.20,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $41.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,50.54,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $50.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.55,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.55,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,PREVEA HEALTH NETWORK,PREVEA360,13.55,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.55,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,35.06,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $35.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.65,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,39.55,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $39.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,TRIOLOGY,TRILOGY MEDICAID,54.93,,,,,,,7.5700,58.2300,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 106% = $91.46 (Service Line reduced to $54.93, claim capped at $54.93 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.49,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,UNITED HEALTHCARE,UHC ONEIDA NATION,12.49,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.57,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,UNITED HEALTHCARE,UNITED HEALTHCARE,12.49,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,UNITY HEALTH PLAN,UNITY HOSPICE,7.57,,,,,,,7.5700,58.2300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,39.55,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $39.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,34.06,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $34.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,39.55,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $39.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,39.55,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $39.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1308-01,CDM,,,,both,1000.000000,UN,54.9300,36.2500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,32.96,,,,,,,7.5700,58.2300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $54.93 in Billed Charges for Rev 636 Proc Q5106 = $32.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,AETNA,AETNA HSHS,52.60,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $52.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,AETNA,AETNA MEDICARE,7.57,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,AETNA,ALL COMMERCIAL AETNA,81.42,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $81.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,ANTHEM,ANTEHM MEDICAID,81.42,,,,,,,7.5700,86.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.42, claim capped at $81.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.57,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,ANTHEM,ANTHEM POS/HMO,12.87,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 170% = $12.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,ANTHEM,ANTHEM PPO,15.90,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 210% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,81.42,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $81.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,CENPATICO,ALL MEDICAID CENPATICO,81.42,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $81.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.21,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $69.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,CIGNA,ALL COMMERCIAL CIGNA,56.99,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $56.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,COFINITY,COFINITY,81.42,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $81.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,81.42,,,,,,,7.5700,86.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.42, claim capped at $81.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,81.42,,,,,,,7.5700,86.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.42, claim capped at $81.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.35,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $77.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,68.39,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $68.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,57.81,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $57.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.44,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $59.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,39.57,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $39.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.21,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $69.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HUMANA,HUMANA CHOICE CARE HMO,11.59,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HUMANA,HUMANA CHOICE CARE PPO,69.21,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $69.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HUMANA,HUMANA MEDICARE ADVANTAGE,7.57,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,HUMANA,HUMANA NATIIONAL POS HMO,11.59,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.44,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $59.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,81.42,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $81.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,81.42,,,,,,,7.5700,86.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.42, claim capped at $81.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.57,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,81.42,,,,,,,7.5700,86.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.42, claim capped at $81.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,MOLINA HEALTHCARE,MOLINA MEDICAID,86.31,,,,,,,7.5700,86.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.42, claim capped at $81.42 in billed charges)... $81.42 at 106% = $86.31 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,MOLINA HEALTHCARE,MOLINA MEDICARE,7.57,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,40.71,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $40.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.39,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $68.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,NAPHCARE,ALL COMMERICAL NAPHCARE,17.03,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.07,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $61.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,74.91,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $74.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.55,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.55,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,PREVEA HEALTH NETWORK,PREVEA360,13.55,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.55,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,51.97,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $51.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.65,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,58.62,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,TRIOLOGY,TRILOGY MEDICAID,81.42,,,,,,,7.5700,86.3100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 106% = $91.46 (Service Line reduced to $81.42, claim capped at $81.42 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.49,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,12.49,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.57,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,12.49,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,UNITY HEALTH PLAN,UNITY HOSPICE,7.57,,,,,,,7.5700,86.3100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,58.62,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.48,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $50.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,58.62,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,58.62,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ RETACRIT NON-ESRD USE,Q5106,HCPCS,636,RC,0069-1305-01,CDM,,,,both,1000.000000,UN,81.4200,53.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,48.85,,,,,,,7.5700,86.3100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.42 in Billed Charges for Rev 636 Proc Q5106 = $48.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,AETNA,AETNA HSHS,33.77,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $33.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,AETNA,AETNA MEDICARE,7.57,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,AETNA,ALL COMMERCIAL AETNA,52.28,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $52.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,ANTHEM,ANTEHM MEDICAID,52.28,,,,,,,7.5700,55.4200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $52.28, claim capped at $52.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.57,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,ANTHEM,ANTHEM POS/HMO,12.87,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 170% = $12.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,ANTHEM,ANTHEM PPO,15.90,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 210% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,52.28,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $52.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,CENPATICO,ALL MEDICAID CENPATICO,52.28,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $52.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,44.44,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $44.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,CIGNA,ALL COMMERCIAL CIGNA,36.60,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $36.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,COFINITY,COFINITY,52.28,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $52.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,52.28,,,,,,,7.5700,55.4200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $52.28, claim capped at $52.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,52.28,,,,,,,7.5700,55.4200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $52.28, claim capped at $52.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,49.67,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $49.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,43.92,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $43.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,37.12,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $37.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,38.16,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,25.41,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $25.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,44.44,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $44.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HUMANA,HUMANA CHOICE CARE HMO,11.59,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HUMANA,HUMANA CHOICE CARE PPO,44.44,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $44.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,7.57,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,HUMANA,HUMANA NATIIONAL POS HMO,11.59,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,38.16,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $38.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,52.28,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $52.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,52.28,,,,,,,7.5700,55.4200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $52.28, claim capped at $52.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.57,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,52.28,,,,,,,7.5700,55.4200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $52.28, claim capped at $52.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,55.42,,,,,,,7.5700,55.4200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $52.28, claim capped at $52.28 in billed charges)... $52.28 at 106% = $55.42 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,7.57,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.14,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $26.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,43.92,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $43.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,17.03,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,39.21,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $39.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,48.10,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $48.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.55,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.55,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,PREVEA HEALTH NETWORK,PREVEA360,13.55,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.55,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,33.37,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $33.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.65,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,37.64,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $37.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,TRIOLOGY,TRILOGY MEDICAID,52.28,,,,,,,7.5700,55.4200,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 106% = $91.46 (Service Line reduced to $52.28, claim capped at $52.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.49,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,12.49,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.57,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,12.49,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,UNITY HEALTH PLAN,UNITY HOSPICE,7.57,,,,,,,7.5700,55.4200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,37.64,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $37.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.41,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $32.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,37.64,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $37.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,37.64,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $37.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1311-01,CDM,,,,both,1000.000000,UN,52.2800,34.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.37,,,,,,,7.5700,55.4200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.28 in Billed Charges for Rev 636 Proc Q5106 = $31.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,AETNA,AETNA HSHS,36.85,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $36.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,AETNA,AETNA MEDICARE,20.50,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,AETNA,ALL COMMERCIAL AETNA,57.04,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $57.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,ANTHEM,ANTEHM MEDICAID,57.04,,,,,,,20.5000,60.4600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00444 Proc J3032 at $125.60 (Base Rate) * 3.5296 (Relative Weight) = $443.32 (Total Line Payment) at 100% = $443.32 (Service Line reduced to $57.04, claim capped at $57.04 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,20.50,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,ANTHEM,ANTHEM POS/HMO,34.85,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $20.50 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3032 * Qty 1 = $20.50 at 170% = $34.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,ANTHEM,ANTHEM PPO,43.05,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $20.50 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3032 * Qty 1 = $20.50 at 210% = $43.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,57.04,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $57.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,CENPATICO,ALL MEDICAID CENPATICO,57.04,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $57.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,48.48,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,CIGNA,ALL COMMERCIAL CIGNA,39.93,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $39.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,COFINITY,COFINITY,57.04,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $57.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,57.04,,,,,,,20.5000,60.4600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00444 Proc J3032 at $125.60 (Base Rate) * 3.5296 (Relative Weight) = $443.32 (Total Line Payment) at 100% = $443.32 (Service Line reduced to $57.04, claim capped at $57.04 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,57.04,,,,,,,20.5000,60.4600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00444 Proc J3032 at $125.60 (Base Rate) * 3.5296 (Relative Weight) = $443.32 (Total Line Payment) at 100% = $443.32 (Service Line reduced to $57.04, claim capped at $57.04 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,54.19,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $54.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,47.91,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $47.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,40.50,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $40.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,41.64,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $41.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,27.72,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $27.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,48.48,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HUMANA,HUMANA CHOICE CARE HMO,31.72,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $31.72 from Fee Schedule 005543_170 for Rev 636 Proc J3032 * Qty 1 = $31.72 at 100% = $31.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HUMANA,HUMANA CHOICE CARE PPO,48.48,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HUMANA,HUMANA MEDICARE ADVANTAGE,20.50,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,HUMANA,HUMANA NATIIONAL POS HMO,31.72,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $31.72 from Fee Schedule 005543_170 for Rev 636 Proc J3032 * Qty 1 = $31.72 at 100% = $31.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,41.64,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $41.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,57.04,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $57.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,57.04,,,,,,,20.5000,60.4600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00444 Proc J3032 at $125.60 (Base Rate) * 3.5296 (Relative Weight) = $443.32 (Total Line Payment) at 100% = $443.32 (Service Line reduced to $57.04, claim capped at $57.04 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,20.50,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,57.04,,,,,,,20.5000,60.4600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00444 Proc J3032 at $125.60 (Base Rate) * 3.5296 (Relative Weight) = $443.32 (Total Line Payment) at 100% = $443.32 (Service Line reduced to $57.04, claim capped at $57.04 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,MOLINA HEALTHCARE,MOLINA MEDICAID,60.46,,,,,,,20.5000,60.4600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00444 Proc J3032 at $125.60 (Base Rate) * 3.5296 (Relative Weight) = $443.32 (Total Line Payment) at 100% = $443.32 (Service Line reduced to $57.04, claim capped at $57.04 in billed charges)... $57.04 at 106% = $60.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,MOLINA HEALTHCARE,MOLINA MEDICARE,20.50,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,28.52,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $28.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,47.91,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $47.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,NAPHCARE,ALL COMMERICAL NAPHCARE,46.13,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,42.78,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $42.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,52.48,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $52.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,36.70,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $20.50 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3032 * Qty 1 = $20.50 at 179% = $36.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,36.70,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $20.50 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3032 * Qty 1 = $20.50 at 179% = $36.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,PREVEA HEALTH NETWORK,PREVEA360,36.70,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $20.50 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3032 * Qty 1 = $20.50 at 179% = $36.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,36.70,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $20.50 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3032 * Qty 1 = $20.50 at 179% = $36.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,36.41,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $36.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,20.71,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,41.07,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $41.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,TRIOLOGY,TRILOGY MEDICAID,57.04,,,,,,,20.5000,60.4600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00444 Proc J3032 at $125.60 (Base Rate) * 3.5296 (Relative Weight) = $443.32 (Total Line Payment) at 106% = $469.92 (Service Line reduced to $57.04, claim capped at $57.04 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,33.83,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $33.83 from Fee Schedule UHC_31190C for Rev 636 Proc J3032 * Qty 1 = $33.83 at 100% = $33.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,UNITED HEALTHCARE,UHC ONEIDA NATION,33.83,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $33.83 from Fee Schedule UHC_31190C for Rev 636 Proc J3032 * Qty 1 = $33.83 at 100% = $33.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,20.50,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,UNITED HEALTHCARE,UNITED HEALTHCARE,33.83,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). $33.83 from Fee Schedule UHC_31190C for Rev 636 Proc J3032 * Qty 1 = $33.83 at 100% = $33.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,UNITY HEALTH PLAN,UNITY HOSPICE,20.50,,,,,,,20.5000,60.4600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,41.07,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $41.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,35.36,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $35.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,41.07,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $41.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,41.07,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $41.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL per 1 mg,J3032,HCPCS,636,RC,67386-130-51,CDM,,,,both,1.000000,ME,57.0400,37.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,34.22,,,,,,,20.5000,60.4600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.04 in Billed Charges for Rev 636 Proc J3032 = $34.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,AETNA,AETNA HSHS,144.77,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $144.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,AETNA,ALL COMMERCIAL AETNA,224.10,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $224.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,ANTHEM,ANTHEM POS/HMO,15.57,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 170% = $15.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,ANTHEM,ANTHEM PPO,19.24,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 210% = $19.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,224.10,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $224.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,CENPATICO,ALL MEDICAID CENPATICO,224.10,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $224.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,190.49,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $190.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,CIGNA,ALL COMMERCIAL CIGNA,156.87,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $156.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,COFINITY,COFINITY,224.10,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $224.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,212.90,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $212.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,HEALTH CARE ALLIANCE,THE ALLIANCE,188.24,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $188.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,159.11,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $159.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,163.59,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $163.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,HSHS EMPLOYEES,HSHS EMPLOYEES,108.91,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $108.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,190.49,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $190.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,HUMANA,HUMANA CHOICE CARE HMO,18.26,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.26 from Fee Schedule 005543_170 for Rev 636 Proc J1335 * Qty 1 = $18.26 at 100% = $18.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,HUMANA,HUMANA CHOICE CARE PPO,190.49,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $190.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,HUMANA,HUMANA NATIIONAL POS HMO,18.26,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.26 from Fee Schedule 005543_170 for Rev 636 Proc J1335 * Qty 1 = $18.26 at 100% = $18.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,163.59,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $163.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,LIVE360,LIVE360 HSHS HEALTHY PLAN,224.10,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $224.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,112.05,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $112.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,188.24,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $188.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,168.08,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $168.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,206.17,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $206.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.40,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.40,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,PREVEA HEALTH NETWORK,PREVEA360,16.40,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.40,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,143.04,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $143.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,161.35,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $161.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.11,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,UNITED HEALTHCARE,UHC ONEIDA NATION,15.11,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,UNITED HEALTHCARE,UNITED HEALTHCARE,15.11,,,,,,,15.1100,224.1000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,161.35,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $161.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,138.94,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $138.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,161.35,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $161.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,161.35,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $161.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,0409-3510-21,CDM,,,,both,500.000000,ME,224.1000,147.9100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,134.46,,,,,,,15.1100,224.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $224.10 in Billed Charges for Rev 636 Proc J1335 = $134.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,AETNA,AETNA HSHS,10.82,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.75 in Billed Charges for Rev 637 = $10.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,AETNA,ALL COMMERCIAL AETNA,16.75,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.75 in Billed Charges for Rev 637 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,ANTHEM,ANTHEM POS/HMO,11.39,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $16.75 in Billed Charges for Rev 637 = $11.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,ANTHEM,ANTHEM PPO,11.39,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $16.75 in Billed Charges for Rev 637 = $11.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.75,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.75 in Billed Charges for Rev 637 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,CENPATICO,ALL MEDICAID CENPATICO,16.75,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.75 in Billed Charges for Rev 637 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.24,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.75 in Billed Charges for Rev 637 = $14.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,CIGNA,ALL COMMERCIAL CIGNA,11.73,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.75 in Billed Charges for Rev 637 = $11.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,COFINITY,COFINITY,16.75,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.75 in Billed Charges for Rev 637 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.91,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.75 in Billed Charges for Rev 637 = $15.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,14.07,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.75 in Billed Charges for Rev 637 = $14.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.89,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.75 in Billed Charges for Rev 637 = $11.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.23,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.75 in Billed Charges for Rev 637 = $12.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,8.14,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.75 in Billed Charges for Rev 637 = $8.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.24,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.75 in Billed Charges for Rev 637 = $14.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,HUMANA,HUMANA CHOICE CARE HMO,10.64,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $16.75 in Billed Charges at 63.5% = $10.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,HUMANA,HUMANA CHOICE CARE PPO,14.24,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.75 in Billed Charges for Rev 637 = $14.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,HUMANA,HUMANA NATIIONAL POS HMO,10.64,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $16.75 in Billed Charges at 63.5% = $10.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.23,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.75 in Billed Charges for Rev 637 = $12.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.75,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.75 in Billed Charges for Rev 637 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.75,,,,,,,8.1400,16.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.38,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.75 in Billed Charges for Rev 637 = $8.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.07,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.75 in Billed Charges for Rev 637 = $14.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.56,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.75 in Billed Charges for Rev 637 = $12.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.41,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.75 in Billed Charges for Rev 637 = $15.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.05,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.75 in Billed Charges for Rev 637 = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.05,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.75 in Billed Charges for Rev 637 = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,PREVEA HEALTH NETWORK,PREVEA360,10.05,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.75 in Billed Charges for Rev 637 = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.05,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.75 in Billed Charges for Rev 637 = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.69,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.75 in Billed Charges for Rev 637 = $10.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.06,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.75 in Billed Charges for Rev 637 = $12.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.26,,,,,,,8.1400,16.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.75 in Billed Charges for Rev 637 = $9.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,9.26,,,,,,,8.1400,16.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.75 in Billed Charges for Rev 637 = $9.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,9.26,,,,,,,8.1400,16.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.75 in Billed Charges for Rev 637 = $9.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,UNITY HEALTH PLAN,UNITY HOSPICE,16.75,,,,,,,8.1400,16.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.06,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.75 in Billed Charges for Rev 637 = $12.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.39,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.75 in Billed Charges for Rev 637 = $10.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.06,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.75 in Billed Charges for Rev 637 = $12.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.06,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.75 in Billed Charges for Rev 637 = $12.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,60687-417-44,CDM,,,,,,both,15.000000,ML,16.7500,11.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.05,,,,,,,8.1400,16.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.75 in Billed Charges for Rev 637 = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,AETNA,AETNA HSHS,514.28,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $796.10 in Billed Charges for Rev 637 = $514.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,AETNA,ALL COMMERCIAL AETNA,796.10,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $796.10 in Billed Charges for Rev 637 = $796.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,ANTHEM,ANTHEM POS/HMO,541.35,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $796.10 in Billed Charges for Rev 637 = $541.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,ANTHEM,ANTHEM PPO,541.35,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $796.10 in Billed Charges for Rev 637 = $541.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,796.10,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $796.10 in Billed Charges for Rev 637 = $796.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,CENPATICO,ALL MEDICAID CENPATICO,796.10,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $796.10 in Billed Charges for Rev 637 = $796.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,676.69,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $796.10 in Billed Charges for Rev 637 = $676.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,CIGNA,ALL COMMERCIAL CIGNA,557.27,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $796.10 in Billed Charges for Rev 637 = $557.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,COFINITY,COFINITY,796.10,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $796.10 in Billed Charges for Rev 637 = $796.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,756.30,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $796.10 in Billed Charges for Rev 637 = $756.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,HEALTH CARE ALLIANCE,THE ALLIANCE,668.72,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $796.10 in Billed Charges for Rev 637 = $668.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,565.23,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $796.10 in Billed Charges for Rev 637 = $565.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,581.15,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $796.10 in Billed Charges for Rev 637 = $581.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,HSHS EMPLOYEES,HSHS EMPLOYEES,386.90,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $796.10 in Billed Charges for Rev 637 = $386.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,676.69,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $796.10 in Billed Charges for Rev 637 = $676.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,HUMANA,HUMANA CHOICE CARE HMO,505.52,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $796.10 in Billed Charges at 63.5% = $505.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,HUMANA,HUMANA CHOICE CARE PPO,676.69,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $796.10 in Billed Charges for Rev 637 = $676.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,HUMANA,HUMANA NATIIONAL POS HMO,505.52,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $796.10 in Billed Charges at 63.5% = $505.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,581.15,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $796.10 in Billed Charges for Rev 637 = $581.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,LIVE360,LIVE360 HSHS HEALTHY PLAN,796.10,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $796.10 in Billed Charges for Rev 637 = $796.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,796.10,,,,,,,386.9000,796.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,398.05,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $796.10 in Billed Charges for Rev 637 = $398.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,668.72,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $796.10 in Billed Charges for Rev 637 = $668.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,597.08,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $796.10 in Billed Charges for Rev 637 = $597.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,732.41,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $796.10 in Billed Charges for Rev 637 = $732.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,477.66,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $796.10 in Billed Charges for Rev 637 = $477.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,477.66,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $796.10 in Billed Charges for Rev 637 = $477.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,PREVEA HEALTH NETWORK,PREVEA360,477.66,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $796.10 in Billed Charges for Rev 637 = $477.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,477.66,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $796.10 in Billed Charges for Rev 637 = $477.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,508.15,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $796.10 in Billed Charges for Rev 637 = $508.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,573.19,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $796.10 in Billed Charges for Rev 637 = $573.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,440.24,,,,,,,386.9000,796.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $796.10 in Billed Charges for Rev 637 = $440.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,UNITED HEALTHCARE,UHC ONEIDA NATION,440.24,,,,,,,386.9000,796.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $796.10 in Billed Charges for Rev 637 = $440.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,UNITED HEALTHCARE,UNITED HEALTHCARE,440.24,,,,,,,386.9000,796.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $796.10 in Billed Charges for Rev 637 = $440.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,UNITY HEALTH PLAN,UNITY HOSPICE,796.10,,,,,,,386.9000,796.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,573.19,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $796.10 in Billed Charges for Rev 637 = $573.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,493.58,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $796.10 in Billed Charges for Rev 637 = $493.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,573.19,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $796.10 in Billed Charges for Rev 637 = $573.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,573.19,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $796.10 in Billed Charges for Rev 637 = $573.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML SOLN,637,RC,64950-343-16,CDM,,,,,,both,473.000000,ML,796.1000,525.4300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,477.66,,,,,,,386.9000,796.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $796.10 in Billed Charges for Rev 637 = $477.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,AETNA,AETNA HSHS,168.99,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $261.60 in Billed Charges for Rev 637 = $168.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,AETNA,ALL COMMERCIAL AETNA,261.60,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.60 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,ANTHEM,ANTHEM POS/HMO,177.89,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $261.60 in Billed Charges for Rev 637 = $177.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,ANTHEM,ANTHEM PPO,177.89,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $261.60 in Billed Charges for Rev 637 = $177.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,261.60,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.60 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,CENPATICO,ALL MEDICAID CENPATICO,261.60,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.60 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,222.36,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $261.60 in Billed Charges for Rev 637 = $222.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,CIGNA,ALL COMMERCIAL CIGNA,183.12,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $261.60 in Billed Charges for Rev 637 = $183.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,COFINITY,COFINITY,261.60,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.60 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,248.52,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $261.60 in Billed Charges for Rev 637 = $248.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,219.74,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $261.60 in Billed Charges for Rev 637 = $219.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,185.74,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $261.60 in Billed Charges for Rev 637 = $185.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,190.97,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $261.60 in Billed Charges for Rev 637 = $190.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,127.14,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $261.60 in Billed Charges for Rev 637 = $127.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,222.36,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $261.60 in Billed Charges for Rev 637 = $222.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,HUMANA,HUMANA CHOICE CARE HMO,166.12,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $261.60 in Billed Charges at 63.5% = $166.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,HUMANA,HUMANA CHOICE CARE PPO,222.36,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $261.60 in Billed Charges for Rev 637 = $222.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,HUMANA,HUMANA NATIIONAL POS HMO,166.12,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $261.60 in Billed Charges at 63.5% = $166.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,190.97,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $261.60 in Billed Charges for Rev 637 = $190.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,261.60,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $261.60 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,261.60,,,,,,,127.1400,261.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,130.80,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $261.60 in Billed Charges for Rev 637 = $130.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,219.74,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $261.60 in Billed Charges for Rev 637 = $219.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,196.20,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $261.60 in Billed Charges for Rev 637 = $196.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,240.67,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $261.60 in Billed Charges for Rev 637 = $240.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,156.96,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $261.60 in Billed Charges for Rev 637 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,156.96,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $261.60 in Billed Charges for Rev 637 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,PREVEA HEALTH NETWORK,PREVEA360,156.96,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $261.60 in Billed Charges for Rev 637 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,156.96,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $261.60 in Billed Charges for Rev 637 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,166.98,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $261.60 in Billed Charges for Rev 637 = $166.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,188.35,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $261.60 in Billed Charges for Rev 637 = $188.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,144.66,,,,,,,127.1400,261.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $261.60 in Billed Charges for Rev 637 = $144.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,144.66,,,,,,,127.1400,261.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $261.60 in Billed Charges for Rev 637 = $144.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,144.66,,,,,,,127.1400,261.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $261.60 in Billed Charges for Rev 637 = $144.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,UNITY HEALTH PLAN,UNITY HOSPICE,261.60,,,,,,,127.1400,261.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,188.35,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $261.60 in Billed Charges for Rev 637 = $188.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,162.19,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $261.60 in Billed Charges for Rev 637 = $162.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,188.35,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $261.60 in Billed Charges for Rev 637 = $188.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,188.35,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $261.60 in Billed Charges for Rev 637 = $188.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCODONE-CHLORPHENIRAMINE ER 10-8 MG/5ML SUER,637,RC,27808-086-01,CDM,,,,,,both,115.000000,ML,261.6000,172.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,156.96,,,,,,,127.1400,261.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $261.60 in Billed Charges for Rev 637 = $156.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,AETNA,AETNA HSHS,31.69,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.05 in Billed Charges for Rev 637 = $31.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,AETNA,ALL COMMERCIAL AETNA,49.05,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.05 in Billed Charges for Rev 637 = $49.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,ANTHEM,ANTHEM POS/HMO,33.35,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $49.05 in Billed Charges for Rev 637 = $33.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,ANTHEM,ANTHEM PPO,33.35,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $49.05 in Billed Charges for Rev 637 = $33.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.05,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.05 in Billed Charges for Rev 637 = $49.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,CENPATICO,ALL MEDICAID CENPATICO,49.05,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.05 in Billed Charges for Rev 637 = $49.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.69,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.05 in Billed Charges for Rev 637 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,CIGNA,ALL COMMERCIAL CIGNA,34.34,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.05 in Billed Charges for Rev 637 = $34.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,COFINITY,COFINITY,49.05,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.05 in Billed Charges for Rev 637 = $49.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.60,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.05 in Billed Charges for Rev 637 = $46.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,41.20,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.05 in Billed Charges for Rev 637 = $41.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.83,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.05 in Billed Charges for Rev 637 = $34.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.81,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.05 in Billed Charges for Rev 637 = $35.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,23.84,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.05 in Billed Charges for Rev 637 = $23.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.69,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.05 in Billed Charges for Rev 637 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,HUMANA,HUMANA CHOICE CARE HMO,31.15,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $49.05 in Billed Charges at 63.5% = $31.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,HUMANA,HUMANA CHOICE CARE PPO,41.69,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.05 in Billed Charges for Rev 637 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,HUMANA,HUMANA NATIIONAL POS HMO,31.15,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $49.05 in Billed Charges at 63.5% = $31.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.81,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.05 in Billed Charges for Rev 637 = $35.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.05,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.05 in Billed Charges for Rev 637 = $49.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,49.05,,,,,,,23.8400,49.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.53,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.05 in Billed Charges for Rev 637 = $24.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.20,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.05 in Billed Charges for Rev 637 = $41.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.79,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.05 in Billed Charges for Rev 637 = $36.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.13,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.05 in Billed Charges for Rev 637 = $45.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.43,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.05 in Billed Charges for Rev 637 = $29.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.43,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.05 in Billed Charges for Rev 637 = $29.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,PREVEA HEALTH NETWORK,PREVEA360,29.43,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.05 in Billed Charges for Rev 637 = $29.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.43,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.05 in Billed Charges for Rev 637 = $29.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.31,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.05 in Billed Charges for Rev 637 = $31.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.32,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.05 in Billed Charges for Rev 637 = $35.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.12,,,,,,,23.8400,49.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.05 in Billed Charges for Rev 637 = $27.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,UNITED HEALTHCARE,UHC ONEIDA NATION,27.12,,,,,,,23.8400,49.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.05 in Billed Charges for Rev 637 = $27.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,UNITED HEALTHCARE,UNITED HEALTHCARE,27.12,,,,,,,23.8400,49.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.05 in Billed Charges for Rev 637 = $27.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,UNITY HEALTH PLAN,UNITY HOSPICE,49.05,,,,,,,23.8400,49.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.32,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.05 in Billed Charges for Rev 637 = $35.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.41,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.05 in Billed Charges for Rev 637 = $30.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.32,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.05 in Billed Charges for Rev 637 = $35.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.32,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.05 in Billed Charges for Rev 637 = $35.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0574-7090-12,CDM,,,,,,both,1.000000,EA,49.0500,32.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.43,,,,,,,23.8400,49.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.05 in Billed Charges for Rev 637 = $29.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,AETNA,AETNA HSHS,49.74,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $77.00 in Billed Charges for Rev 637 = $49.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,AETNA,ALL COMMERCIAL AETNA,77.00,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $77.00 in Billed Charges for Rev 637 = $77.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,ANTHEM,ANTHEM POS/HMO,52.36,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $77.00 in Billed Charges for Rev 637 = $52.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,ANTHEM,ANTHEM PPO,52.36,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $77.00 in Billed Charges for Rev 637 = $52.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,77.00,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $77.00 in Billed Charges for Rev 637 = $77.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,CENPATICO,ALL MEDICAID CENPATICO,77.00,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $77.00 in Billed Charges for Rev 637 = $77.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,65.45,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $77.00 in Billed Charges for Rev 637 = $65.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,CIGNA,ALL COMMERCIAL CIGNA,53.90,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $77.00 in Billed Charges for Rev 637 = $53.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,COFINITY,COFINITY,77.00,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $77.00 in Billed Charges for Rev 637 = $77.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,73.15,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $77.00 in Billed Charges for Rev 637 = $73.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,64.68,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $77.00 in Billed Charges for Rev 637 = $64.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,54.67,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $77.00 in Billed Charges for Rev 637 = $54.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,56.21,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $77.00 in Billed Charges for Rev 637 = $56.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,37.42,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $77.00 in Billed Charges for Rev 637 = $37.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,65.45,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $77.00 in Billed Charges for Rev 637 = $65.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,HUMANA,HUMANA CHOICE CARE HMO,48.90,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $77.00 in Billed Charges at 63.5% = $48.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,HUMANA,HUMANA CHOICE CARE PPO,65.45,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $77.00 in Billed Charges for Rev 637 = $65.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,HUMANA,HUMANA NATIIONAL POS HMO,48.90,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $77.00 in Billed Charges at 63.5% = $48.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,56.21,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $77.00 in Billed Charges for Rev 637 = $56.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,77.00,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $77.00 in Billed Charges for Rev 637 = $77.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,77.00,,,,,,,37.4200,77.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,38.50,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $77.00 in Billed Charges for Rev 637 = $38.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,64.68,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $77.00 in Billed Charges for Rev 637 = $64.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,57.75,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $77.00 in Billed Charges for Rev 637 = $57.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,70.84,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $77.00 in Billed Charges for Rev 637 = $70.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,46.20,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $77.00 in Billed Charges for Rev 637 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,46.20,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $77.00 in Billed Charges for Rev 637 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,PREVEA HEALTH NETWORK,PREVEA360,46.20,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $77.00 in Billed Charges for Rev 637 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,46.20,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $77.00 in Billed Charges for Rev 637 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,49.15,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $77.00 in Billed Charges for Rev 637 = $49.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,55.44,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $77.00 in Billed Charges for Rev 637 = $55.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,42.58,,,,,,,37.4200,77.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $77.00 in Billed Charges for Rev 637 = $42.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,42.58,,,,,,,37.4200,77.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $77.00 in Billed Charges for Rev 637 = $42.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,42.58,,,,,,,37.4200,77.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $77.00 in Billed Charges for Rev 637 = $42.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,UNITY HEALTH PLAN,UNITY HOSPICE,77.00,,,,,,,37.4200,77.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,55.44,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $77.00 in Billed Charges for Rev 637 = $55.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,47.74,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $77.00 in Billed Charges for Rev 637 = $47.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,55.44,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $77.00 in Billed Charges for Rev 637 = $55.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,55.44,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $77.00 in Billed Charges for Rev 637 = $55.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 25 MG SUPP,637,RC,0713-0503-06,CDM,,,,,,both,1.000000,EA,77.0000,50.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,46.20,,,,,,,37.4200,77.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $77.00 in Billed Charges for Rev 637 = $46.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,AETNA,AETNA HSHS,129.72,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $200.80 in Billed Charges for Rev 637 = $129.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,AETNA,ALL COMMERCIAL AETNA,200.80,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.80 in Billed Charges for Rev 637 = $200.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,ANTHEM,ANTHEM POS/HMO,136.54,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $200.80 in Billed Charges for Rev 637 = $136.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,ANTHEM,ANTHEM PPO,136.54,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $200.80 in Billed Charges for Rev 637 = $136.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,200.80,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.80 in Billed Charges for Rev 637 = $200.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,CENPATICO,ALL MEDICAID CENPATICO,200.80,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.80 in Billed Charges for Rev 637 = $200.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,170.68,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $200.80 in Billed Charges for Rev 637 = $170.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,CIGNA,ALL COMMERCIAL CIGNA,140.56,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $200.80 in Billed Charges for Rev 637 = $140.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,COFINITY,COFINITY,200.80,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.80 in Billed Charges for Rev 637 = $200.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,190.76,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $200.80 in Billed Charges for Rev 637 = $190.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,HEALTH CARE ALLIANCE,THE ALLIANCE,168.67,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $200.80 in Billed Charges for Rev 637 = $168.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,142.57,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $200.80 in Billed Charges for Rev 637 = $142.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,146.58,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $200.80 in Billed Charges for Rev 637 = $146.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,HSHS EMPLOYEES,HSHS EMPLOYEES,97.59,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $200.80 in Billed Charges for Rev 637 = $97.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,170.68,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $200.80 in Billed Charges for Rev 637 = $170.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,HUMANA,HUMANA CHOICE CARE HMO,127.51,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $200.80 in Billed Charges at 63.5% = $127.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,HUMANA,HUMANA CHOICE CARE PPO,170.68,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $200.80 in Billed Charges for Rev 637 = $170.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,HUMANA,HUMANA NATIIONAL POS HMO,127.51,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $200.80 in Billed Charges at 63.5% = $127.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,146.58,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $200.80 in Billed Charges for Rev 637 = $146.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,LIVE360,LIVE360 HSHS HEALTHY PLAN,200.80,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $200.80 in Billed Charges for Rev 637 = $200.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,200.80,,,,,,,97.5900,200.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,100.40,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $200.80 in Billed Charges for Rev 637 = $100.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,168.67,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $200.80 in Billed Charges for Rev 637 = $168.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,150.60,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $200.80 in Billed Charges for Rev 637 = $150.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,184.74,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $200.80 in Billed Charges for Rev 637 = $184.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,120.48,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $200.80 in Billed Charges for Rev 637 = $120.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,120.48,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $200.80 in Billed Charges for Rev 637 = $120.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,PREVEA HEALTH NETWORK,PREVEA360,120.48,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $200.80 in Billed Charges for Rev 637 = $120.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,120.48,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $200.80 in Billed Charges for Rev 637 = $120.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,128.17,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $200.80 in Billed Charges for Rev 637 = $128.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,144.58,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $200.80 in Billed Charges for Rev 637 = $144.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,111.04,,,,,,,97.5900,200.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $200.80 in Billed Charges for Rev 637 = $111.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,UNITED HEALTHCARE,UHC ONEIDA NATION,111.04,,,,,,,97.5900,200.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $200.80 in Billed Charges for Rev 637 = $111.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,UNITED HEALTHCARE,UNITED HEALTHCARE,111.04,,,,,,,97.5900,200.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $200.80 in Billed Charges for Rev 637 = $111.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,UNITY HEALTH PLAN,UNITY HOSPICE,200.80,,,,,,,97.5900,200.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,144.58,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $200.80 in Billed Charges for Rev 637 = $144.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,124.50,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $200.80 in Billed Charges for Rev 637 = $124.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,144.58,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $200.80 in Billed Charges for Rev 637 = $144.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,144.58,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $200.80 in Billed Charges for Rev 637 = $144.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GRANISETRON 1 MG TABS,637,RC,51991-735-99,CDM,,,,,,both,1.000000,EA,200.8000,132.5300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,120.48,,,,,,,97.5900,200.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $200.80 in Billed Charges for Rev 637 = $120.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 637 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.00 in Billed Charges for Rev 637 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.00 in Billed Charges for Rev 637 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 637 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 637 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 637 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 637 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 637 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 637 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.00,,,,,,,3.8900,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 637 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 637 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 637 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 637 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,UNITY HEALTH PLAN,UNITY HOSPICE,8.00,,,,,,,3.8900,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 637 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % SOLN 15 ML BOTTLE,637,RC,57896-181-05,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,AETNA,AETNA HSHS,216.93,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $335.80 in Billed Charges for Rev 637 = $216.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,AETNA,ALL COMMERCIAL AETNA,335.80,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.80 in Billed Charges for Rev 637 = $335.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,ANTHEM,ANTHEM POS/HMO,228.34,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $335.80 in Billed Charges for Rev 637 = $228.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,ANTHEM,ANTHEM PPO,228.34,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $335.80 in Billed Charges for Rev 637 = $228.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,335.80,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.80 in Billed Charges for Rev 637 = $335.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,CENPATICO,ALL MEDICAID CENPATICO,335.80,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.80 in Billed Charges for Rev 637 = $335.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,285.43,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.80 in Billed Charges for Rev 637 = $285.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,CIGNA,ALL COMMERCIAL CIGNA,235.06,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $335.80 in Billed Charges for Rev 637 = $235.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,COFINITY,COFINITY,335.80,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.80 in Billed Charges for Rev 637 = $335.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,319.01,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $335.80 in Billed Charges for Rev 637 = $319.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,HEALTH CARE ALLIANCE,THE ALLIANCE,282.07,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $335.80 in Billed Charges for Rev 637 = $282.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,238.42,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $335.80 in Billed Charges for Rev 637 = $238.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,245.13,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $335.80 in Billed Charges for Rev 637 = $245.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,HSHS EMPLOYEES,HSHS EMPLOYEES,163.20,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $335.80 in Billed Charges for Rev 637 = $163.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,285.43,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.80 in Billed Charges for Rev 637 = $285.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,HUMANA,HUMANA CHOICE CARE HMO,213.23,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $335.80 in Billed Charges at 63.5% = $213.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,HUMANA,HUMANA CHOICE CARE PPO,285.43,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $335.80 in Billed Charges for Rev 637 = $285.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,HUMANA,HUMANA NATIIONAL POS HMO,213.23,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $335.80 in Billed Charges at 63.5% = $213.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,245.13,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $335.80 in Billed Charges for Rev 637 = $245.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,LIVE360,LIVE360 HSHS HEALTHY PLAN,335.80,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $335.80 in Billed Charges for Rev 637 = $335.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,335.80,,,,,,,163.2000,335.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,167.90,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $335.80 in Billed Charges for Rev 637 = $167.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,282.07,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $335.80 in Billed Charges for Rev 637 = $282.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,251.85,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $335.80 in Billed Charges for Rev 637 = $251.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,308.94,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $335.80 in Billed Charges for Rev 637 = $308.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,201.48,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $335.80 in Billed Charges for Rev 637 = $201.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,201.48,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $335.80 in Billed Charges for Rev 637 = $201.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,PREVEA HEALTH NETWORK,PREVEA360,201.48,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $335.80 in Billed Charges for Rev 637 = $201.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,201.48,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $335.80 in Billed Charges for Rev 637 = $201.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,214.34,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $335.80 in Billed Charges for Rev 637 = $214.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,241.78,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.80 in Billed Charges for Rev 637 = $241.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,185.70,,,,,,,163.2000,335.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $335.80 in Billed Charges for Rev 637 = $185.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,UNITED HEALTHCARE,UHC ONEIDA NATION,185.70,,,,,,,163.2000,335.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $335.80 in Billed Charges for Rev 637 = $185.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,UNITED HEALTHCARE,UNITED HEALTHCARE,185.70,,,,,,,163.2000,335.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $335.80 in Billed Charges for Rev 637 = $185.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,UNITY HEALTH PLAN,UNITY HOSPICE,335.80,,,,,,,163.2000,335.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,241.78,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.80 in Billed Charges for Rev 637 = $241.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,208.20,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $335.80 in Billed Charges for Rev 637 = $208.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,241.78,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.80 in Billed Charges for Rev 637 = $241.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,241.78,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $335.80 in Billed Charges for Rev 637 = $241.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % OINT 30 G TUBE,637,RC,0713-0682-31,CDM,,,,,,both,30.000000,GR,335.8000,221.6300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,201.48,,,,,,,163.2000,335.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $335.80 in Billed Charges for Rev 637 = $201.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,AETNA,AETNA HSHS,47.67,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $73.80 in Billed Charges for Rev 637 = $47.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,AETNA,ALL COMMERCIAL AETNA,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 637 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,ANTHEM,ANTHEM POS/HMO,50.18,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $73.80 in Billed Charges for Rev 637 = $50.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,ANTHEM,ANTHEM PPO,50.18,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $73.80 in Billed Charges for Rev 637 = $50.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 637 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,CENPATICO,ALL MEDICAID CENPATICO,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 637 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,62.73,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.80 in Billed Charges for Rev 637 = $62.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,CIGNA,ALL COMMERCIAL CIGNA,51.66,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $73.80 in Billed Charges for Rev 637 = $51.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,COFINITY,COFINITY,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 637 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,70.11,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $73.80 in Billed Charges for Rev 637 = $70.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,HEALTH CARE ALLIANCE,THE ALLIANCE,61.99,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.80 in Billed Charges for Rev 637 = $61.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.40,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $73.80 in Billed Charges for Rev 637 = $52.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,53.87,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.80 in Billed Charges for Rev 637 = $53.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,HSHS EMPLOYEES,HSHS EMPLOYEES,35.87,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $73.80 in Billed Charges for Rev 637 = $35.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,62.73,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.80 in Billed Charges for Rev 637 = $62.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,HUMANA,HUMANA CHOICE CARE HMO,46.86,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $73.80 in Billed Charges at 63.5% = $46.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,HUMANA,HUMANA CHOICE CARE PPO,62.73,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.80 in Billed Charges for Rev 637 = $62.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,HUMANA,HUMANA NATIIONAL POS HMO,46.86,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $73.80 in Billed Charges at 63.5% = $46.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,53.87,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.80 in Billed Charges for Rev 637 = $53.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,LIVE360,LIVE360 HSHS HEALTHY PLAN,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 637 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,73.80,,,,,,,35.8700,73.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,36.90,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $73.80 in Billed Charges for Rev 637 = $36.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,61.99,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.80 in Billed Charges for Rev 637 = $61.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.35,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $73.80 in Billed Charges for Rev 637 = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,67.90,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $73.80 in Billed Charges for Rev 637 = $67.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 637 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 637 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,PREVEA HEALTH NETWORK,PREVEA360,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 637 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 637 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.11,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $73.80 in Billed Charges for Rev 637 = $47.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.14,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.80 in Billed Charges for Rev 637 = $53.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,40.81,,,,,,,35.8700,73.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.80 in Billed Charges for Rev 637 = $40.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,UNITED HEALTHCARE,UHC ONEIDA NATION,40.81,,,,,,,35.8700,73.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.80 in Billed Charges for Rev 637 = $40.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,UNITED HEALTHCARE,UNITED HEALTHCARE,40.81,,,,,,,35.8700,73.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.80 in Billed Charges for Rev 637 = $40.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,UNITY HEALTH PLAN,UNITY HOSPICE,73.80,,,,,,,35.8700,73.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.14,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.80 in Billed Charges for Rev 637 = $53.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.76,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $73.80 in Billed Charges for Rev 637 = $45.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.14,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.80 in Billed Charges for Rev 637 = $53.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.14,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.80 in Billed Charges for Rev 637 = $53.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,637,RC,61314-633-05,CDM,,,,,,both,5.000000,ML,73.8000,48.7100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 637 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,AETNA,AETNA HSHS,17.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $27.00 in Billed Charges for Rev 637 = $17.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,AETNA,ALL COMMERCIAL AETNA,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 637 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,ANTHEM,ANTHEM POS/HMO,18.36,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $27.00 in Billed Charges for Rev 637 = $18.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,ANTHEM,ANTHEM PPO,18.36,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $27.00 in Billed Charges for Rev 637 = $18.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 637 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,CENPATICO,ALL MEDICAID CENPATICO,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 637 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,22.95,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.00 in Billed Charges for Rev 637 = $22.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,CIGNA,ALL COMMERCIAL CIGNA,18.90,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $27.00 in Billed Charges for Rev 637 = $18.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,COFINITY,COFINITY,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 637 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,25.65,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $27.00 in Billed Charges for Rev 637 = $25.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,HEALTH CARE ALLIANCE,THE ALLIANCE,22.68,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.00 in Billed Charges for Rev 637 = $22.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19.17,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $27.00 in Billed Charges for Rev 637 = $19.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,19.71,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.00 in Billed Charges for Rev 637 = $19.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,HSHS EMPLOYEES,HSHS EMPLOYEES,13.12,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $27.00 in Billed Charges for Rev 637 = $13.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,22.95,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.00 in Billed Charges for Rev 637 = $22.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,HUMANA,HUMANA CHOICE CARE HMO,17.15,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $27.00 in Billed Charges at 63.5% = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,HUMANA,HUMANA CHOICE CARE PPO,22.95,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.00 in Billed Charges for Rev 637 = $22.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,HUMANA,HUMANA NATIIONAL POS HMO,17.15,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $27.00 in Billed Charges at 63.5% = $17.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,19.71,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.00 in Billed Charges for Rev 637 = $19.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,LIVE360,LIVE360 HSHS HEALTHY PLAN,27.00,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.00 in Billed Charges for Rev 637 = $27.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,27.00,,,,,,,13.1200,27.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.50,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $27.00 in Billed Charges for Rev 637 = $13.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,22.68,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.00 in Billed Charges for Rev 637 = $22.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20.25,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $27.00 in Billed Charges for Rev 637 = $20.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,24.84,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $27.00 in Billed Charges for Rev 637 = $24.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.20,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.00 in Billed Charges for Rev 637 = $16.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.20,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.00 in Billed Charges for Rev 637 = $16.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,PREVEA HEALTH NETWORK,PREVEA360,16.20,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.00 in Billed Charges for Rev 637 = $16.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.20,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.00 in Billed Charges for Rev 637 = $16.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.23,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $27.00 in Billed Charges for Rev 637 = $17.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,19.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.00 in Billed Charges for Rev 637 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.93,,,,,,,13.1200,27.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.00 in Billed Charges for Rev 637 = $14.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,UNITED HEALTHCARE,UHC ONEIDA NATION,14.93,,,,,,,13.1200,27.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.00 in Billed Charges for Rev 637 = $14.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,UNITED HEALTHCARE,UNITED HEALTHCARE,14.93,,,,,,,13.1200,27.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.00 in Billed Charges for Rev 637 = $14.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,UNITY HEALTH PLAN,UNITY HOSPICE,27.00,,,,,,,13.1200,27.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,19.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.00 in Billed Charges for Rev 637 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.74,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $27.00 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,19.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.00 in Billed Charges for Rev 637 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,19.44,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.00 in Billed Charges for Rev 637 = $19.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTEAL TEARS 0.1-0.2-0.3 % SOLN 15 ML BOTTLE,637,RC,0065-0426-36,CDM,,,,,,both,15.000000,ML,27.0000,17.8200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16.20,,,,,,,13.1200,27.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.00 in Billed Charges for Rev 637 = $16.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 637 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.00 in Billed Charges for Rev 637 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.00 in Billed Charges for Rev 637 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 637 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 637 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 637 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 637 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 637 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 637 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.00,,,,,,,3.8900,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 637 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 637 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 637 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 637 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,UNITY HEALTH PLAN,UNITY HOSPICE,8.00,,,,,,,3.8900,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 637 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN 100 MG/5ML LIQD,637,RC,60687-863-42,CDM,,,,,,both,10.000000,ML,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,AETNA,AETNA HSHS,0.29,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,AETNA,ALL COMMERCIAL AETNA,0.45,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,ANTHEM,ANTHEM POS/HMO,0.07,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2401 * Qty 1 = $0.04 at 170% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,ANTHEM,ANTHEM PPO,0.08,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2401 * Qty 1 = $0.04 at 210% = $0.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.45,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,CENPATICO,ALL MEDICAID CENPATICO,0.45,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.38,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,CIGNA,ALL COMMERCIAL CIGNA,0.32,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,COFINITY,COFINITY,0.45,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.43,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,0.38,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.32,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.33,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,0.22,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.38,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,HUMANA,HUMANA CHOICE CARE HMO,0.05,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule 005543_170 for Rev 636 Proc J2401 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,HUMANA,HUMANA CHOICE CARE PPO,0.38,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,HUMANA,HUMANA NATIIONAL POS HMO,0.05,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule 005543_170 for Rev 636 Proc J2401 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.33,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.45,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.23,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.38,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.34,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.41,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.07,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2401 * Qty 1 = $0.04 at 179% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.07,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2401 * Qty 1 = $0.04 at 179% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,PREVEA HEALTH NETWORK,PREVEA360,0.07,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2401 * Qty 1 = $0.04 at 179% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.07,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2401 * Qty 1 = $0.04 at 179% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.29,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.32,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.07,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule UHC_31190C for Rev 636 Proc J2401 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,0.07,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule UHC_31190C for Rev 636 Proc J2401 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,0.07,,,,,,,0.0500,0.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.07 from Fee Schedule UHC_31190C for Rev 636 Proc J2401 * Qty 1 = $0.07 at 100% = $0.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.32,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.28,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.32,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.32,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROPROCAINE (PF) 2 % SOLN per 1 mg,J2401,HCPCS,636,RC,63323-477-01,CDM,,,,both,1.000000,ME,0.4500,0.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.27,,,,,,,0.0500,0.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.45 in Billed Charges for Rev 636 Proc J2401 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,AETNA,AETNA HSHS,266.27,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $266.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,AETNA,AETNA MEDICARE,80.34,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,AETNA,ALL COMMERCIAL AETNA,412.18,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $412.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,ANTHEM,ANTEHM MEDICAID,412.18,,,,,,,80.3400,436.9100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $412.18, claim capped at $412.18 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,80.34,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,ANTHEM,ANTHEM POS/HMO,136.58,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 170% = $136.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,ANTHEM,ANTHEM PPO,168.71,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 210% = $168.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,412.18,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $412.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,CENPATICO,ALL MEDICAID CENPATICO,412.18,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $412.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,350.35,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $350.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,CIGNA,ALL COMMERCIAL CIGNA,288.53,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $288.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,COFINITY,COFINITY,412.18,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $412.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,412.18,,,,,,,80.3400,436.9100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $412.18, claim capped at $412.18 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,412.18,,,,,,,80.3400,436.9100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $412.18, claim capped at $412.18 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,391.57,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $391.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,346.23,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $346.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,292.65,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $292.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,300.89,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $300.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,200.32,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $200.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,350.35,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $350.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HUMANA,HUMANA CHOICE CARE HMO,128.57,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $128.57 from Fee Schedule 005543_170 for Rev 636 Proc J9055 * Qty 1 = $128.57 at 100% = $128.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HUMANA,HUMANA CHOICE CARE PPO,350.35,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $350.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HUMANA,HUMANA MEDICARE ADVANTAGE,80.34,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,HUMANA,HUMANA NATIIONAL POS HMO,128.57,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $128.57 from Fee Schedule 005543_170 for Rev 636 Proc J9055 * Qty 1 = $128.57 at 100% = $128.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,300.89,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $300.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,412.18,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $412.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,412.18,,,,,,,80.3400,436.9100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $412.18, claim capped at $412.18 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,80.34,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,412.18,,,,,,,80.3400,436.9100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $412.18, claim capped at $412.18 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,MOLINA HEALTHCARE,MOLINA MEDICAID,436.91,,,,,,,80.3400,436.9100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $412.18, claim capped at $412.18 in billed charges)... $412.18 at 106% = $436.91 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,MOLINA HEALTHCARE,MOLINA MEDICARE,80.34,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,206.09,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $206.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,346.23,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $346.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,NAPHCARE,ALL COMMERICAL NAPHCARE,180.77,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,309.14,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $309.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,379.21,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $379.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,143.81,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 179% = $143.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,143.81,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 179% = $143.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,PREVEA HEALTH NETWORK,PREVEA360,143.81,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 179% = $143.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,143.81,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 179% = $143.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,263.09,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $263.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,81.14,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,296.77,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $296.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,TRIOLOGY,TRILOGY MEDICAID,412.18,,,,,,,80.3400,436.9100,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 106% = $870.02 (Service Line reduced to $412.18, claim capped at $412.18 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,132.56,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $132.56 from Fee Schedule UHC_31190C for Rev 636 Proc J9055 * Qty 1 = $132.56 at 100% = $132.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,132.56,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $132.56 from Fee Schedule UHC_31190C for Rev 636 Proc J9055 * Qty 1 = $132.56 at 100% = $132.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,80.34,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,132.56,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). $132.56 from Fee Schedule UHC_31190C for Rev 636 Proc J9055 * Qty 1 = $132.56 at 100% = $132.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,UNITY HEALTH PLAN,UNITY HOSPICE,80.34,,,,,,,80.3400,436.9100,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,296.77,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $296.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,255.55,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $255.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,296.77,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $296.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,296.77,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $296.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-958-23,CDM,,,,both,10.000000,ME,412.1800,272.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,247.31,,,,,,,80.3400,436.9100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $412.18 in Billed Charges for Rev 636 Proc J9055 = $247.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,AETNA,AETNA HSHS,269.86,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $269.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,AETNA,AETNA MEDICARE,80.34,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,AETNA,ALL COMMERCIAL AETNA,417.74,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $417.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,ANTHEM,ANTEHM MEDICAID,417.74,,,,,,,80.3400,442.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $417.74, claim capped at $417.74 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,80.34,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,ANTHEM,ANTHEM POS/HMO,136.58,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 170% = $136.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,ANTHEM,ANTHEM PPO,168.71,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 210% = $168.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,417.74,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $417.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,CENPATICO,ALL MEDICAID CENPATICO,417.74,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $417.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,355.08,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $355.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,CIGNA,ALL COMMERCIAL CIGNA,292.42,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $292.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,COFINITY,COFINITY,417.74,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $417.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,417.74,,,,,,,80.3400,442.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $417.74, claim capped at $417.74 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,417.74,,,,,,,80.3400,442.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $417.74, claim capped at $417.74 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,396.85,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $396.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HEALTH CARE ALLIANCE,THE ALLIANCE,350.90,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $350.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,296.60,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $296.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,304.95,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $304.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HSHS EMPLOYEES,HSHS EMPLOYEES,203.02,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $203.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,355.08,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $355.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HUMANA,HUMANA CHOICE CARE HMO,128.57,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $128.57 from Fee Schedule 005543_170 for Rev 636 Proc J9055 * Qty 1 = $128.57 at 100% = $128.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HUMANA,HUMANA CHOICE CARE PPO,355.08,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $355.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HUMANA,HUMANA MEDICARE ADVANTAGE,80.34,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,HUMANA,HUMANA NATIIONAL POS HMO,128.57,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $128.57 from Fee Schedule 005543_170 for Rev 636 Proc J9055 * Qty 1 = $128.57 at 100% = $128.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,304.95,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $304.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,LIVE360,LIVE360 HSHS HEALTHY PLAN,417.74,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $417.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,417.74,,,,,,,80.3400,442.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $417.74, claim capped at $417.74 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,80.34,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,417.74,,,,,,,80.3400,442.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $417.74, claim capped at $417.74 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,MOLINA HEALTHCARE,MOLINA MEDICAID,442.80,,,,,,,80.3400,442.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 100% = $820.77 (Service Line reduced to $417.74, claim capped at $417.74 in billed charges)... $417.74 at 106% = $442.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,MOLINA HEALTHCARE,MOLINA MEDICARE,80.34,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,208.87,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $208.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,350.90,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $350.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,NAPHCARE,ALL COMMERICAL NAPHCARE,180.77,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,313.31,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $313.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,384.32,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $384.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,143.81,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 179% = $143.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,143.81,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 179% = $143.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,PREVEA HEALTH NETWORK,PREVEA360,143.81,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 179% = $143.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,143.81,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $80.34 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9055 * Qty 1 = $80.34 at 179% = $143.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,266.64,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $266.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,81.14,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,300.77,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $300.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,TRIOLOGY,TRILOGY MEDICAID,417.74,,,,,,,80.3400,442.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00461 Proc J9055 at $125.60 (Base Rate) * 6.5348 (Relative Weight) = $820.77 (Total Line Payment) at 106% = $870.02 (Service Line reduced to $417.74, claim capped at $417.74 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,132.56,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $132.56 from Fee Schedule UHC_31190C for Rev 636 Proc J9055 * Qty 1 = $132.56 at 100% = $132.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,UNITED HEALTHCARE,UHC ONEIDA NATION,132.56,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $132.56 from Fee Schedule UHC_31190C for Rev 636 Proc J9055 * Qty 1 = $132.56 at 100% = $132.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,80.34,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,UNITED HEALTHCARE,UNITED HEALTHCARE,132.56,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $132.56 from Fee Schedule UHC_31190C for Rev 636 Proc J9055 * Qty 1 = $132.56 at 100% = $132.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,UNITY HEALTH PLAN,UNITY HOSPICE,80.34,,,,,,,80.3400,442.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,300.77,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $300.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,259.00,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $259.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,300.77,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $300.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,300.77,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $300.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETUXIMAB 100 MG/50ML SOLN per 10 mg,J9055,HCPCS,636,RC,66733-948-23,CDM,,,,both,10.000000,ME,417.7400,275.7100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,250.64,,,,,,,80.3400,442.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $417.74 in Billed Charges for Rev 636 Proc J9055 = $250.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,AETNA,AETNA HSHS,79.33,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $79.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,AETNA,ALL COMMERCIAL AETNA,122.80,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $122.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,ANTHEM,ANTHEM POS/HMO,7.00,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 170% = $7.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,ANTHEM,ANTHEM PPO,8.65,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 210% = $8.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,122.80,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $122.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,CENPATICO,ALL MEDICAID CENPATICO,122.80,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $122.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,104.38,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $104.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,CIGNA,ALL COMMERCIAL CIGNA,85.96,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $85.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,COFINITY,COFINITY,122.80,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $122.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,116.66,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $116.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,103.15,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $103.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,87.19,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $87.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,89.64,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $89.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,59.68,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $59.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,104.38,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $104.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,HUMANA,HUMANA CHOICE CARE HMO,6.12,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.12 from Fee Schedule 005543_170 for Rev 636 Proc J9130 * Qty 1 = $6.12 at 100% = $6.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,HUMANA,HUMANA CHOICE CARE PPO,104.38,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $104.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,HUMANA,HUMANA NATIIONAL POS HMO,6.12,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.12 from Fee Schedule 005543_170 for Rev 636 Proc J9130 * Qty 1 = $6.12 at 100% = $6.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,89.64,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $89.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,122.80,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $122.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,61.40,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $61.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,103.15,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $103.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,92.10,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $92.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,112.98,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $112.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.37,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 179% = $7.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.37,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 179% = $7.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,PREVEA HEALTH NETWORK,PREVEA360,7.37,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 179% = $7.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.37,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $4.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9130 * Qty 1 = $4.12 at 179% = $7.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,78.38,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $78.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,88.42,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $88.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.80,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9130 * Qty 1 = $6.80 at 100% = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,UNITED HEALTHCARE,UHC ONEIDA NATION,6.80,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9130 * Qty 1 = $6.80 at 100% = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,UNITED HEALTHCARE,UNITED HEALTHCARE,6.80,,,,,,,6.1200,122.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.80 from Fee Schedule UHC_31190C for Rev 636 Proc J9130 * Qty 1 = $6.80 at 100% = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,88.42,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $88.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,76.14,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $76.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,88.42,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $88.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,88.42,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $88.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DACARBAZINE 100 MG SOLR 1 EACH VIAL per 100 mg,J9130,HCPCS,636,RC,63323-127-00,CDM,,,,both,100.000000,ME,122.8000,81.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,73.68,,,,,,,6.1200,122.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $122.80 in Billed Charges for Rev 636 Proc J9130 = $73.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,AETNA,AETNA HSHS,705.17,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $705.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,AETNA,AETNA MEDICARE,58.01,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,AETNA,ALL COMMERCIAL AETNA,1091.60,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $1,091.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,ANTHEM,ANTEHM MEDICAID,266.39,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,58.01,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,ANTHEM,ANTHEM POS/HMO,98.62,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 170% = $98.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,ANTHEM,ANTHEM PPO,121.82,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 210% = $121.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1091.60,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $1,091.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,CENPATICO,ALL MEDICAID CENPATICO,1091.60,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $1,091.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,927.86,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $927.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,CIGNA,ALL COMMERCIAL CIGNA,764.12,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $764.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,COFINITY,COFINITY,1091.60,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $1,091.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,266.39,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,266.39,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1037.02,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $1,037.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,916.94,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $916.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,775.04,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $775.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,796.87,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $796.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,530.52,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $530.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,927.86,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $927.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HUMANA,HUMANA CHOICE CARE HMO,171.14,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.14 from Fee Schedule 005543_170 for Rev 636 Proc J1190 * Qty 1 = $171.14 at 100% = $171.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HUMANA,HUMANA CHOICE CARE PPO,927.86,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $927.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,58.01,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,HUMANA,HUMANA NATIIONAL POS HMO,171.14,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $171.14 from Fee Schedule 005543_170 for Rev 636 Proc J1190 * Qty 1 = $171.14 at 100% = $171.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,796.87,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $796.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1091.60,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $1,091.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,266.39,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,58.01,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,266.39,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,282.37,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 100% = $266.39... $266.39 at 106% = $282.37 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,58.01,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,545.80,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $545.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,916.94,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $916.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,130.53,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,818.70,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $818.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1004.27,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $1,004.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,103.84,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,103.84,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,PREVEA HEALTH NETWORK,PREVEA360,103.84,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,103.84,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $58.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1190 * Qty 1 = $58.01 at 179% = $103.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,696.77,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $696.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,58.59,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,785.95,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $785.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,TRIOLOGY,TRILOGY MEDICAID,282.37,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00441 Proc J1190 at $125.60 (Base Rate) * 2.1209 (Relative Weight) = $266.39 (Total Line Payment) at 106% = $282.37. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,95.72,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,95.72,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,58.01,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,95.72,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). $95.72 from Fee Schedule UHC_31190C for Rev 636 Proc J1190 * Qty 1 = $95.72 at 100% = $95.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,UNITY HEALTH PLAN,UNITY HOSPICE,58.01,,,,,,,58.0100,1091.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,785.95,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $785.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,676.79,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $676.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,785.95,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $785.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,785.95,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $785.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXRAZOXANE HCL 250 MG SOLR 1 EACH VIAL per 250 mg,J1190,HCPCS,636,RC,72266-235-01,CDM,,,,both,250.000000,ME,1091.6000,720.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,654.96,,,,,,,58.0100,1091.6000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,091.60 in Billed Charges for Rev 636 Proc J1190 = $654.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,AETNA,AETNA HSHS,181.17,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $181.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,AETNA,ALL COMMERCIAL AETNA,280.45,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $280.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,ANTHEM,ANTEHM MEDICAID,53.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J2597 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,ANTHEM,ANTHEM POS/HMO,5.80,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2597 * Qty 1 = $3.41 at 170% = $5.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,ANTHEM,ANTHEM PPO,7.16,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2597 * Qty 1 = $3.41 at 210% = $7.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,280.45,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $280.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,CENPATICO,ALL MEDICAID CENPATICO,280.45,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $280.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,238.38,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $238.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,CIGNA,ALL COMMERCIAL CIGNA,196.32,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $196.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,COFINITY,COFINITY,280.45,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $280.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,53.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J2597 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,53.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J2597 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,266.43,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $266.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,235.58,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $235.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,199.12,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $199.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,204.73,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $204.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,136.30,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $136.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,238.38,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $238.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,HUMANA,HUMANA CHOICE CARE HMO,9.45,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $9.45 from Fee Schedule 005543_170 for Rev 636 Proc J2597 * Qty 1 = $9.45 at 100% = $9.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,HUMANA,HUMANA CHOICE CARE PPO,238.38,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $238.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,HUMANA,HUMANA NATIIONAL POS HMO,9.45,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $9.45 from Fee Schedule 005543_170 for Rev 636 Proc J2597 * Qty 1 = $9.45 at 100% = $9.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,204.73,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $204.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,280.45,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $280.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,53.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J2597 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,53.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J2597 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,MOLINA HEALTHCARE,MOLINA MEDICAID,56.29,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J2597 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10... $53.10 at 106% = $56.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,140.23,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $140.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,235.58,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $235.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,210.34,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $210.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,258.01,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $258.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2597 * Qty 1 = $3.41 at 179% = $6.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2597 * Qty 1 = $3.41 at 179% = $6.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,PREVEA HEALTH NETWORK,PREVEA360,6.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2597 * Qty 1 = $3.41 at 179% = $6.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.10,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $3.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2597 * Qty 1 = $3.41 at 179% = $6.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,179.01,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $179.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,201.92,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $201.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,TRIOLOGY,TRILOGY MEDICAID,56.29,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J2597 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 106% = $56.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.63,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.63 from Fee Schedule UHC_31190C for Rev 636 Proc J2597 * Qty 1 = $5.63 at 100% = $5.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,5.63,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.63 from Fee Schedule UHC_31190C for Rev 636 Proc J2597 * Qty 1 = $5.63 at 100% = $5.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,5.63,,,,,,,5.6300,280.4500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.63 from Fee Schedule UHC_31190C for Rev 636 Proc J2597 * Qty 1 = $5.63 at 100% = $5.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,201.92,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $201.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,173.88,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $173.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,201.92,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $201.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,201.92,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $201.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ DESMOPRESSIN ACETATE,J2597,HCPCS,636,RC,43598-931-09,CDM,,,,both,1.000000,ML,280.4500,185.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,168.27,,,,,,,5.6300,280.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $280.45 in Billed Charges for Rev 636 Proc J2597 = $168.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,AETNA,AETNA HSHS,2.58,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,AETNA,ALL COMMERCIAL AETNA,4.00,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4.00,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,CENPATICO,ALL MEDICAID CENPATICO,4.00,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3.40,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $3.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,CIGNA,ALL COMMERCIAL CIGNA,2.80,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,COFINITY,COFINITY,4.00,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3.80,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $3.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,3.36,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $3.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2.84,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2.92,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,1.94,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $1.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3.40,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $3.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,HUMANA,HUMANA CHOICE CARE HMO,0.11,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,HUMANA,HUMANA CHOICE CARE PPO,3.40,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $3.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,HUMANA,HUMANA NATIIONAL POS HMO,0.11,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2.92,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,4.00,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.00,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3.36,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $3.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.00,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $3.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3.68,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $3.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2.55,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2.88,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,4.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2.88,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2.48,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2.88,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2.88,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8179-25,CDM,,,,both,0.250000,ME,4.0000,2.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.40,,,,,,,0.0200,4.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.00 in Billed Charges for Rev 636 Proc J8540 = $2.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,AETNA,AETNA HSHS,1.29,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,AETNA,ALL COMMERCIAL AETNA,2.00,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $2.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2.00,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $2.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,CENPATICO,ALL MEDICAID CENPATICO,2.00,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $2.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1.70,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,CIGNA,ALL COMMERCIAL CIGNA,1.40,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,COFINITY,COFINITY,2.00,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $2.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1.90,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,1.68,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1.42,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1.46,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,0.97,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $0.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1.70,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,HUMANA,HUMANA CHOICE CARE HMO,0.11,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,HUMANA,HUMANA CHOICE CARE PPO,1.70,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,HUMANA,HUMANA NATIIONAL POS HMO,0.11,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1.46,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2.00,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $2.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.00,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1.68,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1.50,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1.84,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1.28,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1.44,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,2.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1.44,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1.24,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1.44,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1.44,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 0.5 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,60505-6249-1,CDM,,,,both,0.250000,ME,2.0000,1.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1.20,,,,,,,0.0200,2.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $2.00 in Billed Charges for Rev 636 Proc J8540 = $1.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,AETNA,AETNA HSHS,0.57,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,AETNA,ALL COMMERCIAL AETNA,0.89,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.89,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,CENPATICO,ALL MEDICAID CENPATICO,0.89,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.76,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,CIGNA,ALL COMMERCIAL CIGNA,0.62,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,COFINITY,COFINITY,0.89,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.85,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,HEALTH CARE ALLIANCE,THE ALLIANCE,0.75,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.63,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.65,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,HSHS EMPLOYEES,HSHS EMPLOYEES,0.43,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.76,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,HUMANA,HUMANA CHOICE CARE HMO,0.11,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,HUMANA,HUMANA CHOICE CARE PPO,0.76,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,HUMANA,HUMANA NATIIONAL POS HMO,0.11,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.65,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.89,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.45,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.75,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.67,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.82,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.57,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.64,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.8900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.64,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.55,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.64,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.64,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 1 MG/ML CONC per 0.25 mg,J8540,HCPCS,636,RC,0054-3176-44,CDM,,,,both,0.250000,ME,0.8900,0.5900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.53,,,,,,,0.0200,0.8900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.89 in Billed Charges for Rev 636 Proc J8540 = $0.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,AETNA,AETNA HSHS,0.65,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,AETNA,ALL COMMERCIAL AETNA,1.00,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1.00,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,CENPATICO,ALL MEDICAID CENPATICO,1.00,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.85,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,CIGNA,ALL COMMERCIAL CIGNA,0.70,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,COFINITY,COFINITY,1.00,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.95,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,0.84,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.71,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.73,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,0.49,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.85,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,HUMANA,HUMANA CHOICE CARE HMO,0.11,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,HUMANA,HUMANA CHOICE CARE PPO,0.85,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,HUMANA,HUMANA NATIIONAL POS HMO,0.11,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.73,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1.00,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $1.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.50,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.84,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.75,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.92,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.64,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.72,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,1.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.72,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.62,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.72,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.72,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 2 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,0054-8176-25,CDM,,,,both,0.250000,ME,1.0000,0.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.60,,,,,,,0.0200,1.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $1.00 in Billed Charges for Rev 636 Proc J8540 = $0.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,AETNA,AETNA HSHS,0.17,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,AETNA,ALL COMMERCIAL AETNA,0.26,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,ANTHEM,ANTHEM POS/HMO,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 170% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,ANTHEM,ANTHEM PPO,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 210% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.26,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,CENPATICO,ALL MEDICAID CENPATICO,0.26,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.22,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,CIGNA,ALL COMMERCIAL CIGNA,0.18,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,COFINITY,COFINITY,0.26,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.25,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,0.22,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.18,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.19,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,0.13,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.22,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,HUMANA,HUMANA CHOICE CARE HMO,0.11,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,HUMANA,HUMANA CHOICE CARE PPO,0.22,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,HUMANA,HUMANA NATIIONAL POS HMO,0.11,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule 005543_170 for Rev 636 Proc J8540 * Qty 1 = $0.11 at 100% = $0.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.19,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.26,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.13,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.22,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.20,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.24,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,PREVEA HEALTH NETWORK,PREVEA360,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.01 from Fee Schedule MEDCR_ASP for Rev 636 Proc J8540 * Qty 1 = $0.01 at 179% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.17,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.19,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.02,,,,,,,0.0200,0.2600,fee schedule,ST VINCENT HOSPITAL (ACU). $0.02 from Fee Schedule UHC_31190C for Rev 636 Proc J8540 * Qty 1 = $0.02 at 100% = $0.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.19,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.16,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.19,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.19,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE 4 MG TABS per 0.25 mg,J8540,HCPCS,636,RC,66993-730-51,CDM,,,,both,0.250000,ME,0.2600,0.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.16,,,,,,,0.0200,0.2600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.26 in Billed Charges for Rev 636 Proc J8540 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,AETNA,AETNA HSHS,7.91,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,AETNA,ALL COMMERCIAL AETNA,12.25,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM POS/HMO,0.19,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 170% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,ANTHEM,ANTHEM PPO,0.23,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 210% = $0.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.25,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,CENPATICO,ALL MEDICAID CENPATICO,12.25,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.41,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,CIGNA,ALL COMMERCIAL CIGNA,8.58,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,COFINITY,COFINITY,12.25,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.64,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $11.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,10.29,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.70,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.94,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.95,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.41,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE HMO,0.19,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE PPO,10.41,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,HUMANA,HUMANA NATIIONAL POS HMO,0.19,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.94,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.25,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.13,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.29,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.19,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $9.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.27,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.20,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.20,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360,0.20,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.20,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.82,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.82,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.18,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.18,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.18,,,,,,,0.1800,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.82,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.60,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.82,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.82,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,0641-6145-25,CDM,,,,both,1.000000,ME,12.2500,8.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.35,,,,,,,0.1800,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 636 Proc J1100 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,AETNA,AETNA HSHS,3.17,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,AETNA,ALL COMMERCIAL AETNA,4.90,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,ANTHEM,ANTHEM POS/HMO,0.19,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 170% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,ANTHEM,ANTHEM PPO,0.23,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 210% = $0.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4.90,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,CENPATICO,ALL MEDICAID CENPATICO,4.90,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.17,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,CIGNA,ALL COMMERCIAL CIGNA,3.43,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,COFINITY,COFINITY,4.90,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4.66,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,4.12,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.48,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.58,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,2.38,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $2.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.17,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,HUMANA,HUMANA CHOICE CARE HMO,0.19,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,HUMANA,HUMANA CHOICE CARE PPO,4.17,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,HUMANA,HUMANA NATIIONAL POS HMO,0.19,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.58,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,4.90,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.45,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $2.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.12,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.68,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4.51,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $4.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.20,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.20,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,PREVEA HEALTH NETWORK,PREVEA360,0.20,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.20,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.13,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.53,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.18,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.18,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.18,,,,,,,0.1800,4.9000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.53,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.04,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.53,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.53,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $3.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,55150-304-01,CDM,,,,both,1.000000,ME,4.9000,3.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.94,,,,,,,0.1800,4.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.90 in Billed Charges for Rev 636 Proc J1100 = $2.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,AETNA,AETNA HSHS,3.58,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,AETNA,ALL COMMERCIAL AETNA,5.54,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $5.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,ANTHEM,ANTHEM POS/HMO,0.19,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 170% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,ANTHEM,ANTHEM PPO,0.23,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 210% = $0.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5.54,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $5.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,CENPATICO,ALL MEDICAID CENPATICO,5.54,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $5.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.71,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,CIGNA,ALL COMMERCIAL CIGNA,3.88,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,COFINITY,COFINITY,5.54,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $5.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5.26,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $5.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,4.65,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $4.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.93,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4.04,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $4.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,2.69,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $2.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.71,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,HUMANA,HUMANA CHOICE CARE HMO,0.19,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,HUMANA,HUMANA CHOICE CARE PPO,4.71,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,HUMANA,HUMANA NATIIONAL POS HMO,0.19,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J1100 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4.04,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $4.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,5.54,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $5.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.77,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $2.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.65,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $4.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4.16,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $4.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5.10,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $5.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.20,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.20,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,PREVEA HEALTH NETWORK,PREVEA360,0.20,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.20,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1100 * Qty 1 = $0.11 at 179% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.54,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.99,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.18,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.18,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.18,,,,,,,0.1800,5.5400,fee schedule,ST VINCENT HOSPITAL (ACU). $0.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1100 * Qty 1 = $0.18 at 100% = $0.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.99,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.43,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.99,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.99,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXAMETHASONE SODIUM PHOS,J1100,HCPCS,636,RC,63323-506-01,CDM,,,,both,1.000000,ME,5.5400,3.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3.32,,,,,,,0.1800,5.5400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $5.54 in Billed Charges for Rev 636 Proc J1100 = $3.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,AETNA,AETNA HSHS,44.44,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $44.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,AETNA,ALL COMMERCIAL AETNA,68.80,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,ANTHEM,ANTHEM POS/HMO,11.37,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 170% = $11.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,ANTHEM,ANTHEM PPO,14.05,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 210% = $14.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,68.80,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,CENPATICO,ALL MEDICAID CENPATICO,68.80,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.48,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $58.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,CIGNA,ALL COMMERCIAL CIGNA,48.16,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $48.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,COFINITY,COFINITY,68.80,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.36,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $65.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,57.79,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $57.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.85,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $48.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.22,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $50.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,33.44,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $33.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.48,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $58.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,HUMANA,HUMANA CHOICE CARE HMO,9.27,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.27 from Fee Schedule 005543_170 for Rev 636 Proc J3360 * Qty 1 = $9.27 at 100% = $9.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,HUMANA,HUMANA CHOICE CARE PPO,58.48,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $58.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,HUMANA,HUMANA NATIIONAL POS HMO,9.27,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.27 from Fee Schedule 005543_170 for Rev 636 Proc J3360 * Qty 1 = $9.27 at 100% = $9.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.22,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $50.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,68.80,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.40,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $34.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.79,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $57.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.60,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $51.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.30,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $63.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.98,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 179% = $11.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.98,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 179% = $11.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,PREVEA HEALTH NETWORK,PREVEA360,11.98,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 179% = $11.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.98,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $6.69 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3360 * Qty 1 = $6.69 at 179% = $11.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.92,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $43.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.54,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.04,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.04 from Fee Schedule UHC_31190C for Rev 636 Proc J3360 * Qty 1 = $11.04 at 100% = $11.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,UNITED HEALTHCARE,UHC ONEIDA NATION,11.04,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.04 from Fee Schedule UHC_31190C for Rev 636 Proc J3360 * Qty 1 = $11.04 at 100% = $11.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,UNITED HEALTHCARE,UNITED HEALTHCARE,11.04,,,,,,,9.2700,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.04 from Fee Schedule UHC_31190C for Rev 636 Proc J3360 * Qty 1 = $11.04 at 100% = $11.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.54,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.66,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $42.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.54,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.54,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIAZEPAM 5 MG/ML SOLN per 5 mg,J3360,HCPCS,636,RC,72572-140-01,CDM,,,,both,5.000000,ME,68.8000,45.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.28,,,,,,,9.2700,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.80 in Billed Charges for Rev 636 Proc J3360 = $41.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,0.20,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3480 * Qty 1 = $0.12 at 170% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM PPO,0.25,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3480 * Qty 1 = $0.12 at 210% = $0.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,0.19,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J3480 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,0.19,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.19 from Fee Schedule 005543_170 for Rev 636 Proc J3480 * Qty 1 = $0.19 at 100% = $0.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.21,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3480 * Qty 1 = $0.12 at 179% = $0.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.21,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3480 * Qty 1 = $0.12 at 179% = $0.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,0.21,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3480 * Qty 1 = $0.12 at 179% = $0.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.21,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3480 * Qty 1 = $0.12 at 179% = $0.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.20,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.20 from Fee Schedule UHC_31190C for Rev 636 Proc J3480 * Qty 1 = $0.20 at 100% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,0.20,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.20 from Fee Schedule UHC_31190C for Rev 636 Proc J3480 * Qty 1 = $0.20 at 100% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,0.20,,,,,,,0.1900,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.20 from Fee Schedule UHC_31190C for Rev 636 Proc J3480 * Qty 1 = $0.20 at 100% = $0.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INJ POTASSIUM CHLORIDE,J3480,HCPCS,636,RC,0264-7645-00,CDM,,,,both,1000.000000,ML,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,0.1900,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 636 Proc J3480 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,AETNA,AETNA HSHS,14.21,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $14.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,AETNA,ALL COMMERCIAL AETNA,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,ANTHEM,ANTHEM POS/HMO,14.96,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 68% = $14.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,ANTHEM,ANTHEM PPO,14.96,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 68% = $14.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,CENPATICO,ALL MEDICAID CENPATICO,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,CIGNA,ALL COMMERCIAL CIGNA,15.40,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,COFINITY,COFINITY,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,20.90,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $20.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,18.48,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15.62,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16.06,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $16.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,10.69,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $10.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,HUMANA,HUMANA CHOICE CARE PPO,18.70,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16.06,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $16.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,22.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $22.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.00,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $11.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18.48,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $18.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16.50,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $16.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,20.24,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $20.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 60% = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 60% = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA360,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 60% = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $22.00 in Billed Charges at 60% = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14.04,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $14.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13.64,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $13.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15.84,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $15.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DRUGS UNCLASSIFIED INJECTION,J3490,HCPCS,636,RC,0338-0017-18,CDM,,,,both,100.000000,ML,22.0000,14.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.20,,,,,,,10.6900,22.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.00 in Billed Charges for Rev 636 Proc J3490 = $13.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,AETNA,AETNA HSHS,17.89,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $17.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,AETNA,ALL COMMERCIAL AETNA,27.70,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $27.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,ANTHEM,ANTHEM POS/HMO,18.84,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $27.70 in Billed Charges at 68% = $18.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,ANTHEM,ANTHEM PPO,18.84,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $27.70 in Billed Charges at 68% = $18.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,27.70,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $27.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,CENPATICO,ALL MEDICAID CENPATICO,27.70,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $27.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,23.55,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $23.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,CIGNA,ALL COMMERCIAL CIGNA,19.39,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $19.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,COFINITY,COFINITY,27.70,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $27.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,26.32,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $26.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,23.27,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $23.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19.67,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $19.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,20.22,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $20.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,13.46,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,23.55,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $23.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,HUMANA,HUMANA CHOICE CARE PPO,23.55,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $23.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,20.22,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $20.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,27.70,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $27.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.85,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $13.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,23.27,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $23.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20.78,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $20.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,25.48,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $25.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.62,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $27.70 in Billed Charges at 60% = $16.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.62,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $27.70 in Billed Charges at 60% = $16.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,PREVEA HEALTH NETWORK,PREVEA360,16.62,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $27.70 in Billed Charges at 60% = $16.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.62,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $27.70 in Billed Charges at 60% = $16.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.68,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $17.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,19.94,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $19.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,19.94,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $19.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.17,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $17.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,19.94,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $19.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,19.94,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $19.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,636,RC,0990-7923-23,CDM,,,,both,100.000000,ML,27.7000,18.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16.62,,,,,,,13.4600,27.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.70 in Billed Charges for Rev 636 Proc J3490 = $16.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,AETNA,AETNA HSHS,20.87,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $20.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,AETNA,ALL COMMERCIAL AETNA,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,ANTHEM,ANTHEM POS/HMO,21.96,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $32.30 in Billed Charges at 68% = $21.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,ANTHEM,ANTHEM PPO,21.96,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $32.30 in Billed Charges at 68% = $21.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,CENPATICO,ALL MEDICAID CENPATICO,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,27.46,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $27.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,CIGNA,ALL COMMERCIAL CIGNA,22.61,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $22.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,COFINITY,COFINITY,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,30.69,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $30.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,27.13,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $27.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,22.93,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $22.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,23.58,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $23.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,15.70,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $15.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,27.46,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $27.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,HUMANA,HUMANA CHOICE CARE PPO,27.46,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $27.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,23.58,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $23.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.15,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $16.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,27.13,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $27.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,24.23,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $24.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,29.72,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $29.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $32.30 in Billed Charges at 60% = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $32.30 in Billed Charges at 60% = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,PREVEA HEALTH NETWORK,PREVEA360,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $32.30 in Billed Charges at 60% = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $32.30 in Billed Charges at 60% = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,20.62,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $20.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,23.26,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,23.26,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,20.03,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $20.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,23.26,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,23.26,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0338-0017-02,CDM,,,,both,250.000000,ML,32.3000,21.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.30 in Billed Charges for Rev 636 Proc J3490 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,AETNA,AETNA HSHS,24.84,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $24.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,AETNA,ALL COMMERCIAL AETNA,38.45,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $38.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,ANTHEM,ANTHEM POS/HMO,26.15,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $38.45 in Billed Charges at 68% = $26.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,ANTHEM,ANTHEM PPO,26.15,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $38.45 in Billed Charges at 68% = $26.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,38.45,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $38.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,CENPATICO,ALL MEDICAID CENPATICO,38.45,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $38.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,32.68,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $32.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,CIGNA,ALL COMMERCIAL CIGNA,26.92,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $26.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,COFINITY,COFINITY,38.45,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $38.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,36.53,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $36.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,32.30,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,27.30,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $27.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,28.07,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $28.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,18.69,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $18.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,32.68,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $32.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,HUMANA,HUMANA CHOICE CARE PPO,32.68,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $32.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,28.07,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $28.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,38.45,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $38.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.23,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $19.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,32.30,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,28.84,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $28.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,35.37,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $35.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,23.07,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $38.45 in Billed Charges at 60% = $23.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,23.07,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $38.45 in Billed Charges at 60% = $23.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,PREVEA HEALTH NETWORK,PREVEA360,23.07,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $38.45 in Billed Charges at 60% = $23.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,23.07,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $38.45 in Billed Charges at 60% = $23.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,24.54,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $24.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,27.68,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $27.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,27.68,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $27.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,23.84,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $23.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,27.68,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $27.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,27.68,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $27.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 5 % SOLN 250 ML FLEX CONT per 250 mL,J3490,HCPCS,636,RC,0990-7922-02,CDM,,,,both,250.000000,ML,38.4500,25.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,23.07,,,,,,,18.6900,38.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.45 in Billed Charges for Rev 636 Proc J3490 = $23.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,AETNA,AETNA HSHS,9.55,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $9.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,AETNA,ALL COMMERCIAL AETNA,14.78,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,ANTHEM,ANTHEM POS/HMO,1.36,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 170% = $1.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,ANTHEM,ANTHEM PPO,1.68,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 210% = $1.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14.78,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,CENPATICO,ALL MEDICAID CENPATICO,14.78,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.56,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $12.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,CIGNA,ALL COMMERCIAL CIGNA,10.35,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $10.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,COFINITY,COFINITY,14.78,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14.04,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $14.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,12.42,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $12.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.49,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $10.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.79,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $10.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,7.18,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $7.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.56,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $12.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,HUMANA,HUMANA CHOICE CARE HMO,1.34,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule 005543_170 for Rev 636 Proc J1265 * Qty 1 = $1.34 at 100% = $1.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,HUMANA,HUMANA CHOICE CARE PPO,12.56,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $12.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,HUMANA,HUMANA NATIIONAL POS HMO,1.34,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule 005543_170 for Rev 636 Proc J1265 * Qty 1 = $1.34 at 100% = $1.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.79,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $10.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,14.78,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.39,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $7.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.42,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $12.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.09,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $11.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.60,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.43,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.43,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,PREVEA HEALTH NETWORK,PREVEA360,1.43,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.43,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.43,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $9.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.64,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $10.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.32,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,UNITED HEALTHCARE,UHC ONEIDA NATION,1.32,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,UNITED HEALTHCARE,UNITED HEALTHCARE,1.32,,,,,,,1.3200,14.7800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.64,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $10.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.16,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $9.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.64,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $10.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.64,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $10.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 1.6-5 MG/ML-% SOLN 250 ML FLEX CONT per 40 mg,J1265,HCPCS,636,RC,0409-7809-11,CDM,,,,both,40.000000,ME,14.7800,9.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.87,,,,,,,1.3200,14.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.78 in Billed Charges for Rev 636 Proc J1265 = $8.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,AETNA,AETNA HSHS,6.33,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $6.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,AETNA,ALL COMMERCIAL AETNA,9.80,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,ANTHEM,ANTHEM POS/HMO,1.36,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 170% = $1.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,ANTHEM,ANTHEM PPO,1.68,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 210% = $1.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.80,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,CENPATICO,ALL MEDICAID CENPATICO,9.80,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8.33,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,CIGNA,ALL COMMERCIAL CIGNA,6.86,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,COFINITY,COFINITY,9.80,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9.31,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,8.23,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $8.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.96,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $6.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.15,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $7.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,4.76,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $4.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8.33,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,HUMANA,HUMANA CHOICE CARE HMO,1.34,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule 005543_170 for Rev 636 Proc J1265 * Qty 1 = $1.34 at 100% = $1.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,HUMANA,HUMANA CHOICE CARE PPO,8.33,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,HUMANA,HUMANA NATIIONAL POS HMO,1.34,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.34 from Fee Schedule 005543_170 for Rev 636 Proc J1265 * Qty 1 = $1.34 at 100% = $1.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.15,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $7.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.80,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.90,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8.23,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $8.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.35,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.02,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $9.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.43,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.43,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA360,1.43,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.43,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.80 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1265 * Qty 1 = $0.80 at 179% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.26,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $6.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.06,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.32,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,1.32,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,1.32,,,,,,,1.3200,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.32 from Fee Schedule UHC_31190C for Rev 636 Proc J1265 * Qty 1 = $1.32 at 100% = $1.32 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.06,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.08,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $6.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.06,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.06,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOPAMINE 40 MG/ML SOLN 5 ML VIAL per 40 mg,J1265,HCPCS,636,RC,0143-9252-01,CDM,,,,both,40.000000,ME,9.8000,6.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.88,,,,,,,1.3200,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.80 in Billed Charges for Rev 636 Proc J1265 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,AETNA,AETNA HSHS,56.85,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $56.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,AETNA,ALL COMMERCIAL AETNA,88.00,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $88.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,ANTHEM,ANTHEM POS/HMO,13.63,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 170% = $13.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,ANTHEM,ANTHEM PPO,16.84,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 210% = $16.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,88.00,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $88.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,CENPATICO,ALL MEDICAID CENPATICO,88.00,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $88.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,74.80,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $74.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,CIGNA,ALL COMMERCIAL CIGNA,61.60,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $61.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,COFINITY,COFINITY,88.00,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $88.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,83.60,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $83.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,73.92,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $73.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,62.48,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $62.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,64.24,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $64.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,42.77,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $42.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,74.80,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $74.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,HUMANA,HUMANA CHOICE CARE HMO,12.89,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.89 from Fee Schedule 005543_170 for Rev 636 Proc J1250 * Qty 1 = $12.89 at 100% = $12.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,HUMANA,HUMANA CHOICE CARE PPO,74.80,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $74.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,HUMANA,HUMANA NATIIONAL POS HMO,12.89,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.89 from Fee Schedule 005543_170 for Rev 636 Proc J1250 * Qty 1 = $12.89 at 100% = $12.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,64.24,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $64.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,88.00,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $88.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,44.00,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $44.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,73.92,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $73.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,66.00,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $66.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,80.96,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $80.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.36,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.36,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,PREVEA HEALTH NETWORK,PREVEA360,14.36,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.36,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $8.02 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1250 * Qty 1 = $8.02 at 179% = $14.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,56.17,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $56.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,63.36,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $63.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,13.23,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,13.23,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,13.23,,,,,,,12.8900,88.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $13.23 from Fee Schedule UHC_31190C for Rev 636 Proc J1250 * Qty 1 = $13.23 at 100% = $13.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,63.36,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $63.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,54.56,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $54.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,63.36,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $63.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,63.36,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $63.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DOBUTAMINE 250 MG/20ML SOLN 20 ML VIAL per 250 mg,J1250,HCPCS,636,RC,0409-2344-01,CDM,,,,both,250.000000,ME,88.0000,58.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,52.80,,,,,,,12.8900,88.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $88.00 in Billed Charges for Rev 636 Proc J1250 = $52.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,72.08,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J7121 $106.00 in Billed Charges at 68% = $72.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,ANTHEM,ANTHEM PPO,72.08,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J7121 $106.00 in Billed Charges at 68% = $72.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,12.75,,,,,,,9.9800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.75 from Fee Schedule 005543_170 for Rev 636 Proc J7121 * Qty 1 = $12.75 at 100% = $12.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,12.75,,,,,,,9.9800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.75 from Fee Schedule 005543_170 for Rev 636 Proc J7121 * Qty 1 = $12.75 at 100% = $12.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,63.60,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J7121 $106.00 in Billed Charges at 60% = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,63.60,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J7121 $106.00 in Billed Charges at 60% = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,63.60,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J7121 $106.00 in Billed Charges at 60% = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,63.60,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J7121 $106.00 in Billed Charges at 60% = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.98,,,,,,,9.9800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.98 from Fee Schedule UHC_31190C for Rev 636 Proc J7121 * Qty 1 = $9.98 at 100% = $9.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,9.98,,,,,,,9.9800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.98 from Fee Schedule UHC_31190C for Rev 636 Proc J7121 * Qty 1 = $9.98 at 100% = $9.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,9.98,,,,,,,9.9800,106.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.98 from Fee Schedule UHC_31190C for Rev 636 Proc J7121 * Qty 1 = $9.98 at 100% = $9.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"DEXTROSE 5% LACTATED RINGERS 5 % SOLN 1,000 ML FLEX CONT per 1000 mL",J7121,HCPCS,636,RC,0338-0125-04,CDM,,,,both,1000.000000,ME,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,9.9800,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 636 Proc J7121 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,1.21,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1200 * Qty 1 = $0.71 at 170% = $1.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,ANTHEM,ANTHEM PPO,1.49,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1200 * Qty 1 = $0.71 at 210% = $1.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,1.55,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.55 from Fee Schedule 005543_170 for Rev 636 Proc J1200 * Qty 1 = $1.55 at 100% = $1.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,1.55,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.55 from Fee Schedule 005543_170 for Rev 636 Proc J1200 * Qty 1 = $1.55 at 100% = $1.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.27,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1200 * Qty 1 = $0.71 at 179% = $1.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.27,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1200 * Qty 1 = $0.71 at 179% = $1.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,1.27,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1200 * Qty 1 = $0.71 at 179% = $1.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.27,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $0.71 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1200 * Qty 1 = $0.71 at 179% = $1.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.17,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.17 from Fee Schedule UHC_31190C for Rev 636 Proc J1200 * Qty 1 = $1.17 at 100% = $1.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,1.17,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.17 from Fee Schedule UHC_31190C for Rev 636 Proc J1200 * Qty 1 = $1.17 at 100% = $1.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,1.17,,,,,,,1.1700,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.17 from Fee Schedule UHC_31190C for Rev 636 Proc J1200 * Qty 1 = $1.17 at 100% = $1.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIPHENHYDRAMINE HCL INJECTIO,J1200,HCPCS,636,RC,0641-0376-21,CDM,,,,both,50.000000,ME,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,1.1700,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 636 Proc J1200 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,AETNA,AETNA HSHS,400.78,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $400.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,AETNA,ALL COMMERCIAL AETNA,620.40,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $620.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,ANTHEM,ANTHEM POS/HMO,19.26,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0500 * Qty 1 = $11.33 at 170% = $19.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,ANTHEM,ANTHEM PPO,23.79,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0500 * Qty 1 = $11.33 at 210% = $23.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,620.40,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $620.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,CENPATICO,ALL MEDICAID CENPATICO,620.40,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $620.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,527.34,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $527.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,CIGNA,ALL COMMERCIAL CIGNA,434.28,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $434.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,COFINITY,COFINITY,620.40,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $620.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,589.38,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $589.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,521.14,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $521.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,440.48,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $440.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,452.89,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $452.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,301.51,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $301.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,527.34,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $527.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,HUMANA,HUMANA CHOICE CARE HMO,34.56,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.56 from Fee Schedule 005543_170 for Rev 636 Proc J0500 * Qty 1 = $34.56 at 100% = $34.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,HUMANA,HUMANA CHOICE CARE PPO,527.34,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $527.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,HUMANA,HUMANA NATIIONAL POS HMO,34.56,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $34.56 from Fee Schedule 005543_170 for Rev 636 Proc J0500 * Qty 1 = $34.56 at 100% = $34.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,452.89,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $452.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,620.40,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $620.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,310.20,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $310.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,521.14,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $521.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,465.30,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $465.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,570.77,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $570.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,20.28,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0500 * Qty 1 = $11.33 at 179% = $20.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,20.28,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0500 * Qty 1 = $11.33 at 179% = $20.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,PREVEA HEALTH NETWORK,PREVEA360,20.28,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0500 * Qty 1 = $11.33 at 179% = $20.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,20.28,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $11.33 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0500 * Qty 1 = $11.33 at 179% = $20.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,396.00,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $396.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,446.69,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $446.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,18.69,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.69 from Fee Schedule UHC_31190C for Rev 636 Proc J0500 * Qty 1 = $18.69 at 100% = $18.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,18.69,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.69 from Fee Schedule UHC_31190C for Rev 636 Proc J0500 * Qty 1 = $18.69 at 100% = $18.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,18.69,,,,,,,18.6900,620.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.69 from Fee Schedule UHC_31190C for Rev 636 Proc J0500 * Qty 1 = $18.69 at 100% = $18.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,446.69,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $446.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,384.65,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $384.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,446.69,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $446.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,446.69,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $446.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DICYCLOMINE INJECTION,J0500,HCPCS,636,RC,58914-080-52,CDM,,,,both,20.000000,ME,620.4000,409.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,372.24,,,,,,,18.6900,620.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $620.40 in Billed Charges for Rev 636 Proc J0500 = $372.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,16.27,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1160 * Qty 1 = $9.57 at 170% = $16.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,ANTHEM,ANTHEM PPO,20.10,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1160 * Qty 1 = $9.57 at 210% = $20.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,12.19,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.19 from Fee Schedule 005543_170 for Rev 636 Proc J1160 * Qty 1 = $12.19 at 100% = $12.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,12.19,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $12.19 from Fee Schedule 005543_170 for Rev 636 Proc J1160 * Qty 1 = $12.19 at 100% = $12.19 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.13,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1160 * Qty 1 = $9.57 at 179% = $17.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.13,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1160 * Qty 1 = $9.57 at 179% = $17.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,17.13,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1160 * Qty 1 = $9.57 at 179% = $17.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.13,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1160 * Qty 1 = $9.57 at 179% = $17.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.79,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.79 from Fee Schedule UHC_31190C for Rev 636 Proc J1160 * Qty 1 = $15.79 at 100% = $15.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,15.79,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.79 from Fee Schedule UHC_31190C for Rev 636 Proc J1160 * Qty 1 = $15.79 at 100% = $15.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,15.79,,,,,,,12.1900,49.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.79 from Fee Schedule UHC_31190C for Rev 636 Proc J1160 * Qty 1 = $15.79 at 100% = $15.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIGOXIN INJECTION,J1160,HCPCS,636,RC,0641-1410-31,CDM,,,,both,0.500000,ME,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,12.1900,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 636 Proc J1160 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,AETNA,AETNA HSHS,480.98,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $480.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,AETNA,ALL COMMERCIAL AETNA,744.55,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $744.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,ANTHEM,ANTHEM POS/HMO,97.04,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $57.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1110 * Qty 1 = $57.08 at 170% = $97.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,ANTHEM,ANTHEM PPO,119.87,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $57.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1110 * Qty 1 = $57.08 at 210% = $119.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,744.55,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $744.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,CENPATICO,ALL MEDICAID CENPATICO,744.55,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $744.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,632.87,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $632.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,CIGNA,ALL COMMERCIAL CIGNA,521.19,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $521.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,COFINITY,COFINITY,744.55,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $744.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,707.32,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $707.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,625.42,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $625.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,528.63,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $528.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,543.52,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $543.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,361.85,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $361.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,632.87,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $632.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,HUMANA,HUMANA CHOICE CARE HMO,80.09,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $80.09 from Fee Schedule 005543_170 for Rev 636 Proc J1110 * Qty 1 = $80.09 at 100% = $80.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,HUMANA,HUMANA CHOICE CARE PPO,632.87,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $632.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,HUMANA,HUMANA NATIIONAL POS HMO,80.09,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $80.09 from Fee Schedule 005543_170 for Rev 636 Proc J1110 * Qty 1 = $80.09 at 100% = $80.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,543.52,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $543.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,744.55,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $744.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,372.28,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $372.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,625.42,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $625.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,558.41,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $558.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,684.99,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $684.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,102.17,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $57.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1110 * Qty 1 = $57.08 at 179% = $102.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,102.17,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $57.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1110 * Qty 1 = $57.08 at 179% = $102.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,PREVEA HEALTH NETWORK,PREVEA360,102.17,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $57.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1110 * Qty 1 = $57.08 at 179% = $102.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,102.17,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $57.08 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1110 * Qty 1 = $57.08 at 179% = $102.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,475.25,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $475.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,536.08,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $536.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,94.18,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $94.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1110 * Qty 1 = $94.18 at 100% = $94.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,94.18,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $94.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1110 * Qty 1 = $94.18 at 100% = $94.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,94.18,,,,,,,80.0900,744.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $94.18 from Fee Schedule UHC_31190C for Rev 636 Proc J1110 * Qty 1 = $94.18 at 100% = $94.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,536.08,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $536.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,461.62,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $461.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,536.08,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $536.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,536.08,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $536.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPULE per 1 mg,J1110,HCPCS,636,RC,0143-9273-01,CDM,,,,both,1.000000,ME,744.5500,491.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,446.73,,,,,,,80.0900,744.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $744.55 in Billed Charges for Rev 636 Proc J1110 = $446.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,AETNA,AETNA HSHS,0.17,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,AETNA,ALL COMMERCIAL AETNA,0.27,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,ANTHEM,ANTHEM POS/HMO,0.05,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 170% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,ANTHEM,ANTHEM PPO,0.06,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 210% = $0.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,0.27,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,CENPATICO,ALL MEDICAID CENPATICO,0.27,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,0.23,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,CIGNA,ALL COMMERCIAL CIGNA,0.19,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,COFINITY,COFINITY,0.27,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,0.26,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,0.23,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,0.19,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,0.20,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,0.13,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,0.23,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,HUMANA,HUMANA CHOICE CARE HMO,0.17,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1163 $0.27 in Billed Charges at 63.5% = $0.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,HUMANA,HUMANA CHOICE CARE PPO,0.23,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,HUMANA,HUMANA NATIIONAL POS HMO,0.17,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J1163 $0.27 in Billed Charges at 63.5% = $0.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,0.20,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,0.27,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,0.14,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,0.23,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,0.20,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,0.25,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.05,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.05,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,PREVEA HEALTH NETWORK,PREVEA360,0.05,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.05,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.03 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1163 * Qty 1 = $0.03 at 179% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,0.17,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,0.19,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,0.05,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,0.05,,,,,,,0.0500,0.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.05 from Fee Schedule UHC_31190C for Rev 636 Proc J1163 * Qty 1 = $0.05 at 100% = $0.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,0.19,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,0.17,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,0.19,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,0.19,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"INJ, DILTIAZEM HCL, 0.5 MG",J1163,HCPCS,636,RC,0641-6015-10,CDM,,,,both,0.500000,ME,0.2700,0.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,0.16,,,,,,,0.0500,0.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $0.27 in Billed Charges for Rev 636 Proc J1163 = $0.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,AETNA,AETNA HSHS,353.07,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $353.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,AETNA,ALL COMMERCIAL AETNA,546.55,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $546.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,ANTHEM,ANTHEM POS/HMO,34.27,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $20.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1364 * Qty 1 = $20.16 at 170% = $34.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,ANTHEM,ANTHEM PPO,42.34,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $20.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1364 * Qty 1 = $20.16 at 210% = $42.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,546.55,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $546.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,CENPATICO,ALL MEDICAID CENPATICO,546.55,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $546.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,464.57,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $464.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,CIGNA,ALL COMMERCIAL CIGNA,382.59,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $382.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,COFINITY,COFINITY,546.55,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $546.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,519.22,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $519.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,459.10,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $459.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,388.05,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $388.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,398.98,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $398.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,265.62,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $265.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,464.57,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $464.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,HUMANA,HUMANA CHOICE CARE HMO,118.64,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $118.64 from Fee Schedule 005543_170 for Rev 636 Proc J1364 * Qty 1 = $118.64 at 100% = $118.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,HUMANA,HUMANA CHOICE CARE PPO,464.57,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $464.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,HUMANA,HUMANA NATIIONAL POS HMO,118.64,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $118.64 from Fee Schedule 005543_170 for Rev 636 Proc J1364 * Qty 1 = $118.64 at 100% = $118.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,398.98,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $398.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,546.55,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $546.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,273.28,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $273.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,459.10,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $459.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,409.91,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $409.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,502.83,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $502.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,36.09,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $20.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1364 * Qty 1 = $20.16 at 179% = $36.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,36.09,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $20.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1364 * Qty 1 = $20.16 at 179% = $36.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,PREVEA HEALTH NETWORK,PREVEA360,36.09,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $20.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1364 * Qty 1 = $20.16 at 179% = $36.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,36.09,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $20.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1364 * Qty 1 = $20.16 at 179% = $36.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,348.86,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $348.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,393.52,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $393.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,33.26,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $33.26 from Fee Schedule UHC_31190C for Rev 636 Proc J1364 * Qty 1 = $33.26 at 100% = $33.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,33.26,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $33.26 from Fee Schedule UHC_31190C for Rev 636 Proc J1364 * Qty 1 = $33.26 at 100% = $33.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,33.26,,,,,,,33.2600,546.5500,fee schedule,ST VINCENT HOSPITAL (ACU). $33.26 from Fee Schedule UHC_31190C for Rev 636 Proc J1364 * Qty 1 = $33.26 at 100% = $33.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,393.52,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $393.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,338.86,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $338.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,393.52,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $393.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,393.52,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $393.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL per 500 mg,J1364,HCPCS,636,RC,0409-6482-11,CDM,,,,both,500.000000,ME,546.5500,360.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,327.93,,,,,,,33.2600,546.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $546.55 in Billed Charges for Rev 636 Proc J1364 = $327.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,AETNA,AETNA HSHS,10.55,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,AETNA,ALL COMMERCIAL AETNA,16.33,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.33,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,CENPATICO,ALL MEDICAID CENPATICO,16.33,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.88,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,CIGNA,ALL COMMERCIAL CIGNA,11.43,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,COFINITY,COFINITY,16.33,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.51,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,13.72,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.59,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $11.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.92,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,7.94,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $7.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.88,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,HUMANA,HUMANA CHOICE CARE PPO,13.88,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $13.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.92,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.33,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.17,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.72,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.25,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.02,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $15.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.42,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $10.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.76,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,16.3300,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.76,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.12,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $10.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.76,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.76,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $11.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 250 MCG/5ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,0409-9094-25,CDM,,,,both,0.100000,ME,16.3300,10.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.80,,,,,,,1.4300,16.3300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.33 in Billed Charges for Rev 636 Proc J3010 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,AETNA,AETNA HSHS,4.77,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $4.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,AETNA,ALL COMMERCIAL AETNA,7.38,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7.38,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,CENPATICO,ALL MEDICAID CENPATICO,7.38,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.27,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $6.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,CIGNA,ALL COMMERCIAL CIGNA,5.17,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,COFINITY,COFINITY,7.38,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.01,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,6.20,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $6.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.24,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.39,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,3.59,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $3.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.27,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $6.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,HUMANA,HUMANA CHOICE CARE PPO,6.27,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $6.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.39,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,7.38,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.69,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $3.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.20,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $6.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5.54,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,6.79,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $6.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.71,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $4.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.31,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,7.3800,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.31,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.58,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $4.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.31,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.31,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL CITRATE INJECTION,J3010,HCPCS,636,RC,0641-6030-01,CDM,,,,both,0.100000,ME,7.3800,4.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.43,,,,,,,1.4300,7.3800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $7.38 in Billed Charges for Rev 636 Proc J3010 = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,AETNA,AETNA HSHS,9.30,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $9.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,AETNA,ALL COMMERCIAL AETNA,14.40,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $14.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,ANTHEM,ANTHEM POS/HMO,2.02,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 170% = $2.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,ANTHEM,ANTHEM PPO,2.50,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 210% = $2.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14.40,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $14.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,CENPATICO,ALL MEDICAID CENPATICO,14.40,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $14.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.24,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $12.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,CIGNA,ALL COMMERCIAL CIGNA,10.08,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,COFINITY,COFINITY,14.40,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $14.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13.68,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $13.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,12.10,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $12.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.22,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.51,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,7.00,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $7.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.24,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $12.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,HUMANA,HUMANA CHOICE CARE HMO,1.43,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,HUMANA,HUMANA CHOICE CARE PPO,12.24,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $12.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,HUMANA,HUMANA NATIIONAL POS HMO,1.43,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.43 from Fee Schedule 005543_170 for Rev 636 Proc J3010 * Qty 1 = $1.43 at 100% = $1.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.51,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,14.40,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $14.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.20,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $7.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.10,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $12.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.80,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.25,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $13.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.13,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.13,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,PREVEA HEALTH NETWORK,PREVEA360,2.13,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.13,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.19 from Fee Schedule MEDCR_ASP for Rev 636 Proc J3010 * Qty 1 = $1.19 at 179% = $2.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.19,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $9.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.37,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.96,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,1.96,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,1.96,,,,,,,1.4300,14.4000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.96 from Fee Schedule UHC_31190C for Rev 636 Proc J3010 * Qty 1 = $1.96 at 100% = $1.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.37,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.93,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $8.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.37,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.37,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $10.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FENTANYL 50 MCG/ML SOLN per 0.1 mg,J3010,HCPCS,636,RC,73702-204-25,CDM,,,,both,0.100000,ME,14.4000,9.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.64,,,,,,,1.4300,14.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.40 in Billed Charges for Rev 636 Proc J3010 = $8.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,AETNA,AETNA HSHS,6.58,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $6.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,AETNA,AETNA MEDICARE,1.12,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,AETNA,ALL COMMERCIAL AETNA,10.19,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $10.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,ANTHEM,ANTEHM MEDICAID,10.19,,,,,,,1.1200,10.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc J1439 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $10.19, claim capped at $10.19 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,1.12,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,ANTHEM,ANTHEM POS/HMO,1.90,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1439 * Qty 1 = $1.12 at 170% = $1.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,ANTHEM,ANTHEM PPO,2.35,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1439 * Qty 1 = $1.12 at 210% = $2.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.19,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $10.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,CENPATICO,ALL MEDICAID CENPATICO,10.19,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $10.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8.66,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $8.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,CIGNA,ALL COMMERCIAL CIGNA,7.13,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,COFINITY,COFINITY,10.19,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $10.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,10.19,,,,,,,1.1200,10.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc J1439 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $10.19, claim capped at $10.19 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,10.19,,,,,,,1.1200,10.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc J1439 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $10.19, claim capped at $10.19 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9.68,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $9.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,8.56,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $8.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.23,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.44,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,4.95,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8.66,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $8.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HUMANA,HUMANA CHOICE CARE HMO,1.92,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J1439 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HUMANA,HUMANA CHOICE CARE PPO,8.66,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $8.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HUMANA,HUMANA MEDICARE ADVANTAGE,1.12,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,HUMANA,HUMANA NATIIONAL POS HMO,1.92,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J1439 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.44,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.19,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $10.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,10.19,,,,,,,1.1200,10.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc J1439 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $10.19, claim capped at $10.19 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1.12,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,10.19,,,,,,,1.1200,10.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc J1439 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $10.19, claim capped at $10.19 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,MOLINA HEALTHCARE,MOLINA MEDICAID,10.80,,,,,,,1.1200,10.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc J1439 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 100% = $208.24 (Service Line reduced to $10.19, claim capped at $10.19 in billed charges)... $10.19 at 106% = $10.80 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,MOLINA HEALTHCARE,MOLINA MEDICARE,1.12,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.10,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $5.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8.56,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $8.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,NAPHCARE,ALL COMMERICAL NAPHCARE,2.51,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.64,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.37,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $9.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.00,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1439 * Qty 1 = $1.12 at 179% = $2.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.00,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1439 * Qty 1 = $1.12 at 179% = $2.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,PREVEA HEALTH NETWORK,PREVEA360,2.00,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1439 * Qty 1 = $1.12 at 179% = $2.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.00,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.12 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1439 * Qty 1 = $1.12 at 179% = $2.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.50,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $6.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,1.13,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.34,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,TRIOLOGY,TRILOGY MEDICAID,10.19,,,,,,,1.1200,10.8000,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00439 Proc J1439 at $125.60 (Base Rate) * 1.658 (Relative Weight) = $208.24 (Total Line Payment) at 106% = $220.74 (Service Line reduced to $10.19, claim capped at $10.19 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.85,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.85 from Fee Schedule UHC_31190C for Rev 636 Proc J1439 * Qty 1 = $1.85 at 100% = $1.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,UNITED HEALTHCARE,UHC ONEIDA NATION,1.85,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.85 from Fee Schedule UHC_31190C for Rev 636 Proc J1439 * Qty 1 = $1.85 at 100% = $1.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,1.12,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,UNITED HEALTHCARE,UNITED HEALTHCARE,1.85,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.85 from Fee Schedule UHC_31190C for Rev 636 Proc J1439 * Qty 1 = $1.85 at 100% = $1.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,UNITY HEALTH PLAN,UNITY HOSPICE,1.12,,,,,,,1.1200,10.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.34,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.32,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $6.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.34,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.34,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $7.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC CARBOXYMALTOSE 750 MG/15ML SOLN 15 ML VIAL per 1 mg,J1439,HCPCS,636,RC,0517-0650-01,CDM,,,,both,1.000000,ME,10.1900,6.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.11,,,,,,,1.1200,10.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.19 in Billed Charges for Rev 636 Proc J1439 = $6.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,AETNA,AETNA HSHS,30.32,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $30.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,AETNA,ALL COMMERCIAL AETNA,46.94,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $46.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,ANTHEM,ANTHEM POS/HMO,3.76,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2916 * Qty 1 = $2.21 at 170% = $3.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,ANTHEM,ANTHEM PPO,4.64,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2916 * Qty 1 = $2.21 at 210% = $4.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,46.94,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $46.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,CENPATICO,ALL MEDICAID CENPATICO,46.94,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $46.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,39.90,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,CIGNA,ALL COMMERCIAL CIGNA,32.86,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $32.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,COFINITY,COFINITY,46.94,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $46.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,44.59,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $44.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,39.43,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $39.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,33.33,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $33.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,34.27,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $34.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,22.81,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $22.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,39.90,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,HUMANA,HUMANA CHOICE CARE HMO,3.64,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $3.64 from Fee Schedule 005543_170 for Rev 636 Proc J2916 * Qty 1 = $3.64 at 100% = $3.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,HUMANA,HUMANA CHOICE CARE PPO,39.90,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,HUMANA,HUMANA NATIIONAL POS HMO,3.64,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $3.64 from Fee Schedule 005543_170 for Rev 636 Proc J2916 * Qty 1 = $3.64 at 100% = $3.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,34.27,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $34.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,46.94,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $46.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,23.47,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $23.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,39.43,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $39.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,35.21,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $35.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,43.18,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $43.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3.96,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2916 * Qty 1 = $2.21 at 179% = $3.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3.96,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2916 * Qty 1 = $2.21 at 179% = $3.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,PREVEA HEALTH NETWORK,PREVEA360,3.96,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2916 * Qty 1 = $2.21 at 179% = $3.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3.96,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $2.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J2916 * Qty 1 = $2.21 at 179% = $3.96 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,29.96,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $29.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,33.80,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $33.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3.65,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $3.65 from Fee Schedule UHC_31190C for Rev 636 Proc J2916 * Qty 1 = $3.65 at 100% = $3.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,UNITED HEALTHCARE,UHC ONEIDA NATION,3.65,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $3.65 from Fee Schedule UHC_31190C for Rev 636 Proc J2916 * Qty 1 = $3.65 at 100% = $3.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,UNITED HEALTHCARE,UNITED HEALTHCARE,3.65,,,,,,,3.6400,46.9400,fee schedule,ST VINCENT HOSPITAL (ACU). $3.65 from Fee Schedule UHC_31190C for Rev 636 Proc J2916 * Qty 1 = $3.65 at 100% = $3.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,33.80,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $33.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,29.10,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $29.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,33.80,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $33.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,33.80,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $33.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERRIC GLUCONATE 12.5 MG/ML SOLN 5 ML VIAL per 12.5 mg,J2916,HCPCS,636,RC,0143-9570-01,CDM,,,,both,12.500000,ME,46.9400,30.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,28.16,,,,,,,3.6400,46.9400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $46.94 in Billed Charges for Rev 636 Proc J2916 = $28.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,AETNA,AETNA HSHS,5.21,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,AETNA,ALL COMMERCIAL AETNA,8.07,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,ANTHEM,ANTHEM POS/HMO,1.77,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 170% = $1.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,ANTHEM,ANTHEM PPO,2.18,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 210% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.07,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,CENPATICO,ALL MEDICAID CENPATICO,8.07,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.86,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,CIGNA,ALL COMMERCIAL CIGNA,5.65,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,COFINITY,COFINITY,8.07,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.67,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $7.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,6.78,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.73,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.89,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,3.92,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $3.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.86,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,HUMANA,HUMANA CHOICE CARE HMO,1.92,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,HUMANA,HUMANA CHOICE CARE PPO,6.86,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,HUMANA,HUMANA NATIIONAL POS HMO,1.92,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.89,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.07,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.04,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $4.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.78,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.05,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $6.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.42,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $7.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.86,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.86,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,PREVEA HEALTH NETWORK,PREVEA360,1.86,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.86,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.15,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.81,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.72,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,1.72,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,1.72,,,,,,,1.7200,8.0700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.81,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.00,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.81,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.81,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $5.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 25 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-08,CDM,,,,both,10.000000,ME,8.0700,5.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.84,,,,,,,1.7200,8.0700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.07 in Billed Charges for Rev 636 Proc J9181 = $4.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,AETNA,AETNA HSHS,5.99,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $5.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,AETNA,ALL COMMERCIAL AETNA,9.27,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $9.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,ANTHEM,ANTHEM POS/HMO,1.77,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 170% = $1.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,ANTHEM,ANTHEM PPO,2.18,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 210% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.27,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $9.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,CENPATICO,ALL MEDICAID CENPATICO,9.27,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $9.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.88,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,CIGNA,ALL COMMERCIAL CIGNA,6.49,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,COFINITY,COFINITY,9.27,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $9.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.81,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $8.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,7.79,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $7.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.58,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.77,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,4.51,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $4.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.88,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,HUMANA,HUMANA CHOICE CARE HMO,1.92,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,HUMANA,HUMANA CHOICE CARE PPO,7.88,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,HUMANA,HUMANA NATIIONAL POS HMO,1.92,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.77,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.27,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $9.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.64,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $4.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.79,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $7.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.95,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.53,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $8.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.86,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.86,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,PREVEA HEALTH NETWORK,PREVEA360,1.86,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.86,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.92,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $5.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.67,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.72,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,1.72,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,1.72,,,,,,,1.7200,9.2700,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.67,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.75,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $5.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.67,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.67,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $6.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,16729-114-31,CDM,,,,both,10.000000,ME,9.2700,6.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.56,,,,,,,1.7200,9.2700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.27 in Billed Charges for Rev 636 Proc J9181 = $5.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,AETNA,AETNA HSHS,5.50,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $5.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,AETNA,ALL COMMERCIAL AETNA,8.52,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $8.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,ANTHEM,ANTHEM POS/HMO,1.77,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 170% = $1.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,ANTHEM,ANTHEM PPO,2.18,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 210% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.52,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $8.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,CENPATICO,ALL MEDICAID CENPATICO,8.52,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $8.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.24,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $7.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,CIGNA,ALL COMMERCIAL CIGNA,5.96,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,COFINITY,COFINITY,8.52,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $8.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.09,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $8.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,7.16,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $7.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.05,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $6.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.22,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $6.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,4.14,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $4.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.24,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $7.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,HUMANA,HUMANA CHOICE CARE HMO,1.92,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,HUMANA,HUMANA CHOICE CARE PPO,7.24,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $7.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,HUMANA,HUMANA NATIIONAL POS HMO,1.92,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.22,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $6.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.52,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $8.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.26,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $4.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.16,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $7.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.39,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $6.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.84,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $7.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.86,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.86,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,PREVEA HEALTH NETWORK,PREVEA360,1.86,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.86,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.44,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.13,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.72,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,UNITED HEALTHCARE,UHC ONEIDA NATION,1.72,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,UNITED HEALTHCARE,UNITED HEALTHCARE,1.72,,,,,,,1.7200,8.5200,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.13,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.28,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $5.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.13,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.13,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,63323-104-06,CDM,,,,both,10.000000,ME,8.5200,5.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.11,,,,,,,1.7200,8.5200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.52 in Billed Charges for Rev 636 Proc J9181 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,AETNA,AETNA HSHS,4.98,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $4.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,AETNA,ALL COMMERCIAL AETNA,7.71,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,ANTHEM,ANTHEM POS/HMO,1.77,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 170% = $1.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,ANTHEM,ANTHEM PPO,2.18,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 210% = $2.18 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,7.71,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,CENPATICO,ALL MEDICAID CENPATICO,7.71,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.55,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $6.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,CIGNA,ALL COMMERCIAL CIGNA,5.40,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,COFINITY,COFINITY,7.71,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.32,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $7.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,6.48,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $6.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.47,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.63,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,3.75,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $3.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.55,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $6.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,HUMANA,HUMANA CHOICE CARE HMO,1.92,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,HUMANA,HUMANA CHOICE CARE PPO,6.55,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $6.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,HUMANA,HUMANA NATIIONAL POS HMO,1.92,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.92 from Fee Schedule 005543_170 for Rev 636 Proc J9181 * Qty 1 = $1.92 at 100% = $1.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.63,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,7.71,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3.86,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $3.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.48,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $6.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,5.78,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.09,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $7.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.86,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.86,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,PREVEA HEALTH NETWORK,PREVEA360,1.86,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.86,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.04 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9181 * Qty 1 = $1.04 at 179% = $1.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,4.92,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.55,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.72,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,1.72,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,1.72,,,,,,,1.7200,7.7100,fee schedule,ST VINCENT HOSPITAL (ACU). $1.72 from Fee Schedule UHC_31190C for Rev 636 Proc J9181 * Qty 1 = $1.72 at 100% = $1.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.55,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.78,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $4.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.55,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.55,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $5.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOPOSIDE 100 MG/5ML SOLN 5 ML VIAL per 10 mg,J9181,HCPCS,636,RC,68001-265-25,CDM,,,,both,10.000000,ME,7.7100,5.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.63,,,,,,,1.7200,7.7100,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $7.71 in Billed Charges for Rev 636 Proc J9181 = $4.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,AETNA,AETNA HSHS,6.33,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $6.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,AETNA,ALL COMMERCIAL AETNA,9.80,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,ANTHEM,ANTHEM POS/HMO,1.89,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 170% = $1.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,ANTHEM,ANTHEM PPO,2.33,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 210% = $2.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.80,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,CENPATICO,ALL MEDICAID CENPATICO,9.80,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,8.33,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,CIGNA,ALL COMMERCIAL CIGNA,6.86,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $6.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,COFINITY,COFINITY,9.80,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,9.31,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,8.23,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $8.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.96,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $6.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.15,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $7.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,4.76,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $4.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,8.33,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,HUMANA,HUMANA CHOICE CARE HMO,6.22,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0166 $9.80 in Billed Charges at 63.5% = $6.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,HUMANA,HUMANA CHOICE CARE PPO,8.33,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,HUMANA,HUMANA NATIIONAL POS HMO,6.22,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0166 $9.80 in Billed Charges at 63.5% = $6.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.15,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $7.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.80,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.90,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $4.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8.23,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $8.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.35,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.02,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $9.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1.99,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 179% = $1.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1.99,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 179% = $1.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA360,1.99,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 179% = $1.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1.99,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.11 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0166 * Qty 1 = $1.11 at 179% = $1.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.26,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $6.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.06,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1.83,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.83 from Fee Schedule UHC_31190C for Rev 636 Proc J0166 * Qty 1 = $1.83 at 100% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,1.83,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.83 from Fee Schedule UHC_31190C for Rev 636 Proc J0166 * Qty 1 = $1.83 at 100% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,1.83,,,,,,,1.8300,9.8000,fee schedule,ST VINCENT HOSPITAL (ACU). $1.83 from Fee Schedule UHC_31190C for Rev 636 Proc J0166 * Qty 1 = $1.83 at 100% = $1.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.06,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.08,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $6.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.06,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.06,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $7.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/ML SOLN 10 ML VIAL per 0.1 mg,J0166,HCPCS,636,RC,54288-120-01,CDM,,,,both,0.100000,ME,9.8000,6.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.88,,,,,,,1.8300,9.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.80 in Billed Charges for Rev 636 Proc J0166 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,AETNA,AETNA HSHS,7.14,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $7.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,AETNA,ALL COMMERCIAL AETNA,11.05,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $11.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,ANTHEM,ANTHEM POS/HMO,2.35,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 170% = $2.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,ANTHEM,ANTHEM PPO,2.90,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 210% = $2.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11.05,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $11.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,CENPATICO,ALL MEDICAID CENPATICO,11.05,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $11.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.39,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $9.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,CIGNA,ALL COMMERCIAL CIGNA,7.74,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $7.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,COFINITY,COFINITY,11.05,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $11.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.50,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $10.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,HEALTH CARE ALLIANCE,THE ALLIANCE,9.28,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $9.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.85,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.07,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.37,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $5.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.39,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $9.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,HUMANA,HUMANA CHOICE CARE HMO,7.02,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0169 $11.05 in Billed Charges at 63.5% = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,HUMANA,HUMANA CHOICE CARE PPO,9.39,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $9.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,HUMANA,HUMANA NATIIONAL POS HMO,7.02,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J0169 $11.05 in Billed Charges at 63.5% = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.07,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,LIVE360,LIVE360 HSHS HEALTHY PLAN,11.05,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $11.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.53,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $5.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.28,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $9.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.29,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $8.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.17,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $10.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.47,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 179% = $2.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.47,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 179% = $2.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,PREVEA HEALTH NETWORK,PREVEA360,2.47,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 179% = $2.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.47,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $1.38 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0169 * Qty 1 = $1.38 at 179% = $2.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.05,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $7.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.96,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.28,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.28 from Fee Schedule UHC_31190C for Rev 636 Proc J0169 * Qty 1 = $2.28 at 100% = $2.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,UNITED HEALTHCARE,UHC ONEIDA NATION,2.28,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.28 from Fee Schedule UHC_31190C for Rev 636 Proc J0169 * Qty 1 = $2.28 at 100% = $2.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,UNITED HEALTHCARE,UNITED HEALTHCARE,2.28,,,,,,,2.2800,11.0500,fee schedule,ST VINCENT HOSPITAL (ACU). $2.28 from Fee Schedule UHC_31190C for Rev 636 Proc J0169 * Qty 1 = $2.28 at 100% = $2.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.96,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.85,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $6.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.96,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.96,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 30 MG/30ML SOLN 1 ML VIAL per 0.1 mg,J0169,HCPCS,636,RC,42023-159-25,CDM,,,,both,0.100000,ME,11.0500,7.2900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.63,,,,,,,2.2800,11.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.05 in Billed Charges for Rev 636 Proc J0169 = $6.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,AETNA,AETNA HSHS,81.58,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $81.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,AETNA,AETNA MEDICARE,32.22,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,AETNA,ALL COMMERCIAL AETNA,126.28,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $126.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,ANTHEM,ANTEHM MEDICAID,126.28,,,,,,,32.2200,133.8600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9332 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $126.28, claim capped at $126.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,32.22,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,ANTHEM,ANTHEM POS/HMO,54.77,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $32.22 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9332 * Qty 1 = $32.22 at 170% = $54.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,ANTHEM,ANTHEM PPO,67.66,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $32.22 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9332 * Qty 1 = $32.22 at 210% = $67.66 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,126.28,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $126.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,CENPATICO,ALL MEDICAID CENPATICO,126.28,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $126.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,107.34,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $107.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,CIGNA,ALL COMMERCIAL CIGNA,88.40,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $88.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,COFINITY,COFINITY,126.28,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $126.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,126.28,,,,,,,32.2200,133.8600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9332 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $126.28, claim capped at $126.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,126.28,,,,,,,32.2200,133.8600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9332 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $126.28, claim capped at $126.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,119.97,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $119.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,106.08,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $106.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,89.66,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $89.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,92.18,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $92.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,61.37,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,107.34,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $107.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HUMANA,HUMANA CHOICE CARE HMO,54.60,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $54.60 from Fee Schedule 005543_170 for Rev 636 Proc J9332 * Qty 1 = $54.60 at 100% = $54.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HUMANA,HUMANA CHOICE CARE PPO,107.34,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $107.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HUMANA,HUMANA MEDICARE ADVANTAGE,32.22,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,HUMANA,HUMANA NATIIONAL POS HMO,54.60,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $54.60 from Fee Schedule 005543_170 for Rev 636 Proc J9332 * Qty 1 = $54.60 at 100% = $54.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,92.18,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $92.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,126.28,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $126.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,126.28,,,,,,,32.2200,133.8600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9332 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $126.28, claim capped at $126.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,32.22,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,126.28,,,,,,,32.2200,133.8600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9332 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $126.28, claim capped at $126.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,MOLINA HEALTHCARE,MOLINA MEDICAID,133.86,,,,,,,32.2200,133.8600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9332 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 100% = $3,239.39 (Service Line reduced to $126.28, claim capped at $126.28 in billed charges)... $126.28 at 106% = $133.86 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,MOLINA HEALTHCARE,MOLINA MEDICARE,32.22,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,63.14,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $63.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,106.08,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $106.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,NAPHCARE,ALL COMMERICAL NAPHCARE,72.50,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,94.71,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $94.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,116.18,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $116.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,57.67,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $32.22 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9332 * Qty 1 = $32.22 at 179% = $57.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,57.67,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $32.22 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9332 * Qty 1 = $32.22 at 179% = $57.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,PREVEA HEALTH NETWORK,PREVEA360,57.67,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $32.22 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9332 * Qty 1 = $32.22 at 179% = $57.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,57.67,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $32.22 from Fee Schedule MEDCR_ASP for Rev 636 Proc J9332 * Qty 1 = $32.22 at 179% = $57.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,80.60,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $80.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,32.54,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,90.92,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $90.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,TRIOLOGY,TRILOGY MEDICAID,126.28,,,,,,,32.2200,133.8600,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00464 Proc J9332 at $125.60 (Base Rate) * 25.7913 (Relative Weight) = $3,239.39 (Total Line Payment) at 106% = $3,433.75 (Service Line reduced to $126.28, claim capped at $126.28 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,53.16,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $53.16 from Fee Schedule UHC_31190C for Rev 636 Proc J9332 * Qty 1 = $53.16 at 100% = $53.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,53.16,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $53.16 from Fee Schedule UHC_31190C for Rev 636 Proc J9332 * Qty 1 = $53.16 at 100% = $53.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,32.22,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,53.16,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $53.16 from Fee Schedule UHC_31190C for Rev 636 Proc J9332 * Qty 1 = $53.16 at 100% = $53.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,UNITY HEALTH PLAN,UNITY HOSPICE,32.22,,,,,,,32.2200,133.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,90.92,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $90.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,78.29,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $78.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,90.92,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $90.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,90.92,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $90.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EFGARTIGIMOD ALFA-FCAB 400 MG/20ML SOLN 20 ML VIAL per 2 mg,J9332,HCPCS,636,RC,73475-3041-5,CDM,,,,both,2.000000,ME,126.2800,83.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,75.77,,,,,,,32.2200,133.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $126.28 in Billed Charges for Rev 636 Proc J9332 = $75.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,AETNA,AETNA HSHS,3.18,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,AETNA,ALL COMMERCIAL AETNA,4.93,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,ANTHEM,ANTHEM POS/HMO,0.70,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 170% = $0.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,ANTHEM,ANTHEM PPO,0.86,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 210% = $0.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4.93,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,CENPATICO,ALL MEDICAID CENPATICO,4.93,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.19,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,CIGNA,ALL COMMERCIAL CIGNA,3.45,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,COFINITY,COFINITY,4.93,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4.68,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,HEALTH CARE ALLIANCE,THE ALLIANCE,4.14,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.50,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.60,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,HSHS EMPLOYEES,HSHS EMPLOYEES,2.40,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $2.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.19,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,HUMANA,HUMANA CHOICE CARE HMO,0.68,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule 005543_170 for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,HUMANA,HUMANA CHOICE CARE PPO,4.19,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,HUMANA,HUMANA NATIIONAL POS HMO,0.68,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule 005543_170 for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.60,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,LIVE360,LIVE360 HSHS HEALTHY PLAN,4.93,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.47,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $2.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.14,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.70,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4.54,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $4.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.73,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 179% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.73,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 179% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,PREVEA HEALTH NETWORK,PREVEA360,0.73,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 179% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.73,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.41 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1806 * Qty 1 = $0.41 at 179% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.15,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.55,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.68,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule UHC_31190C for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,UNITED HEALTHCARE,UHC ONEIDA NATION,0.68,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule UHC_31190C for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,UNITED HEALTHCARE,UNITED HEALTHCARE,0.68,,,,,,,0.6800,4.9300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.68 from Fee Schedule UHC_31190C for Rev 636 Proc J1806 * Qty 1 = $0.68 at 100% = $0.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.55,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.06,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.55,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.55,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $3.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1806,HCPCS,636,RC,44567-812-10,CDM,,,,both,10.000000,ME,4.9300,3.2500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.96,,,,,,,0.6800,4.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.93 in Billed Charges for Rev 636 Proc J1806 = $2.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,AETNA,AETNA HSHS,10.90,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $10.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,AETNA,ALL COMMERCIAL AETNA,16.87,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $16.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,ANTHEM,ANTHEM POS/HMO,0.36,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 170% = $0.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,ANTHEM,ANTHEM PPO,0.44,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 210% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.87,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $16.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,CENPATICO,ALL MEDICAID CENPATICO,16.87,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $16.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.34,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $14.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,CIGNA,ALL COMMERCIAL CIGNA,11.81,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $11.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,COFINITY,COFINITY,16.87,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $16.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16.03,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $16.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,HEALTH CARE ALLIANCE,THE ALLIANCE,14.17,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $14.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.98,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $11.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.32,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $12.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,HSHS EMPLOYEES,HSHS EMPLOYEES,8.20,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $8.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.34,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $14.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,HUMANA,HUMANA CHOICE CARE HMO,0.44,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,HUMANA,HUMANA CHOICE CARE PPO,14.34,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $14.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,HUMANA,HUMANA NATIIONAL POS HMO,0.44,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.32,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $12.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.87,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $16.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.44,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $8.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.17,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $14.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.65,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $12.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.52,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $15.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.38,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.38,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,PREVEA HEALTH NETWORK,PREVEA360,0.38,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.38,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.77,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $10.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.15,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $12.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.35,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,UNITED HEALTHCARE,UHC ONEIDA NATION,0.35,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,UNITED HEALTHCARE,UNITED HEALTHCARE,0.35,,,,,,,0.3500,16.8700,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.15,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $12.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.46,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $10.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.15,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $12.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.15,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $12.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2000 MG/100ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-658-10,CDM,,,,both,10.000000,ME,16.8700,11.1300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.12,,,,,,,0.3500,16.8700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.87 in Billed Charges for Rev 636 Proc J1805 = $10.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,AETNA,AETNA HSHS,2.55,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,AETNA,ALL COMMERCIAL AETNA,3.95,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,ANTHEM,ANTHEM POS/HMO,0.36,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 170% = $0.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,ANTHEM,ANTHEM PPO,0.44,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 210% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3.95,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,CENPATICO,ALL MEDICAID CENPATICO,3.95,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3.36,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,CIGNA,ALL COMMERCIAL CIGNA,2.77,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,COFINITY,COFINITY,3.95,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3.75,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,3.32,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2.80,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2.88,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,1.92,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $1.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3.36,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,HUMANA,HUMANA CHOICE CARE HMO,0.44,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,HUMANA,HUMANA CHOICE CARE PPO,3.36,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,HUMANA,HUMANA NATIIONAL POS HMO,0.44,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2.88,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,3.95,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1.98,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $1.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3.32,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2.96,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3.63,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $3.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.38,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.38,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,PREVEA HEALTH NETWORK,PREVEA360,0.38,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.38,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2.52,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2.84,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.35,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,0.35,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,0.35,,,,,,,0.3500,3.9500,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2.84,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2.45,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2.84,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2.84,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,10019-055-61,CDM,,,,both,10.000000,ME,3.9500,2.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.37,,,,,,,0.3500,3.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $3.95 in Billed Charges for Rev 636 Proc J1805 = $2.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,AETNA,AETNA HSHS,3.22,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,AETNA,ALL COMMERCIAL AETNA,4.99,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,ANTHEM,ANTHEM POS/HMO,0.36,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 170% = $0.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,ANTHEM,ANTHEM PPO,0.44,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 210% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4.99,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,CENPATICO,ALL MEDICAID CENPATICO,4.99,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4.24,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,CIGNA,ALL COMMERCIAL CIGNA,3.49,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,COFINITY,COFINITY,4.99,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4.74,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,HEALTH CARE ALLIANCE,THE ALLIANCE,4.19,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3.54,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3.64,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,HSHS EMPLOYEES,HSHS EMPLOYEES,2.43,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $2.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4.24,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,HUMANA,HUMANA CHOICE CARE HMO,0.44,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,HUMANA,HUMANA CHOICE CARE PPO,4.24,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,HUMANA,HUMANA NATIIONAL POS HMO,0.44,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3.64,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,LIVE360,LIVE360 HSHS HEALTHY PLAN,4.99,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.50,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $2.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4.19,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.74,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4.59,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $4.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.38,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.38,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,PREVEA HEALTH NETWORK,PREVEA360,0.38,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.38,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3.19,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3.59,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.35,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,UNITED HEALTHCARE,UHC ONEIDA NATION,0.35,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,UNITED HEALTHCARE,UNITED HEALTHCARE,0.35,,,,,,,0.3500,4.9900,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3.59,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3.09,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3.59,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3.59,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $3.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,25021-308-84,CDM,,,,both,10.000000,ME,4.9900,3.2900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.99,,,,,,,0.3500,4.9900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.99 in Billed Charges for Rev 636 Proc J1805 = $2.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,AETNA,AETNA HSHS,8.09,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $8.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,AETNA,ALL COMMERCIAL AETNA,12.53,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,ANTHEM,ANTHEM POS/HMO,0.36,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 170% = $0.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,ANTHEM,ANTHEM PPO,0.44,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 210% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.53,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,CENPATICO,ALL MEDICAID CENPATICO,12.53,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.65,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,CIGNA,ALL COMMERCIAL CIGNA,8.77,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $8.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,COFINITY,COFINITY,12.53,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.90,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $11.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,10.53,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $10.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.90,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $8.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.15,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $9.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,6.09,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $6.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.65,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,HUMANA,HUMANA CHOICE CARE HMO,0.44,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,HUMANA,HUMANA CHOICE CARE PPO,10.65,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,HUMANA,HUMANA NATIIONAL POS HMO,0.44,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.44 from Fee Schedule 005543_170 for Rev 636 Proc J1805 * Qty 1 = $0.44 at 100% = $0.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.15,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $9.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.53,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.27,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $6.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.53,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $10.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.40,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $9.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.53,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $11.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,0.38,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,0.38,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,PREVEA HEALTH NETWORK,PREVEA360,0.38,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,0.38,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.21 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1805 * Qty 1 = $0.21 at 179% = $0.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.00,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.02,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $9.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,0.35,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,UNITED HEALTHCARE,UHC ONEIDA NATION,0.35,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,UNITED HEALTHCARE,UNITED HEALTHCARE,0.35,,,,,,,0.3500,12.5300,fee schedule,ST VINCENT HOSPITAL (ACU). $0.35 from Fee Schedule UHC_31190C for Rev 636 Proc J1805 * Qty 1 = $0.35 at 100% = $0.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.02,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $9.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.77,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $7.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.02,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $9.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.02,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $9.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ESMOLOL 2500 MG/250ML SOLN per 10 mg,J1805,HCPCS,636,RC,67457-657-25,CDM,,,,both,10.000000,ME,12.5300,8.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.52,,,,,,,0.3500,12.5300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.53 in Billed Charges for Rev 636 Proc J1805 = $7.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,AETNA,AETNA HSHS,73.45,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $73.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,AETNA,ALL COMMERCIAL AETNA,113.70,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $113.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,ANTHEM,ANTHEM POS/HMO,77.32,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $113.70 in Billed Charges at 68% = $77.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,ANTHEM,ANTHEM PPO,77.32,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $113.70 in Billed Charges at 68% = $77.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,113.70,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $113.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,CENPATICO,ALL MEDICAID CENPATICO,113.70,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $113.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,96.65,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $96.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,CIGNA,ALL COMMERCIAL CIGNA,79.59,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $79.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,COFINITY,COFINITY,113.70,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $113.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,108.02,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $108.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,95.51,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $95.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.73,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $80.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,83.00,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $83.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,55.26,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $55.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,96.65,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $96.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,HUMANA,HUMANA CHOICE CARE PPO,96.65,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $96.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,83.00,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $83.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,113.70,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $113.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,56.85,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $56.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,95.51,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $95.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,85.28,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $85.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,104.60,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $104.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,68.22,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $113.70 in Billed Charges at 60% = $68.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,68.22,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $113.70 in Billed Charges at 60% = $68.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,PREVEA HEALTH NETWORK,PREVEA360,68.22,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $113.70 in Billed Charges at 60% = $68.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,68.22,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 636 Proc J3490 $113.70 in Billed Charges at 60% = $68.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,72.57,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $72.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,81.86,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $81.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,81.86,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $81.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,70.49,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $70.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,81.86,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $81.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,81.86,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $81.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 50 MG/ML SOLN per 50 mg,J3490,HCPCS,636,RC,70069-819-01,CDM,,,,both,50.000000,ME,113.7000,75.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,68.22,,,,,,,55.2600,113.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $113.70 in Billed Charges for Rev 636 Proc J3490 = $68.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,AETNA,AETNA HSHS,53.34,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $53.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,AETNA,AETNA MEDICARE,7.74,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,AETNA,ALL COMMERCIAL AETNA,82.57,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $82.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,ANTHEM,ANTEHM MEDICAID,53.10,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0885 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.74,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,ANTHEM,ANTHEM POS/HMO,13.16,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $7.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0885 * Qty 1 = $7.74 at 170% = $13.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,ANTHEM,ANTHEM PPO,16.25,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $7.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0885 * Qty 1 = $7.74 at 210% = $16.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,82.57,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $82.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,CENPATICO,ALL MEDICAID CENPATICO,82.57,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $82.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,70.18,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $70.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,CIGNA,ALL COMMERCIAL CIGNA,57.80,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $57.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,COFINITY,COFINITY,82.57,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $82.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,53.10,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0885 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,53.10,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0885 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,78.44,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $78.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,69.36,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $69.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,58.62,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,60.28,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $60.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,40.13,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $40.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,70.18,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $70.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HUMANA,HUMANA CHOICE CARE HMO,13.82,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $13.82 from Fee Schedule 005543_170 for Rev 636 Proc J0885 * Qty 1 = $13.82 at 100% = $13.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HUMANA,HUMANA CHOICE CARE PPO,70.18,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $70.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HUMANA,HUMANA MEDICARE ADVANTAGE,7.74,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,HUMANA,HUMANA NATIIONAL POS HMO,13.82,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $13.82 from Fee Schedule 005543_170 for Rev 636 Proc J0885 * Qty 1 = $13.82 at 100% = $13.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,60.28,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $60.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,82.57,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $82.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,53.10,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0885 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.74,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,53.10,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0885 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,MOLINA HEALTHCARE,MOLINA MEDICAID,56.29,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0885 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 100% = $53.10... $53.10 at 106% = $56.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,MOLINA HEALTHCARE,MOLINA MEDICARE,7.74,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,41.29,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $41.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,69.36,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $69.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,NAPHCARE,ALL COMMERICAL NAPHCARE,17.42,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.93,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $61.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,75.96,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $75.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.85,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $7.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0885 * Qty 1 = $7.74 at 179% = $13.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.85,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $7.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0885 * Qty 1 = $7.74 at 179% = $13.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,PREVEA HEALTH NETWORK,PREVEA360,13.85,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $7.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0885 * Qty 1 = $7.74 at 179% = $13.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.85,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $7.74 from Fee Schedule MEDCR_ASP for Rev 636 Proc J0885 * Qty 1 = $7.74 at 179% = $13.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,52.70,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $52.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.82,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,59.45,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,TRIOLOGY,TRILOGY MEDICAID,56.29,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00437 Proc J0885 at $125.60 (Base Rate) * 0.4228 (Relative Weight) = $53.10 (Total Line Payment) at 106% = $56.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.77,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $12.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0885 * Qty 1 = $12.77 at 100% = $12.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,12.77,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $12.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0885 * Qty 1 = $12.77 at 100% = $12.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.74,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,12.77,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). $12.77 from Fee Schedule UHC_31190C for Rev 636 Proc J0885 * Qty 1 = $12.77 at 100% = $12.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,UNITY HEALTH PLAN,UNITY HOSPICE,7.74,,,,,,,7.7400,82.5700,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,59.45,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,51.19,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $51.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,59.45,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,59.45,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA 10000 UNIT/ML SOLN per 1000 Units,J0885,HCPCS,636,RC,55513-144-10,CDM,,,,both,1000.000000,UN,82.5700,54.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,49.54,,,,,,,7.7400,82.5700,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $82.57 in Billed Charges for Rev 636 Proc J0885 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,AETNA,AETNA HSHS,70.97,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $70.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,AETNA,AETNA MEDICARE,7.57,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,AETNA,ALL COMMERCIAL AETNA,109.86,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $109.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,ANTHEM,ANTEHM MEDICAID,86.29,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.57,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,ANTHEM,ANTHEM POS/HMO,12.87,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 170% = $12.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,ANTHEM,ANTHEM PPO,15.90,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 210% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,109.86,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $109.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,CENPATICO,ALL MEDICAID CENPATICO,109.86,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $109.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,93.38,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $93.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,CIGNA,ALL COMMERCIAL CIGNA,76.90,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $76.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,COFINITY,COFINITY,109.86,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $109.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,86.29,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,86.29,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,104.37,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $104.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,92.28,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $92.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,78.00,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $78.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,80.20,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $80.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,53.39,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $53.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,93.38,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $93.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HUMANA,HUMANA CHOICE CARE HMO,11.59,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HUMANA,HUMANA CHOICE CARE PPO,93.38,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $93.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HUMANA,HUMANA MEDICARE ADVANTAGE,7.57,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,HUMANA,HUMANA NATIIONAL POS HMO,11.59,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,80.20,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $80.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,109.86,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $109.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,86.29,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.57,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,86.29,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,MOLINA HEALTHCARE,MOLINA MEDICAID,91.47,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29... $86.29 at 106% = $91.47 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,MOLINA HEALTHCARE,MOLINA MEDICARE,7.57,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,54.93,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $54.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,92.28,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $92.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,NAPHCARE,ALL COMMERICAL NAPHCARE,17.03,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,82.40,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $82.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,101.07,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $101.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.55,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.55,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,PREVEA HEALTH NETWORK,PREVEA360,13.55,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.55,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,70.12,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $70.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.65,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,79.10,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $79.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,TRIOLOGY,TRILOGY MEDICAID,91.46,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 106% = $91.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.49,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,UNITED HEALTHCARE,UHC ONEIDA NATION,12.49,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.57,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,UNITED HEALTHCARE,UNITED HEALTHCARE,12.49,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,UNITY HEALTH PLAN,UNITY HOSPICE,7.57,,,,,,,7.5700,109.8600,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,79.10,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $79.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,68.11,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $68.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,79.10,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $79.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,79.10,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $79.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 10000 UNITS/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1318-01,CDM,,,,both,1000.000000,UN,109.8600,72.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,65.92,,,,,,,7.5700,109.8600,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $109.86 in Billed Charges for Rev 636 Proc Q5106 = $65.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,AETNA,AETNA HSHS,52.59,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $52.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,AETNA,AETNA MEDICARE,7.57,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,AETNA,ALL COMMERCIAL AETNA,81.41,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $81.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,ANTHEM,ANTEHM MEDICAID,81.41,,,,,,,7.5700,86.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.41, claim capped at $81.41 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.57,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,ANTHEM,ANTHEM POS/HMO,12.87,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 170% = $12.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,ANTHEM,ANTHEM PPO,15.90,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 210% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,81.41,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $81.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,CENPATICO,ALL MEDICAID CENPATICO,81.41,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $81.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.20,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $69.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,CIGNA,ALL COMMERCIAL CIGNA,56.99,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $56.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,COFINITY,COFINITY,81.41,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $81.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,81.41,,,,,,,7.5700,86.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.41, claim capped at $81.41 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,81.41,,,,,,,7.5700,86.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.41, claim capped at $81.41 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.34,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $77.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HEALTH CARE ALLIANCE,THE ALLIANCE,68.38,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $68.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,57.80,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $57.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.43,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $59.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HSHS EMPLOYEES,HSHS EMPLOYEES,39.57,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $39.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.20,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $69.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HUMANA,HUMANA CHOICE CARE HMO,11.59,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HUMANA,HUMANA CHOICE CARE PPO,69.20,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $69.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HUMANA,HUMANA MEDICARE ADVANTAGE,7.57,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,HUMANA,HUMANA NATIIONAL POS HMO,11.59,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.43,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $59.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,LIVE360,LIVE360 HSHS HEALTHY PLAN,81.41,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $81.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,81.41,,,,,,,7.5700,86.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.41, claim capped at $81.41 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.57,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,81.41,,,,,,,7.5700,86.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.41, claim capped at $81.41 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,MOLINA HEALTHCARE,MOLINA MEDICAID,86.29,,,,,,,7.5700,86.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $81.41, claim capped at $81.41 in billed charges)... $81.41 at 106% = $86.29 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,MOLINA HEALTHCARE,MOLINA MEDICARE,7.57,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,40.71,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $40.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.38,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $68.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,NAPHCARE,ALL COMMERICAL NAPHCARE,17.03,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.06,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $61.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,74.90,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $74.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.55,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.55,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,PREVEA HEALTH NETWORK,PREVEA360,13.55,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.55,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,51.96,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $51.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.65,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,58.62,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,TRIOLOGY,TRILOGY MEDICAID,81.41,,,,,,,7.5700,86.2900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 106% = $91.46 (Service Line reduced to $81.41, claim capped at $81.41 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.49,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,UNITED HEALTHCARE,UHC ONEIDA NATION,12.49,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.57,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,UNITED HEALTHCARE,UNITED HEALTHCARE,12.49,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,UNITY HEALTH PLAN,UNITY HOSPICE,7.57,,,,,,,7.5700,86.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,58.62,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.47,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $50.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,58.62,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,58.62,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $58.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 4000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1307-01,CDM,,,,both,1000.000000,UN,81.4100,53.7300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,48.85,,,,,,,7.5700,86.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.41 in Billed Charges for Rev 636 Proc Q5106 = $48.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,AETNA,AETNA HSHS,26.93,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $26.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,AETNA,AETNA MEDICARE,7.57,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,AETNA,ALL COMMERCIAL AETNA,41.69,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,ANTHEM,ANTEHM MEDICAID,41.69,,,,,,,7.5700,44.1900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $41.69, claim capped at $41.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,7.57,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,ANTHEM,ANTHEM POS/HMO,12.87,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 170% = $12.87 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,ANTHEM,ANTHEM PPO,15.90,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 210% = $15.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,41.69,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,CENPATICO,ALL MEDICAID CENPATICO,41.69,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,35.44,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $35.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,CIGNA,ALL COMMERCIAL CIGNA,29.18,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $29.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,COFINITY,COFINITY,41.69,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,41.69,,,,,,,7.5700,44.1900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $41.69, claim capped at $41.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,41.69,,,,,,,7.5700,44.1900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $41.69, claim capped at $41.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,39.61,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $39.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,35.02,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $35.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.60,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $29.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,30.43,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $30.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,20.26,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $20.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,35.44,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $35.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HUMANA,HUMANA CHOICE CARE HMO,11.59,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HUMANA,HUMANA CHOICE CARE PPO,35.44,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $35.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HUMANA,HUMANA MEDICARE ADVANTAGE,7.57,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,HUMANA,HUMANA NATIIONAL POS HMO,11.59,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $11.59 from Fee Schedule 005543_170 for Rev 636 Proc Q5106 * Qty 1 = $11.59 at 100% = $11.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,30.43,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $30.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,41.69,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,41.69,,,,,,,7.5700,44.1900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $41.69, claim capped at $41.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,7.57,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,41.69,,,,,,,7.5700,44.1900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $41.69, claim capped at $41.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,MOLINA HEALTHCARE,MOLINA MEDICAID,44.19,,,,,,,7.5700,44.1900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 100% = $86.29 (Service Line reduced to $41.69, claim capped at $41.69 in billed charges)... $41.69 at 106% = $44.19 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,MOLINA HEALTHCARE,MOLINA MEDICARE,7.57,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,20.85,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $20.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,35.02,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $35.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,NAPHCARE,ALL COMMERICAL NAPHCARE,17.03,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,31.27,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $31.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,38.35,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $38.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.55,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.55,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,PREVEA HEALTH NETWORK,PREVEA360,13.55,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.55,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $7.57 from Fee Schedule MEDCR_ASP for Rev 636 Proc Q5106 * Qty 1 = $7.57 at 179% = $13.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.61,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $26.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,7.65,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,30.02,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $30.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,TRIOLOGY,TRILOGY MEDICAID,41.69,,,,,,,7.5700,44.1900,fee schedule,"ST VINCENT HOSPITAL (ACU). APG 00438 Proc Q5106 at $125.60 (Base Rate) * 0.687 (Relative Weight) = $86.29 (Total Line Payment) at 106% = $91.46 (Service Line reduced to $41.69, claim capped at $41.69 in billed charges). The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.49,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,12.49,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,7.57,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,12.49,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). $12.49 from Fee Schedule UHC_31190C for Rev 636 Proc Q5106 * Qty 1 = $12.49 at 100% = $12.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,UNITY HEALTH PLAN,UNITY HOSPICE,7.57,,,,,,,7.5700,44.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,30.02,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $30.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,25.85,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $25.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,30.02,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $30.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,30.02,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $30.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPOETIN ALFA-EPBX 40000 UNIT/ML SOLN per 1000 Units,Q5106,HCPCS,636,RC,0069-1309-01,CDM,,,,both,1000.000000,UN,41.6900,27.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,25.01,,,,,,,7.5700,44.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.69 in Billed Charges for Rev 636 Proc Q5106 = $25.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,AETNA,AETNA HSHS,5.72,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.85 in Billed Charges for Rev 637 = $5.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,AETNA,ALL COMMERCIAL AETNA,8.85,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.85 in Billed Charges for Rev 637 = $8.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,ANTHEM,ANTHEM POS/HMO,6.02,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.85 in Billed Charges for Rev 637 = $6.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,ANTHEM,ANTHEM PPO,6.02,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.85 in Billed Charges for Rev 637 = $6.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.85,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.85 in Billed Charges for Rev 637 = $8.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,CENPATICO,ALL MEDICAID CENPATICO,8.85,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.85 in Billed Charges for Rev 637 = $8.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.52,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.85 in Billed Charges for Rev 637 = $7.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,CIGNA,ALL COMMERCIAL CIGNA,6.20,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.85 in Billed Charges for Rev 637 = $6.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,COFINITY,COFINITY,8.85,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.85 in Billed Charges for Rev 637 = $8.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.41,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.85 in Billed Charges for Rev 637 = $8.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,7.43,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.85 in Billed Charges for Rev 637 = $7.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.28,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.85 in Billed Charges for Rev 637 = $6.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.46,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.85 in Billed Charges for Rev 637 = $6.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,4.30,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.85 in Billed Charges for Rev 637 = $4.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.52,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.85 in Billed Charges for Rev 637 = $7.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,HUMANA,HUMANA CHOICE CARE HMO,5.62,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.85 in Billed Charges at 63.5% = $5.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,HUMANA,HUMANA CHOICE CARE PPO,7.52,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.85 in Billed Charges for Rev 637 = $7.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,HUMANA,HUMANA NATIIONAL POS HMO,5.62,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.85 in Billed Charges at 63.5% = $5.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.46,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.85 in Billed Charges for Rev 637 = $6.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.85,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.85 in Billed Charges for Rev 637 = $8.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.85,,,,,,,4.3000,8.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.43,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.85 in Billed Charges for Rev 637 = $4.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.43,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.85 in Billed Charges for Rev 637 = $7.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.64,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.85 in Billed Charges for Rev 637 = $6.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.14,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.85 in Billed Charges for Rev 637 = $8.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.31,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.85 in Billed Charges for Rev 637 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.31,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.85 in Billed Charges for Rev 637 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,PREVEA HEALTH NETWORK,PREVEA360,5.31,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.85 in Billed Charges for Rev 637 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.31,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.85 in Billed Charges for Rev 637 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.65,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.85 in Billed Charges for Rev 637 = $5.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.37,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.85 in Billed Charges for Rev 637 = $6.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.89,,,,,,,4.3000,8.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.85 in Billed Charges for Rev 637 = $4.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,UNITED HEALTHCARE,UHC ONEIDA NATION,4.89,,,,,,,4.3000,8.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.85 in Billed Charges for Rev 637 = $4.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,UNITED HEALTHCARE,UNITED HEALTHCARE,4.89,,,,,,,4.3000,8.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.85 in Billed Charges for Rev 637 = $4.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,UNITY HEALTH PLAN,UNITY HOSPICE,8.85,,,,,,,4.3000,8.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.37,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.85 in Billed Charges for Rev 637 = $6.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.49,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.85 in Billed Charges for Rev 637 = $5.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.37,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.85 in Billed Charges for Rev 637 = $6.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.37,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.85 in Billed Charges for Rev 637 = $6.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,68001-399-00,CDM,,,,,,both,1.000000,EA,8.8500,5.8400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.31,,,,,,,4.3000,8.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.85 in Billed Charges for Rev 637 = $5.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,AETNA,AETNA HSHS,258.04,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $399.45 in Billed Charges for Rev 637 = $258.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,AETNA,ALL COMMERCIAL AETNA,399.45,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $399.45 in Billed Charges for Rev 637 = $399.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,ANTHEM,ANTHEM POS/HMO,271.63,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $399.45 in Billed Charges for Rev 637 = $271.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,ANTHEM,ANTHEM PPO,271.63,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $399.45 in Billed Charges for Rev 637 = $271.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,399.45,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $399.45 in Billed Charges for Rev 637 = $399.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,CENPATICO,ALL MEDICAID CENPATICO,399.45,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $399.45 in Billed Charges for Rev 637 = $399.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,339.53,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $399.45 in Billed Charges for Rev 637 = $339.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,CIGNA,ALL COMMERCIAL CIGNA,279.62,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $399.45 in Billed Charges for Rev 637 = $279.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,COFINITY,COFINITY,399.45,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $399.45 in Billed Charges for Rev 637 = $399.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,379.48,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $399.45 in Billed Charges for Rev 637 = $379.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,335.54,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $399.45 in Billed Charges for Rev 637 = $335.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,283.61,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $399.45 in Billed Charges for Rev 637 = $283.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,291.60,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $399.45 in Billed Charges for Rev 637 = $291.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,194.13,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $399.45 in Billed Charges for Rev 637 = $194.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,339.53,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $399.45 in Billed Charges for Rev 637 = $339.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,HUMANA,HUMANA CHOICE CARE HMO,253.65,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $399.45 in Billed Charges at 63.5% = $253.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,HUMANA,HUMANA CHOICE CARE PPO,339.53,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $399.45 in Billed Charges for Rev 637 = $339.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,HUMANA,HUMANA NATIIONAL POS HMO,253.65,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $399.45 in Billed Charges at 63.5% = $253.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,291.60,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $399.45 in Billed Charges for Rev 637 = $291.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,399.45,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $399.45 in Billed Charges for Rev 637 = $399.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,399.45,,,,,,,194.1300,399.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,199.73,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $399.45 in Billed Charges for Rev 637 = $199.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,335.54,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $399.45 in Billed Charges for Rev 637 = $335.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,299.59,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $399.45 in Billed Charges for Rev 637 = $299.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,367.49,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $399.45 in Billed Charges for Rev 637 = $367.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,239.67,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $399.45 in Billed Charges for Rev 637 = $239.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,239.67,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $399.45 in Billed Charges for Rev 637 = $239.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,PREVEA HEALTH NETWORK,PREVEA360,239.67,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $399.45 in Billed Charges for Rev 637 = $239.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,239.67,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $399.45 in Billed Charges for Rev 637 = $239.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,254.97,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $399.45 in Billed Charges for Rev 637 = $254.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,287.60,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $399.45 in Billed Charges for Rev 637 = $287.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,220.90,,,,,,,194.1300,399.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $399.45 in Billed Charges for Rev 637 = $220.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,220.90,,,,,,,194.1300,399.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $399.45 in Billed Charges for Rev 637 = $220.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,220.90,,,,,,,194.1300,399.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $399.45 in Billed Charges for Rev 637 = $220.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,UNITY HEALTH PLAN,UNITY HOSPICE,399.45,,,,,,,194.1300,399.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,287.60,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $399.45 in Billed Charges for Rev 637 = $287.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,247.66,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $399.45 in Billed Charges for Rev 637 = $247.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,287.60,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $399.45 in Billed Charges for Rev 637 = $287.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,287.60,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $399.45 in Billed Charges for Rev 637 = $287.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG/5ML SOLN,637,RC,0832-6032-12,CDM,,,,,,both,120.000000,ML,399.4500,263.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,239.67,,,,,,,194.1300,399.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $399.45 in Billed Charges for Rev 637 = $239.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,AETNA,AETNA HSHS,14.94,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $23.12 in Billed Charges for Rev 637 = $14.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,AETNA,ALL COMMERCIAL AETNA,23.12,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.12 in Billed Charges for Rev 637 = $23.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,ANTHEM,ANTHEM POS/HMO,15.72,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $23.12 in Billed Charges for Rev 637 = $15.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,ANTHEM,ANTHEM PPO,15.72,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $23.12 in Billed Charges for Rev 637 = $15.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,23.12,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.12 in Billed Charges for Rev 637 = $23.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,CENPATICO,ALL MEDICAID CENPATICO,23.12,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.12 in Billed Charges for Rev 637 = $23.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,19.65,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.12 in Billed Charges for Rev 637 = $19.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,CIGNA,ALL COMMERCIAL CIGNA,16.18,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $23.12 in Billed Charges for Rev 637 = $16.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,COFINITY,COFINITY,23.12,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.12 in Billed Charges for Rev 637 = $23.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,21.96,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $23.12 in Billed Charges for Rev 637 = $21.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,19.42,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.12 in Billed Charges for Rev 637 = $19.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,16.42,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $23.12 in Billed Charges for Rev 637 = $16.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16.88,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.12 in Billed Charges for Rev 637 = $16.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,11.24,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $23.12 in Billed Charges for Rev 637 = $11.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,19.65,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.12 in Billed Charges for Rev 637 = $19.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,HUMANA,HUMANA CHOICE CARE HMO,14.68,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $23.12 in Billed Charges at 63.5% = $14.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,HUMANA,HUMANA CHOICE CARE PPO,19.65,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.12 in Billed Charges for Rev 637 = $19.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,HUMANA,HUMANA NATIIONAL POS HMO,14.68,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $23.12 in Billed Charges at 63.5% = $14.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16.88,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.12 in Billed Charges for Rev 637 = $16.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,23.12,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.12 in Billed Charges for Rev 637 = $23.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,23.12,,,,,,,11.2400,23.1200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.56,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $23.12 in Billed Charges for Rev 637 = $11.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,19.42,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.12 in Billed Charges for Rev 637 = $19.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,17.34,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $23.12 in Billed Charges for Rev 637 = $17.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,21.27,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $23.12 in Billed Charges for Rev 637 = $21.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.87,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.12 in Billed Charges for Rev 637 = $13.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.87,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.12 in Billed Charges for Rev 637 = $13.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,PREVEA HEALTH NETWORK,PREVEA360,13.87,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.12 in Billed Charges for Rev 637 = $13.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.87,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.12 in Billed Charges for Rev 637 = $13.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14.76,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $23.12 in Billed Charges for Rev 637 = $14.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,16.65,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.12 in Billed Charges for Rev 637 = $16.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.79,,,,,,,11.2400,23.1200,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.12 in Billed Charges for Rev 637 = $12.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,12.79,,,,,,,11.2400,23.1200,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.12 in Billed Charges for Rev 637 = $12.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,12.79,,,,,,,11.2400,23.1200,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.12 in Billed Charges for Rev 637 = $12.79 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,UNITY HEALTH PLAN,UNITY HOSPICE,23.12,,,,,,,11.2400,23.1200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,16.65,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.12 in Billed Charges for Rev 637 = $16.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.33,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $23.12 in Billed Charges for Rev 637 = $14.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,16.65,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.12 in Billed Charges for Rev 637 = $16.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,16.65,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.12 in Billed Charges for Rev 637 = $16.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 2.5 MG TABS,637,RC,69238-1679-1,CDM,,,,,,both,1.000000,EA,23.1200,15.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.87,,,,,,,11.2400,23.1200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.12 in Billed Charges for Rev 637 = $13.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,AETNA,AETNA HSHS,20.21,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $31.28 in Billed Charges for Rev 637 = $20.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,AETNA,ALL COMMERCIAL AETNA,31.28,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.28 in Billed Charges for Rev 637 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,ANTHEM,ANTHEM POS/HMO,21.27,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $31.28 in Billed Charges for Rev 637 = $21.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,ANTHEM,ANTHEM PPO,21.27,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $31.28 in Billed Charges for Rev 637 = $21.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,31.28,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.28 in Billed Charges for Rev 637 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,CENPATICO,ALL MEDICAID CENPATICO,31.28,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.28 in Billed Charges for Rev 637 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,26.59,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $31.28 in Billed Charges for Rev 637 = $26.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,CIGNA,ALL COMMERCIAL CIGNA,21.90,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $31.28 in Billed Charges for Rev 637 = $21.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,COFINITY,COFINITY,31.28,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.28 in Billed Charges for Rev 637 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,29.72,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $31.28 in Billed Charges for Rev 637 = $29.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,26.28,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $31.28 in Billed Charges for Rev 637 = $26.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,22.21,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $31.28 in Billed Charges for Rev 637 = $22.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,22.83,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $31.28 in Billed Charges for Rev 637 = $22.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,15.20,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $31.28 in Billed Charges for Rev 637 = $15.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,26.59,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $31.28 in Billed Charges for Rev 637 = $26.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,HUMANA,HUMANA CHOICE CARE HMO,19.86,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $31.28 in Billed Charges at 63.5% = $19.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,HUMANA,HUMANA CHOICE CARE PPO,26.59,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $31.28 in Billed Charges for Rev 637 = $26.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,HUMANA,HUMANA NATIIONAL POS HMO,19.86,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $31.28 in Billed Charges at 63.5% = $19.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,22.83,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $31.28 in Billed Charges for Rev 637 = $22.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,31.28,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.28 in Billed Charges for Rev 637 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,31.28,,,,,,,15.2000,31.2800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,15.64,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $31.28 in Billed Charges for Rev 637 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,26.28,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $31.28 in Billed Charges for Rev 637 = $26.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,23.46,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $31.28 in Billed Charges for Rev 637 = $23.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,28.78,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $31.28 in Billed Charges for Rev 637 = $28.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.77,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.28 in Billed Charges for Rev 637 = $18.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.77,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.28 in Billed Charges for Rev 637 = $18.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,PREVEA HEALTH NETWORK,PREVEA360,18.77,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.28 in Billed Charges for Rev 637 = $18.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.77,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.28 in Billed Charges for Rev 637 = $18.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,19.97,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $31.28 in Billed Charges for Rev 637 = $19.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,22.52,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $31.28 in Billed Charges for Rev 637 = $22.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.30,,,,,,,15.2000,31.2800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $31.28 in Billed Charges for Rev 637 = $17.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,17.30,,,,,,,15.2000,31.2800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $31.28 in Billed Charges for Rev 637 = $17.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,17.30,,,,,,,15.2000,31.2800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $31.28 in Billed Charges for Rev 637 = $17.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,UNITY HEALTH PLAN,UNITY HOSPICE,31.28,,,,,,,15.2000,31.2800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,22.52,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $31.28 in Billed Charges for Rev 637 = $22.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,19.39,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $31.28 in Billed Charges for Rev 637 = $19.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,22.52,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $31.28 in Billed Charges for Rev 637 = $22.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,22.52,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $31.28 in Billed Charges for Rev 637 = $22.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUPHENAZINE 5 MG TABS,637,RC,69238-1680-1,CDM,,,,,,both,1.000000,EA,31.2800,20.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,18.77,,,,,,,15.2000,31.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.28 in Billed Charges for Rev 637 = $18.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,AETNA,AETNA HSHS,685.66,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,061.40 in Billed Charges for Rev 637 = $685.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,AETNA,ALL COMMERCIAL AETNA,1061.40,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.40 in Billed Charges for Rev 637 = $1,061.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,ANTHEM,ANTHEM POS/HMO,721.75,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,061.40 in Billed Charges for Rev 637 = $721.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,ANTHEM,ANTHEM PPO,721.75,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,061.40 in Billed Charges for Rev 637 = $721.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1061.40,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.40 in Billed Charges for Rev 637 = $1,061.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,CENPATICO,ALL MEDICAID CENPATICO,1061.40,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.40 in Billed Charges for Rev 637 = $1,061.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,902.19,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,061.40 in Billed Charges for Rev 637 = $902.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,CIGNA,ALL COMMERCIAL CIGNA,742.98,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,061.40 in Billed Charges for Rev 637 = $742.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,COFINITY,COFINITY,1061.40,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.40 in Billed Charges for Rev 637 = $1,061.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1008.33,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,061.40 in Billed Charges for Rev 637 = $1,008.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,891.58,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,061.40 in Billed Charges for Rev 637 = $891.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,753.59,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,061.40 in Billed Charges for Rev 637 = $753.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,774.82,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,061.40 in Billed Charges for Rev 637 = $774.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,515.84,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,061.40 in Billed Charges for Rev 637 = $515.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,902.19,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,061.40 in Billed Charges for Rev 637 = $902.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,HUMANA,HUMANA CHOICE CARE HMO,673.99,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,061.40 in Billed Charges at 63.5% = $673.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,HUMANA,HUMANA CHOICE CARE PPO,902.19,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,061.40 in Billed Charges for Rev 637 = $902.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,HUMANA,HUMANA NATIIONAL POS HMO,673.99,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,061.40 in Billed Charges at 63.5% = $673.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,774.82,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,061.40 in Billed Charges for Rev 637 = $774.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1061.40,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,061.40 in Billed Charges for Rev 637 = $1,061.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1061.40,,,,,,,515.8400,1061.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,530.70,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,061.40 in Billed Charges for Rev 637 = $530.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,891.58,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,061.40 in Billed Charges for Rev 637 = $891.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,796.05,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,061.40 in Billed Charges for Rev 637 = $796.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,976.49,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,061.40 in Billed Charges for Rev 637 = $976.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,636.84,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,061.40 in Billed Charges for Rev 637 = $636.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,636.84,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,061.40 in Billed Charges for Rev 637 = $636.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,PREVEA HEALTH NETWORK,PREVEA360,636.84,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,061.40 in Billed Charges for Rev 637 = $636.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,636.84,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,061.40 in Billed Charges for Rev 637 = $636.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,677.49,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,061.40 in Billed Charges for Rev 637 = $677.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,764.21,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,061.40 in Billed Charges for Rev 637 = $764.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,586.95,,,,,,,515.8400,1061.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,061.40 in Billed Charges for Rev 637 = $586.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,586.95,,,,,,,515.8400,1061.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,061.40 in Billed Charges for Rev 637 = $586.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,586.95,,,,,,,515.8400,1061.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,061.40 in Billed Charges for Rev 637 = $586.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,UNITY HEALTH PLAN,UNITY HOSPICE,1061.40,,,,,,,515.8400,1061.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,764.21,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,061.40 in Billed Charges for Rev 637 = $764.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,658.07,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,061.40 in Billed Charges for Rev 637 = $658.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,764.21,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,061.40 in Billed Charges for Rev 637 = $764.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,764.21,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,061.40 in Billed Charges for Rev 637 = $764.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE 110 MCG/ACT AERO,637,RC,66993-079-96,CDM,,,,,,both,12.000000,GR,1061.4000,700.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,636.84,,,,,,,515.8400,1061.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,061.40 in Billed Charges for Rev 637 = $636.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,AETNA,AETNA HSHS,1065.03,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,648.65 in Billed Charges for Rev 637 = $1,065.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,AETNA,ALL COMMERCIAL AETNA,1648.65,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,648.65 in Billed Charges for Rev 637 = $1,648.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,ANTHEM,ANTHEM POS/HMO,1121.08,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,648.65 in Billed Charges for Rev 637 = $1,121.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,ANTHEM,ANTHEM PPO,1121.08,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,648.65 in Billed Charges for Rev 637 = $1,121.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1648.65,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,648.65 in Billed Charges for Rev 637 = $1,648.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,CENPATICO,ALL MEDICAID CENPATICO,1648.65,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,648.65 in Billed Charges for Rev 637 = $1,648.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1401.35,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,648.65 in Billed Charges for Rev 637 = $1,401.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,CIGNA,ALL COMMERCIAL CIGNA,1154.06,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,648.65 in Billed Charges for Rev 637 = $1,154.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,COFINITY,COFINITY,1648.65,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,648.65 in Billed Charges for Rev 637 = $1,648.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1566.22,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,648.65 in Billed Charges for Rev 637 = $1,566.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,1384.87,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,648.65 in Billed Charges for Rev 637 = $1,384.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1170.54,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,648.65 in Billed Charges for Rev 637 = $1,170.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1203.51,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,648.65 in Billed Charges for Rev 637 = $1,203.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,801.24,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,648.65 in Billed Charges for Rev 637 = $801.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1401.35,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,648.65 in Billed Charges for Rev 637 = $1,401.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,HUMANA,HUMANA CHOICE CARE HMO,1046.89,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,648.65 in Billed Charges at 63.5% = $1,046.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,HUMANA,HUMANA CHOICE CARE PPO,1401.35,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,648.65 in Billed Charges for Rev 637 = $1,401.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,HUMANA,HUMANA NATIIONAL POS HMO,1046.89,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,648.65 in Billed Charges at 63.5% = $1,046.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1203.51,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,648.65 in Billed Charges for Rev 637 = $1,203.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1648.65,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,648.65 in Billed Charges for Rev 637 = $1,648.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1648.65,,,,,,,801.2400,1648.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,824.33,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,648.65 in Billed Charges for Rev 637 = $824.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1384.87,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,648.65 in Billed Charges for Rev 637 = $1,384.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1236.49,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,648.65 in Billed Charges for Rev 637 = $1,236.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1516.76,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,648.65 in Billed Charges for Rev 637 = $1,516.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,989.19,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,648.65 in Billed Charges for Rev 637 = $989.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,989.19,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,648.65 in Billed Charges for Rev 637 = $989.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,PREVEA HEALTH NETWORK,PREVEA360,989.19,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,648.65 in Billed Charges for Rev 637 = $989.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,989.19,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,648.65 in Billed Charges for Rev 637 = $989.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1052.33,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,648.65 in Billed Charges for Rev 637 = $1,052.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1187.03,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,648.65 in Billed Charges for Rev 637 = $1,187.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,911.70,,,,,,,801.2400,1648.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,648.65 in Billed Charges for Rev 637 = $911.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,UNITED HEALTHCARE,UHC ONEIDA NATION,911.70,,,,,,,801.2400,1648.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,648.65 in Billed Charges for Rev 637 = $911.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,UNITED HEALTHCARE,UNITED HEALTHCARE,911.70,,,,,,,801.2400,1648.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,648.65 in Billed Charges for Rev 637 = $911.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,UNITY HEALTH PLAN,UNITY HOSPICE,1648.65,,,,,,,801.2400,1648.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1187.03,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,648.65 in Billed Charges for Rev 637 = $1,187.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1022.16,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,648.65 in Billed Charges for Rev 637 = $1,022.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1187.03,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,648.65 in Billed Charges for Rev 637 = $1,187.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1187.03,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,648.65 in Billed Charges for Rev 637 = $1,187.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE PROPIONATE 220 MCG/ACT AERO,637,RC,66993-080-96,CDM,,,,,,both,12.000000,GR,1648.6500,1088.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,989.19,,,,,,,801.2400,1648.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,648.65 in Billed Charges for Rev 637 = $989.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,AETNA,AETNA HSHS,1336.19,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,068.40 in Billed Charges for Rev 637 = $1,336.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,AETNA,ALL COMMERCIAL AETNA,2068.40,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.40 in Billed Charges for Rev 637 = $2,068.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,ANTHEM,ANTHEM POS/HMO,1406.51,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,068.40 in Billed Charges for Rev 637 = $1,406.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,ANTHEM,ANTHEM PPO,1406.51,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,068.40 in Billed Charges for Rev 637 = $1,406.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2068.40,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.40 in Billed Charges for Rev 637 = $2,068.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,CENPATICO,ALL MEDICAID CENPATICO,2068.40,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.40 in Billed Charges for Rev 637 = $2,068.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1758.14,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,068.40 in Billed Charges for Rev 637 = $1,758.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,CIGNA,ALL COMMERCIAL CIGNA,1447.88,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,068.40 in Billed Charges for Rev 637 = $1,447.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,COFINITY,COFINITY,2068.40,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.40 in Billed Charges for Rev 637 = $2,068.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1964.98,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,068.40 in Billed Charges for Rev 637 = $1,964.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,1737.46,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,068.40 in Billed Charges for Rev 637 = $1,737.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1468.56,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,068.40 in Billed Charges for Rev 637 = $1,468.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1509.93,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,068.40 in Billed Charges for Rev 637 = $1,509.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,1005.24,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,068.40 in Billed Charges for Rev 637 = $1,005.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1758.14,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,068.40 in Billed Charges for Rev 637 = $1,758.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,HUMANA,HUMANA CHOICE CARE HMO,1313.43,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $2,068.40 in Billed Charges at 63.5% = $1,313.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,HUMANA,HUMANA CHOICE CARE PPO,1758.14,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,068.40 in Billed Charges for Rev 637 = $1,758.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,HUMANA,HUMANA NATIIONAL POS HMO,1313.43,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $2,068.40 in Billed Charges at 63.5% = $1,313.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1509.93,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,068.40 in Billed Charges for Rev 637 = $1,509.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2068.40,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,068.40 in Billed Charges for Rev 637 = $2,068.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2068.40,,,,,,,1005.2400,2068.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1034.20,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,068.40 in Billed Charges for Rev 637 = $1,034.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1737.46,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,068.40 in Billed Charges for Rev 637 = $1,737.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1551.30,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,068.40 in Billed Charges for Rev 637 = $1,551.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1902.93,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,068.40 in Billed Charges for Rev 637 = $1,902.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1241.04,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,068.40 in Billed Charges for Rev 637 = $1,241.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1241.04,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,068.40 in Billed Charges for Rev 637 = $1,241.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,PREVEA HEALTH NETWORK,PREVEA360,1241.04,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,068.40 in Billed Charges for Rev 637 = $1,241.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1241.04,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,068.40 in Billed Charges for Rev 637 = $1,241.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1320.26,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,068.40 in Billed Charges for Rev 637 = $1,320.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1489.25,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,068.40 in Billed Charges for Rev 637 = $1,489.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1143.83,,,,,,,1005.2400,2068.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,068.40 in Billed Charges for Rev 637 = $1,143.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,1143.83,,,,,,,1005.2400,2068.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,068.40 in Billed Charges for Rev 637 = $1,143.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,1143.83,,,,,,,1005.2400,2068.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,068.40 in Billed Charges for Rev 637 = $1,143.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,UNITY HEALTH PLAN,UNITY HOSPICE,2068.40,,,,,,,1005.2400,2068.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1489.25,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,068.40 in Billed Charges for Rev 637 = $1,489.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1282.41,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,068.40 in Billed Charges for Rev 637 = $1,282.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1489.25,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,068.40 in Billed Charges for Rev 637 = $1,489.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1489.25,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,068.40 in Billed Charges for Rev 637 = $1,489.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 230-21 MCG/ACT AERO,637,RC,66993-088-96,CDM,,,,,,both,12.000000,GR,2068.4000,1365.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1241.04,,,,,,,1005.2400,2068.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,068.40 in Billed Charges for Rev 637 = $1,241.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,AETNA,AETNA HSHS,5.65,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.74 in Billed Charges for Rev 637 = $5.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,AETNA,ALL COMMERCIAL AETNA,8.74,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.74 in Billed Charges for Rev 637 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,ANTHEM,ANTHEM POS/HMO,5.94,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.74 in Billed Charges for Rev 637 = $5.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,ANTHEM,ANTHEM PPO,5.94,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.74 in Billed Charges for Rev 637 = $5.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.74,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.74 in Billed Charges for Rev 637 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,CENPATICO,ALL MEDICAID CENPATICO,8.74,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.74 in Billed Charges for Rev 637 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.43,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.74 in Billed Charges for Rev 637 = $7.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,CIGNA,ALL COMMERCIAL CIGNA,6.12,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.74 in Billed Charges for Rev 637 = $6.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,COFINITY,COFINITY,8.74,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.74 in Billed Charges for Rev 637 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.30,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.74 in Billed Charges for Rev 637 = $8.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,7.34,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.74 in Billed Charges for Rev 637 = $7.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.21,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.74 in Billed Charges for Rev 637 = $6.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.38,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.74 in Billed Charges for Rev 637 = $6.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,4.25,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.74 in Billed Charges for Rev 637 = $4.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.43,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.74 in Billed Charges for Rev 637 = $7.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,HUMANA,HUMANA CHOICE CARE HMO,5.55,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.74 in Billed Charges at 63.5% = $5.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,HUMANA,HUMANA CHOICE CARE PPO,7.43,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.74 in Billed Charges for Rev 637 = $7.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,HUMANA,HUMANA NATIIONAL POS HMO,5.55,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.74 in Billed Charges at 63.5% = $5.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.38,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.74 in Billed Charges for Rev 637 = $6.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.74,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.74 in Billed Charges for Rev 637 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.74,,,,,,,4.2500,8.7400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.37,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.74 in Billed Charges for Rev 637 = $4.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.34,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.74 in Billed Charges for Rev 637 = $7.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.56,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.74 in Billed Charges for Rev 637 = $6.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.04,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.74 in Billed Charges for Rev 637 = $8.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.24,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.74 in Billed Charges for Rev 637 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.24,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.74 in Billed Charges for Rev 637 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,PREVEA HEALTH NETWORK,PREVEA360,5.24,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.74 in Billed Charges for Rev 637 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.24,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.74 in Billed Charges for Rev 637 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.58,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.74 in Billed Charges for Rev 637 = $5.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.29,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.74 in Billed Charges for Rev 637 = $6.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.83,,,,,,,4.2500,8.7400,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.74 in Billed Charges for Rev 637 = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,UNITED HEALTHCARE,UHC ONEIDA NATION,4.83,,,,,,,4.2500,8.7400,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.74 in Billed Charges for Rev 637 = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,UNITED HEALTHCARE,UNITED HEALTHCARE,4.83,,,,,,,4.2500,8.7400,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.74 in Billed Charges for Rev 637 = $4.83 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,UNITY HEALTH PLAN,UNITY HOSPICE,8.74,,,,,,,4.2500,8.7400,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.29,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.74 in Billed Charges for Rev 637 = $6.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.42,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.74 in Billed Charges for Rev 637 = $5.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.29,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.74 in Billed Charges for Rev 637 = $6.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.29,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.74 in Billed Charges for Rev 637 = $6.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUVOXAMINE 50 MG TABS,637,RC,62559-159-01,CDM,,,,,,both,1.000000,EA,8.7400,5.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.24,,,,,,,4.2500,8.7400,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.74 in Billed Charges for Rev 637 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,AETNA,AETNA HSHS,615.35,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $952.55 in Billed Charges for Rev 637 = $615.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,AETNA,ALL COMMERCIAL AETNA,952.55,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $952.55 in Billed Charges for Rev 637 = $952.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,ANTHEM,ANTHEM POS/HMO,647.73,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $952.55 in Billed Charges for Rev 637 = $647.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,ANTHEM,ANTHEM PPO,647.73,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $952.55 in Billed Charges for Rev 637 = $647.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,952.55,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $952.55 in Billed Charges for Rev 637 = $952.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,CENPATICO,ALL MEDICAID CENPATICO,952.55,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $952.55 in Billed Charges for Rev 637 = $952.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,809.67,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $952.55 in Billed Charges for Rev 637 = $809.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,CIGNA,ALL COMMERCIAL CIGNA,666.79,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $952.55 in Billed Charges for Rev 637 = $666.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,COFINITY,COFINITY,952.55,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $952.55 in Billed Charges for Rev 637 = $952.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,904.92,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $952.55 in Billed Charges for Rev 637 = $904.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,800.14,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $952.55 in Billed Charges for Rev 637 = $800.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,676.31,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $952.55 in Billed Charges for Rev 637 = $676.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,695.36,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $952.55 in Billed Charges for Rev 637 = $695.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,462.94,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $952.55 in Billed Charges for Rev 637 = $462.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,809.67,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $952.55 in Billed Charges for Rev 637 = $809.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,HUMANA,HUMANA CHOICE CARE HMO,604.87,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $952.55 in Billed Charges at 63.5% = $604.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,HUMANA,HUMANA CHOICE CARE PPO,809.67,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $952.55 in Billed Charges for Rev 637 = $809.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,HUMANA,HUMANA NATIIONAL POS HMO,604.87,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $952.55 in Billed Charges at 63.5% = $604.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,695.36,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $952.55 in Billed Charges for Rev 637 = $695.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,952.55,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $952.55 in Billed Charges for Rev 637 = $952.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,952.55,,,,,,,462.9400,952.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,476.28,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $952.55 in Billed Charges for Rev 637 = $476.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,800.14,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $952.55 in Billed Charges for Rev 637 = $800.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,714.41,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $952.55 in Billed Charges for Rev 637 = $714.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,876.35,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $952.55 in Billed Charges for Rev 637 = $876.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,571.53,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $952.55 in Billed Charges for Rev 637 = $571.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,571.53,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $952.55 in Billed Charges for Rev 637 = $571.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,PREVEA HEALTH NETWORK,PREVEA360,571.53,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $952.55 in Billed Charges for Rev 637 = $571.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,571.53,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $952.55 in Billed Charges for Rev 637 = $571.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,608.01,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $952.55 in Billed Charges for Rev 637 = $608.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,685.84,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $952.55 in Billed Charges for Rev 637 = $685.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,526.76,,,,,,,462.9400,952.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $952.55 in Billed Charges for Rev 637 = $526.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,526.76,,,,,,,462.9400,952.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $952.55 in Billed Charges for Rev 637 = $526.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,526.76,,,,,,,462.9400,952.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $952.55 in Billed Charges for Rev 637 = $526.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,UNITY HEALTH PLAN,UNITY HOSPICE,952.55,,,,,,,462.9400,952.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,685.84,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $952.55 in Billed Charges for Rev 637 = $685.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,590.58,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $952.55 in Billed Charges for Rev 637 = $590.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,685.84,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $952.55 in Billed Charges for Rev 637 = $685.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,685.84,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $952.55 in Billed Charges for Rev 637 = $685.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FIDAXOMICIN 200 MG TABS,637,RC,52015-080-01,CDM,,,,,,both,1.000000,EA,952.5500,628.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,571.53,,,,,,,462.9400,952.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $952.55 in Billed Charges for Rev 637 = $571.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,AETNA,AETNA HSHS,285.53,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $442.00 in Billed Charges for Rev 637 = $285.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,AETNA,ALL COMMERCIAL AETNA,442.00,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $442.00 in Billed Charges for Rev 637 = $442.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,ANTHEM,ANTHEM POS/HMO,300.56,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $442.00 in Billed Charges for Rev 637 = $300.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,ANTHEM,ANTHEM PPO,300.56,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $442.00 in Billed Charges for Rev 637 = $300.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,442.00,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $442.00 in Billed Charges for Rev 637 = $442.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,CENPATICO,ALL MEDICAID CENPATICO,442.00,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $442.00 in Billed Charges for Rev 637 = $442.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,375.70,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $442.00 in Billed Charges for Rev 637 = $375.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,CIGNA,ALL COMMERCIAL CIGNA,309.40,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $442.00 in Billed Charges for Rev 637 = $309.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,COFINITY,COFINITY,442.00,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $442.00 in Billed Charges for Rev 637 = $442.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,419.90,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $442.00 in Billed Charges for Rev 637 = $419.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,371.28,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $442.00 in Billed Charges for Rev 637 = $371.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,313.82,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $442.00 in Billed Charges for Rev 637 = $313.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,322.66,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $442.00 in Billed Charges for Rev 637 = $322.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,214.81,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $442.00 in Billed Charges for Rev 637 = $214.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,375.70,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $442.00 in Billed Charges for Rev 637 = $375.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,HUMANA,HUMANA CHOICE CARE HMO,280.67,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $442.00 in Billed Charges at 63.5% = $280.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,HUMANA,HUMANA CHOICE CARE PPO,375.70,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $442.00 in Billed Charges for Rev 637 = $375.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,HUMANA,HUMANA NATIIONAL POS HMO,280.67,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $442.00 in Billed Charges at 63.5% = $280.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,322.66,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $442.00 in Billed Charges for Rev 637 = $322.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,442.00,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $442.00 in Billed Charges for Rev 637 = $442.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,442.00,,,,,,,214.8100,442.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,221.00,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $442.00 in Billed Charges for Rev 637 = $221.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,371.28,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $442.00 in Billed Charges for Rev 637 = $371.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,331.50,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $442.00 in Billed Charges for Rev 637 = $331.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,406.64,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $442.00 in Billed Charges for Rev 637 = $406.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,265.20,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $442.00 in Billed Charges for Rev 637 = $265.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,265.20,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $442.00 in Billed Charges for Rev 637 = $265.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,PREVEA HEALTH NETWORK,PREVEA360,265.20,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $442.00 in Billed Charges for Rev 637 = $265.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,265.20,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $442.00 in Billed Charges for Rev 637 = $265.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,282.13,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $442.00 in Billed Charges for Rev 637 = $282.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,318.24,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $442.00 in Billed Charges for Rev 637 = $318.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,244.43,,,,,,,214.8100,442.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $442.00 in Billed Charges for Rev 637 = $244.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,244.43,,,,,,,214.8100,442.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $442.00 in Billed Charges for Rev 637 = $244.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,244.43,,,,,,,214.8100,442.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $442.00 in Billed Charges for Rev 637 = $244.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,UNITY HEALTH PLAN,UNITY HOSPICE,442.00,,,,,,,214.8100,442.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,318.24,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $442.00 in Billed Charges for Rev 637 = $318.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,274.04,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $442.00 in Billed Charges for Rev 637 = $274.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,318.24,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $442.00 in Billed Charges for Rev 637 = $318.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,318.24,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $442.00 in Billed Charges for Rev 637 = $318.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,70436-227-48,CDM,,,,,,both,35.000000,ML,442.0000,291.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,265.20,,,,,,,214.8100,442.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $442.00 in Billed Charges for Rev 637 = $265.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,AETNA,AETNA HSHS,286.44,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $443.40 in Billed Charges for Rev 637 = $286.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,AETNA,ALL COMMERCIAL AETNA,443.40,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.40 in Billed Charges for Rev 637 = $443.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,ANTHEM,ANTHEM POS/HMO,301.51,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $443.40 in Billed Charges for Rev 637 = $301.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,ANTHEM,ANTHEM PPO,301.51,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $443.40 in Billed Charges for Rev 637 = $301.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,443.40,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.40 in Billed Charges for Rev 637 = $443.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,CENPATICO,ALL MEDICAID CENPATICO,443.40,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.40 in Billed Charges for Rev 637 = $443.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,376.89,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.40 in Billed Charges for Rev 637 = $376.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,CIGNA,ALL COMMERCIAL CIGNA,310.38,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $443.40 in Billed Charges for Rev 637 = $310.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,COFINITY,COFINITY,443.40,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.40 in Billed Charges for Rev 637 = $443.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,421.23,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $443.40 in Billed Charges for Rev 637 = $421.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,372.46,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $443.40 in Billed Charges for Rev 637 = $372.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,314.81,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $443.40 in Billed Charges for Rev 637 = $314.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,323.68,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $443.40 in Billed Charges for Rev 637 = $323.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,215.49,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $443.40 in Billed Charges for Rev 637 = $215.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,376.89,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.40 in Billed Charges for Rev 637 = $376.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,HUMANA,HUMANA CHOICE CARE HMO,281.56,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $443.40 in Billed Charges at 63.5% = $281.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,HUMANA,HUMANA CHOICE CARE PPO,376.89,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $443.40 in Billed Charges for Rev 637 = $376.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,HUMANA,HUMANA NATIIONAL POS HMO,281.56,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $443.40 in Billed Charges at 63.5% = $281.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,323.68,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $443.40 in Billed Charges for Rev 637 = $323.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,443.40,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $443.40 in Billed Charges for Rev 637 = $443.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,443.40,,,,,,,215.4900,443.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,221.70,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $443.40 in Billed Charges for Rev 637 = $221.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,372.46,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $443.40 in Billed Charges for Rev 637 = $372.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,332.55,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $443.40 in Billed Charges for Rev 637 = $332.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,407.93,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $443.40 in Billed Charges for Rev 637 = $407.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,266.04,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $443.40 in Billed Charges for Rev 637 = $266.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,266.04,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $443.40 in Billed Charges for Rev 637 = $266.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,PREVEA HEALTH NETWORK,PREVEA360,266.04,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $443.40 in Billed Charges for Rev 637 = $266.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,266.04,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $443.40 in Billed Charges for Rev 637 = $266.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,283.02,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $443.40 in Billed Charges for Rev 637 = $283.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,319.25,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.40 in Billed Charges for Rev 637 = $319.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,245.20,,,,,,,215.4900,443.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $443.40 in Billed Charges for Rev 637 = $245.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,245.20,,,,,,,215.4900,443.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $443.40 in Billed Charges for Rev 637 = $245.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,245.20,,,,,,,215.4900,443.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $443.40 in Billed Charges for Rev 637 = $245.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,UNITY HEALTH PLAN,UNITY HOSPICE,443.40,,,,,,,215.4900,443.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,319.25,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.40 in Billed Charges for Rev 637 = $319.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,274.91,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $443.40 in Billed Charges for Rev 637 = $274.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,319.25,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.40 in Billed Charges for Rev 637 = $319.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,319.25,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $443.40 in Billed Charges for Rev 637 = $319.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 40 MG/ML SUSR,637,RC,57237-150-35,CDM,,,,,,both,35.000000,ML,443.4000,292.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,266.04,,,,,,,215.4900,443.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $443.40 in Billed Charges for Rev 637 = $266.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,AETNA,AETNA HSHS,12.31,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $19.05 in Billed Charges for Rev 637 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,AETNA,ALL COMMERCIAL AETNA,19.05,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.05 in Billed Charges for Rev 637 = $19.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,ANTHEM,ANTHEM POS/HMO,12.95,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $19.05 in Billed Charges for Rev 637 = $12.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,ANTHEM,ANTHEM PPO,12.95,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $19.05 in Billed Charges for Rev 637 = $12.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,19.05,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.05 in Billed Charges for Rev 637 = $19.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,CENPATICO,ALL MEDICAID CENPATICO,19.05,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.05 in Billed Charges for Rev 637 = $19.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,16.19,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.05 in Billed Charges for Rev 637 = $16.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,CIGNA,ALL COMMERCIAL CIGNA,13.34,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $19.05 in Billed Charges for Rev 637 = $13.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,COFINITY,COFINITY,19.05,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.05 in Billed Charges for Rev 637 = $19.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,18.10,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $19.05 in Billed Charges for Rev 637 = $18.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,16.00,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.05 in Billed Charges for Rev 637 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.53,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $19.05 in Billed Charges for Rev 637 = $13.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13.91,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.05 in Billed Charges for Rev 637 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,9.26,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $19.05 in Billed Charges for Rev 637 = $9.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,16.19,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.05 in Billed Charges for Rev 637 = $16.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,HUMANA,HUMANA CHOICE CARE HMO,12.10,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $19.05 in Billed Charges at 63.5% = $12.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,HUMANA,HUMANA CHOICE CARE PPO,16.19,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.05 in Billed Charges for Rev 637 = $16.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,HUMANA,HUMANA NATIIONAL POS HMO,12.10,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $19.05 in Billed Charges at 63.5% = $12.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13.91,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.05 in Billed Charges for Rev 637 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,19.05,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.05 in Billed Charges for Rev 637 = $19.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,19.05,,,,,,,9.2600,19.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.53,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $19.05 in Billed Charges for Rev 637 = $9.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,16.00,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.05 in Billed Charges for Rev 637 = $16.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.29,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $19.05 in Billed Charges for Rev 637 = $14.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,17.53,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $19.05 in Billed Charges for Rev 637 = $17.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.43,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.05 in Billed Charges for Rev 637 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.43,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.05 in Billed Charges for Rev 637 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,PREVEA HEALTH NETWORK,PREVEA360,11.43,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.05 in Billed Charges for Rev 637 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.43,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.05 in Billed Charges for Rev 637 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.16,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $19.05 in Billed Charges for Rev 637 = $12.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.72,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.05 in Billed Charges for Rev 637 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.53,,,,,,,9.2600,19.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.05 in Billed Charges for Rev 637 = $10.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,UNITED HEALTHCARE,UHC ONEIDA NATION,10.53,,,,,,,9.2600,19.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.05 in Billed Charges for Rev 637 = $10.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,UNITED HEALTHCARE,UNITED HEALTHCARE,10.53,,,,,,,9.2600,19.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.05 in Billed Charges for Rev 637 = $10.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,UNITY HEALTH PLAN,UNITY HOSPICE,19.05,,,,,,,9.2600,19.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.72,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.05 in Billed Charges for Rev 637 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.81,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $19.05 in Billed Charges for Rev 637 = $11.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.72,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.05 in Billed Charges for Rev 637 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.72,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.05 in Billed Charges for Rev 637 = $13.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 50 MG TABS,637,RC,68001-251-04,CDM,,,,,,both,1.000000,EA,19.0500,12.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.43,,,,,,,9.2600,19.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.05 in Billed Charges for Rev 637 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,AETNA,AETNA HSHS,328.29,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $508.19 in Billed Charges for Rev 637 = $328.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,AETNA,ALL COMMERCIAL AETNA,508.19,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.19 in Billed Charges for Rev 637 = $508.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,ANTHEM,ANTHEM POS/HMO,345.57,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $508.19 in Billed Charges for Rev 637 = $345.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,ANTHEM,ANTHEM PPO,345.57,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $508.19 in Billed Charges for Rev 637 = $345.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,508.19,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.19 in Billed Charges for Rev 637 = $508.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,CENPATICO,ALL MEDICAID CENPATICO,508.19,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.19 in Billed Charges for Rev 637 = $508.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,431.96,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $508.19 in Billed Charges for Rev 637 = $431.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,CIGNA,ALL COMMERCIAL CIGNA,355.73,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $508.19 in Billed Charges for Rev 637 = $355.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,COFINITY,COFINITY,508.19,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.19 in Billed Charges for Rev 637 = $508.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,482.78,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $508.19 in Billed Charges for Rev 637 = $482.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,426.88,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $508.19 in Billed Charges for Rev 637 = $426.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,360.81,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $508.19 in Billed Charges for Rev 637 = $360.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,370.98,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $508.19 in Billed Charges for Rev 637 = $370.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,246.98,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $508.19 in Billed Charges for Rev 637 = $246.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,431.96,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $508.19 in Billed Charges for Rev 637 = $431.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,HUMANA,HUMANA CHOICE CARE HMO,322.70,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $508.19 in Billed Charges at 63.5% = $322.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,HUMANA,HUMANA CHOICE CARE PPO,431.96,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $508.19 in Billed Charges for Rev 637 = $431.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,HUMANA,HUMANA NATIIONAL POS HMO,322.70,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $508.19 in Billed Charges at 63.5% = $322.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,370.98,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $508.19 in Billed Charges for Rev 637 = $370.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,508.19,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $508.19 in Billed Charges for Rev 637 = $508.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,508.19,,,,,,,246.9800,508.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,254.10,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $508.19 in Billed Charges for Rev 637 = $254.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,426.88,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $508.19 in Billed Charges for Rev 637 = $426.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,381.14,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $508.19 in Billed Charges for Rev 637 = $381.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,467.53,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $508.19 in Billed Charges for Rev 637 = $467.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,304.91,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $508.19 in Billed Charges for Rev 637 = $304.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,304.91,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $508.19 in Billed Charges for Rev 637 = $304.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,PREVEA HEALTH NETWORK,PREVEA360,304.91,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $508.19 in Billed Charges for Rev 637 = $304.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,304.91,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $508.19 in Billed Charges for Rev 637 = $304.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,324.38,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $508.19 in Billed Charges for Rev 637 = $324.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,365.90,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $508.19 in Billed Charges for Rev 637 = $365.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,281.03,,,,,,,246.9800,508.1900,other,ST VINCENT HOSPITAL (ACU). 55.3% of $508.19 in Billed Charges for Rev 637 = $281.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,UNITED HEALTHCARE,UHC ONEIDA NATION,281.03,,,,,,,246.9800,508.1900,other,ST VINCENT HOSPITAL (ACU). 55.3% of $508.19 in Billed Charges for Rev 637 = $281.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,UNITED HEALTHCARE,UNITED HEALTHCARE,281.03,,,,,,,246.9800,508.1900,other,ST VINCENT HOSPITAL (ACU). 55.3% of $508.19 in Billed Charges for Rev 637 = $281.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,UNITY HEALTH PLAN,UNITY HOSPICE,508.19,,,,,,,246.9800,508.1900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,365.90,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $508.19 in Billed Charges for Rev 637 = $365.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,315.08,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $508.19 in Billed Charges for Rev 637 = $315.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,365.90,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $508.19 in Billed Charges for Rev 637 = $365.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,365.90,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $508.19 in Billed Charges for Rev 637 = $365.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCYTOSINE 500 MG CAPS,637,RC,59651-332-01,CDM,,,,,,both,1.000000,EA,508.1900,335.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,304.91,,,,,,,246.9800,508.1900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $508.19 in Billed Charges for Rev 637 = $304.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,AETNA,AETNA HSHS,7.62,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $11.80 in Billed Charges for Rev 637 = $7.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,AETNA,ALL COMMERCIAL AETNA,11.80,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.80 in Billed Charges for Rev 637 = $11.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,ANTHEM,ANTHEM POS/HMO,8.02,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.80 in Billed Charges for Rev 637 = $8.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,ANTHEM,ANTHEM PPO,8.02,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.80 in Billed Charges for Rev 637 = $8.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11.80,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.80 in Billed Charges for Rev 637 = $11.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,CENPATICO,ALL MEDICAID CENPATICO,11.80,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.80 in Billed Charges for Rev 637 = $11.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.03,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.80 in Billed Charges for Rev 637 = $10.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,CIGNA,ALL COMMERCIAL CIGNA,8.26,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $11.80 in Billed Charges for Rev 637 = $8.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,COFINITY,COFINITY,11.80,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.80 in Billed Charges for Rev 637 = $11.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.21,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $11.80 in Billed Charges for Rev 637 = $11.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,9.91,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.80 in Billed Charges for Rev 637 = $9.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.38,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $11.80 in Billed Charges for Rev 637 = $8.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.61,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.80 in Billed Charges for Rev 637 = $8.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.73,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $11.80 in Billed Charges for Rev 637 = $5.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.03,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.80 in Billed Charges for Rev 637 = $10.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,HUMANA,HUMANA CHOICE CARE HMO,7.49,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.80 in Billed Charges at 63.5% = $7.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,HUMANA,HUMANA CHOICE CARE PPO,10.03,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.80 in Billed Charges for Rev 637 = $10.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,HUMANA,HUMANA NATIIONAL POS HMO,7.49,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.80 in Billed Charges at 63.5% = $7.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.61,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.80 in Billed Charges for Rev 637 = $8.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,11.80,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.80 in Billed Charges for Rev 637 = $11.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.80,,,,,,,5.7300,11.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.90,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $11.80 in Billed Charges for Rev 637 = $5.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.91,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.80 in Billed Charges for Rev 637 = $9.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.85,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $11.80 in Billed Charges for Rev 637 = $8.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.86,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $11.80 in Billed Charges for Rev 637 = $10.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.08,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.80 in Billed Charges for Rev 637 = $7.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.08,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.80 in Billed Charges for Rev 637 = $7.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,PREVEA HEALTH NETWORK,PREVEA360,7.08,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.80 in Billed Charges for Rev 637 = $7.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.08,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.80 in Billed Charges for Rev 637 = $7.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.53,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $11.80 in Billed Charges for Rev 637 = $7.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.50,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.80 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.53,,,,,,,5.7300,11.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.80 in Billed Charges for Rev 637 = $6.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,UNITED HEALTHCARE,UHC ONEIDA NATION,6.53,,,,,,,5.7300,11.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.80 in Billed Charges for Rev 637 = $6.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,UNITED HEALTHCARE,UNITED HEALTHCARE,6.53,,,,,,,5.7300,11.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.80 in Billed Charges for Rev 637 = $6.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,UNITY HEALTH PLAN,UNITY HOSPICE,11.80,,,,,,,5.7300,11.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.50,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.80 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.32,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $11.80 in Billed Charges for Rev 637 = $7.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.50,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.80 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.50,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.80 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,68094-004-59,CDM,,,,,,both,5.000000,ML,11.8000,7.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.08,,,,,,,5.7300,11.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.80 in Billed Charges for Rev 637 = $7.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,AETNA,AETNA HSHS,12.73,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $19.70 in Billed Charges for Rev 637 = $12.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,AETNA,ALL COMMERCIAL AETNA,19.70,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.70 in Billed Charges for Rev 637 = $19.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,ANTHEM,ANTHEM POS/HMO,13.40,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $19.70 in Billed Charges for Rev 637 = $13.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,ANTHEM,ANTHEM PPO,13.40,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $19.70 in Billed Charges for Rev 637 = $13.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,19.70,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.70 in Billed Charges for Rev 637 = $19.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,CENPATICO,ALL MEDICAID CENPATICO,19.70,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.70 in Billed Charges for Rev 637 = $19.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,16.75,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.70 in Billed Charges for Rev 637 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,CIGNA,ALL COMMERCIAL CIGNA,13.79,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $19.70 in Billed Charges for Rev 637 = $13.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,COFINITY,COFINITY,19.70,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.70 in Billed Charges for Rev 637 = $19.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,18.72,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $19.70 in Billed Charges for Rev 637 = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,16.55,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.70 in Billed Charges for Rev 637 = $16.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.99,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $19.70 in Billed Charges for Rev 637 = $13.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.38,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.70 in Billed Charges for Rev 637 = $14.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,9.57,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $19.70 in Billed Charges for Rev 637 = $9.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,16.75,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.70 in Billed Charges for Rev 637 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,HUMANA,HUMANA CHOICE CARE HMO,12.51,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $19.70 in Billed Charges at 63.5% = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,HUMANA,HUMANA CHOICE CARE PPO,16.75,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.70 in Billed Charges for Rev 637 = $16.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,HUMANA,HUMANA NATIIONAL POS HMO,12.51,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $19.70 in Billed Charges at 63.5% = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.38,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.70 in Billed Charges for Rev 637 = $14.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,19.70,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.70 in Billed Charges for Rev 637 = $19.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,19.70,,,,,,,9.5700,19.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.85,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $19.70 in Billed Charges for Rev 637 = $9.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,16.55,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.70 in Billed Charges for Rev 637 = $16.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.78,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $19.70 in Billed Charges for Rev 637 = $14.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.12,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $19.70 in Billed Charges for Rev 637 = $18.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.82,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.70 in Billed Charges for Rev 637 = $11.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.82,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.70 in Billed Charges for Rev 637 = $11.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,PREVEA HEALTH NETWORK,PREVEA360,11.82,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.70 in Billed Charges for Rev 637 = $11.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.82,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.70 in Billed Charges for Rev 637 = $11.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.57,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $19.70 in Billed Charges for Rev 637 = $12.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.18,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.70 in Billed Charges for Rev 637 = $14.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.89,,,,,,,9.5700,19.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.70 in Billed Charges for Rev 637 = $10.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,10.89,,,,,,,9.5700,19.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.70 in Billed Charges for Rev 637 = $10.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,10.89,,,,,,,9.5700,19.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.70 in Billed Charges for Rev 637 = $10.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,UNITY HEALTH PLAN,UNITY HOSPICE,19.70,,,,,,,9.5700,19.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.18,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.70 in Billed Charges for Rev 637 = $14.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.21,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $19.70 in Billed Charges for Rev 637 = $12.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.18,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.70 in Billed Charges for Rev 637 = $14.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.18,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.70 in Billed Charges for Rev 637 = $14.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 5 MG/5ML SOLN,637,RC,0904-6765-20,CDM,,,,,,both,118.000000,ML,19.7000,13.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.82,,,,,,,9.5700,19.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.70 in Billed Charges for Rev 637 = $11.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,AETNA,AETNA HSHS,63.28,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $97.95 in Billed Charges for Rev 637 = $63.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,AETNA,ALL COMMERCIAL AETNA,97.95,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.95 in Billed Charges for Rev 637 = $97.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,ANTHEM,ANTHEM POS/HMO,66.61,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $97.95 in Billed Charges for Rev 637 = $66.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,ANTHEM,ANTHEM PPO,66.61,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $97.95 in Billed Charges for Rev 637 = $66.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,97.95,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.95 in Billed Charges for Rev 637 = $97.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,CENPATICO,ALL MEDICAID CENPATICO,97.95,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.95 in Billed Charges for Rev 637 = $97.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,83.26,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.95 in Billed Charges for Rev 637 = $83.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,CIGNA,ALL COMMERCIAL CIGNA,68.57,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $97.95 in Billed Charges for Rev 637 = $68.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,COFINITY,COFINITY,97.95,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.95 in Billed Charges for Rev 637 = $97.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,93.05,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $97.95 in Billed Charges for Rev 637 = $93.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,82.28,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $97.95 in Billed Charges for Rev 637 = $82.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,69.54,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $97.95 in Billed Charges for Rev 637 = $69.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,71.50,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $97.95 in Billed Charges for Rev 637 = $71.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,47.60,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $97.95 in Billed Charges for Rev 637 = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,83.26,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.95 in Billed Charges for Rev 637 = $83.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,HUMANA,HUMANA CHOICE CARE HMO,62.20,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $97.95 in Billed Charges at 63.5% = $62.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,HUMANA,HUMANA CHOICE CARE PPO,83.26,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.95 in Billed Charges for Rev 637 = $83.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,HUMANA,HUMANA NATIIONAL POS HMO,62.20,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $97.95 in Billed Charges at 63.5% = $62.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,71.50,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $97.95 in Billed Charges for Rev 637 = $71.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,97.95,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.95 in Billed Charges for Rev 637 = $97.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,97.95,,,,,,,47.6000,97.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,48.98,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $97.95 in Billed Charges for Rev 637 = $48.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,82.28,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $97.95 in Billed Charges for Rev 637 = $82.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,73.46,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $97.95 in Billed Charges for Rev 637 = $73.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,90.11,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $97.95 in Billed Charges for Rev 637 = $90.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,58.77,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.95 in Billed Charges for Rev 637 = $58.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,58.77,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.95 in Billed Charges for Rev 637 = $58.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,PREVEA HEALTH NETWORK,PREVEA360,58.77,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.95 in Billed Charges for Rev 637 = $58.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,58.77,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.95 in Billed Charges for Rev 637 = $58.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,62.52,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $97.95 in Billed Charges for Rev 637 = $62.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,70.52,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.95 in Billed Charges for Rev 637 = $70.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,54.17,,,,,,,47.6000,97.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $97.95 in Billed Charges for Rev 637 = $54.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,UNITED HEALTHCARE,UHC ONEIDA NATION,54.17,,,,,,,47.6000,97.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $97.95 in Billed Charges for Rev 637 = $54.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,UNITED HEALTHCARE,UNITED HEALTHCARE,54.17,,,,,,,47.6000,97.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $97.95 in Billed Charges for Rev 637 = $54.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,UNITY HEALTH PLAN,UNITY HOSPICE,97.95,,,,,,,47.6000,97.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,70.52,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.95 in Billed Charges for Rev 637 = $70.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,60.73,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $97.95 in Billed Charges for Rev 637 = $60.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,70.52,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.95 in Billed Charges for Rev 637 = $70.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,70.52,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.95 in Billed Charges for Rev 637 = $70.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEPHALEXIN 250 MG/5ML SUSR,637,RC,0093-4177-73,CDM,,,,,,both,100.000000,ML,97.9500,64.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,58.77,,,,,,,47.6000,97.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.95 in Billed Charges for Rev 637 = $58.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,AETNA,AETNA HSHS,9.63,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $14.90 in Billed Charges for Rev 637 = $9.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,AETNA,ALL COMMERCIAL AETNA,14.90,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.90 in Billed Charges for Rev 637 = $14.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,ANTHEM,ANTHEM POS/HMO,10.13,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $14.90 in Billed Charges for Rev 637 = $10.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,ANTHEM,ANTHEM PPO,10.13,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $14.90 in Billed Charges for Rev 637 = $10.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14.90,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.90 in Billed Charges for Rev 637 = $14.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,CENPATICO,ALL MEDICAID CENPATICO,14.90,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.90 in Billed Charges for Rev 637 = $14.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.67,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.90 in Billed Charges for Rev 637 = $12.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,CIGNA,ALL COMMERCIAL CIGNA,10.43,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $14.90 in Billed Charges for Rev 637 = $10.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,COFINITY,COFINITY,14.90,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.90 in Billed Charges for Rev 637 = $14.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14.16,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $14.90 in Billed Charges for Rev 637 = $14.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,HEALTH CARE ALLIANCE,THE ALLIANCE,12.52,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.90 in Billed Charges for Rev 637 = $12.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.58,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $14.90 in Billed Charges for Rev 637 = $10.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.88,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.90 in Billed Charges for Rev 637 = $10.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,HSHS EMPLOYEES,HSHS EMPLOYEES,7.24,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $14.90 in Billed Charges for Rev 637 = $7.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.67,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.90 in Billed Charges for Rev 637 = $12.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,HUMANA,HUMANA CHOICE CARE HMO,9.46,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $14.90 in Billed Charges at 63.5% = $9.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,HUMANA,HUMANA CHOICE CARE PPO,12.67,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.90 in Billed Charges for Rev 637 = $12.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,HUMANA,HUMANA NATIIONAL POS HMO,9.46,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $14.90 in Billed Charges at 63.5% = $9.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.88,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.90 in Billed Charges for Rev 637 = $10.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,LIVE360,LIVE360 HSHS HEALTHY PLAN,14.90,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.90 in Billed Charges for Rev 637 = $14.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.90,,,,,,,7.2400,14.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.45,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $14.90 in Billed Charges for Rev 637 = $7.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.52,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.90 in Billed Charges for Rev 637 = $12.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.18,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $14.90 in Billed Charges for Rev 637 = $11.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.71,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $14.90 in Billed Charges for Rev 637 = $13.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.94,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.90 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.94,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.90 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,PREVEA HEALTH NETWORK,PREVEA360,8.94,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.90 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.94,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.90 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.51,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $14.90 in Billed Charges for Rev 637 = $9.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.73,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.90 in Billed Charges for Rev 637 = $10.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.24,,,,,,,7.2400,14.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.90 in Billed Charges for Rev 637 = $8.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,UNITED HEALTHCARE,UHC ONEIDA NATION,8.24,,,,,,,7.2400,14.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.90 in Billed Charges for Rev 637 = $8.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,UNITED HEALTHCARE,UNITED HEALTHCARE,8.24,,,,,,,7.2400,14.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.90 in Billed Charges for Rev 637 = $8.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,UNITY HEALTH PLAN,UNITY HOSPICE,14.90,,,,,,,7.2400,14.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.73,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.90 in Billed Charges for Rev 637 = $10.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.24,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $14.90 in Billed Charges for Rev 637 = $9.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.73,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.90 in Billed Charges for Rev 637 = $10.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.73,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.90 in Billed Charges for Rev 637 = $10.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFPROZIL 250 MG TABS,637,RC,68180-403-01,CDM,,,,,,both,1.000000,EA,14.9000,9.8300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.94,,,,,,,7.2400,14.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.90 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,AETNA,AETNA HSHS,38.47,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $59.55 in Billed Charges for Rev 637 = $38.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,AETNA,ALL COMMERCIAL AETNA,59.55,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.55 in Billed Charges for Rev 637 = $59.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,ANTHEM,ANTHEM POS/HMO,40.49,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $59.55 in Billed Charges for Rev 637 = $40.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,ANTHEM,ANTHEM PPO,40.49,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $59.55 in Billed Charges for Rev 637 = $40.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,59.55,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.55 in Billed Charges for Rev 637 = $59.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,CENPATICO,ALL MEDICAID CENPATICO,59.55,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.55 in Billed Charges for Rev 637 = $59.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,50.62,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.55 in Billed Charges for Rev 637 = $50.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,CIGNA,ALL COMMERCIAL CIGNA,41.69,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $59.55 in Billed Charges for Rev 637 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,COFINITY,COFINITY,59.55,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.55 in Billed Charges for Rev 637 = $59.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,56.57,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $59.55 in Billed Charges for Rev 637 = $56.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,50.02,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $59.55 in Billed Charges for Rev 637 = $50.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42.28,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $59.55 in Billed Charges for Rev 637 = $42.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,43.47,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $59.55 in Billed Charges for Rev 637 = $43.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,28.94,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $59.55 in Billed Charges for Rev 637 = $28.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,50.62,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.55 in Billed Charges for Rev 637 = $50.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,HUMANA,HUMANA CHOICE CARE HMO,37.81,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $59.55 in Billed Charges at 63.5% = $37.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,HUMANA,HUMANA CHOICE CARE PPO,50.62,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.55 in Billed Charges for Rev 637 = $50.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,HUMANA,HUMANA NATIIONAL POS HMO,37.81,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $59.55 in Billed Charges at 63.5% = $37.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,43.47,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $59.55 in Billed Charges for Rev 637 = $43.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,59.55,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.55 in Billed Charges for Rev 637 = $59.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,59.55,,,,,,,28.9400,59.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,29.78,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $59.55 in Billed Charges for Rev 637 = $29.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,50.02,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $59.55 in Billed Charges for Rev 637 = $50.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,44.66,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $59.55 in Billed Charges for Rev 637 = $44.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,54.79,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $59.55 in Billed Charges for Rev 637 = $54.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,35.73,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.55 in Billed Charges for Rev 637 = $35.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,35.73,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.55 in Billed Charges for Rev 637 = $35.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,PREVEA HEALTH NETWORK,PREVEA360,35.73,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.55 in Billed Charges for Rev 637 = $35.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,35.73,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.55 in Billed Charges for Rev 637 = $35.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,38.01,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $59.55 in Billed Charges for Rev 637 = $38.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,42.88,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.55 in Billed Charges for Rev 637 = $42.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32.93,,,,,,,28.9400,59.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $59.55 in Billed Charges for Rev 637 = $32.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,32.93,,,,,,,28.9400,59.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $59.55 in Billed Charges for Rev 637 = $32.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,32.93,,,,,,,28.9400,59.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $59.55 in Billed Charges for Rev 637 = $32.93 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,UNITY HEALTH PLAN,UNITY HOSPICE,59.55,,,,,,,28.9400,59.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,42.88,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.55 in Billed Charges for Rev 637 = $42.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,36.92,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $59.55 in Billed Charges for Rev 637 = $36.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,42.88,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.55 in Billed Charges for Rev 637 = $42.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,42.88,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.55 in Billed Charges for Rev 637 = $42.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHERRY SYRUP SYRP 473 ML BOTTLE,637,RC,0395-2662-16,CDM,,,,,,both,473.000000,ML,59.5500,39.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,35.73,,,,,,,28.9400,59.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.55 in Billed Charges for Rev 637 = $35.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,AETNA,AETNA HSHS,7.91,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.25 in Billed Charges for Rev 637 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,AETNA,ALL COMMERCIAL AETNA,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,ANTHEM,ANTHEM POS/HMO,8.33,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.25 in Billed Charges for Rev 637 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,ANTHEM,ANTHEM PPO,8.33,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.25 in Billed Charges for Rev 637 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,CENPATICO,ALL MEDICAID CENPATICO,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.41,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 637 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,CIGNA,ALL COMMERCIAL CIGNA,8.58,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.25 in Billed Charges for Rev 637 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,COFINITY,COFINITY,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.64,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.25 in Billed Charges for Rev 637 = $11.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,10.29,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 637 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.70,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.25 in Billed Charges for Rev 637 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.94,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.95,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.25 in Billed Charges for Rev 637 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.41,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 637 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE HMO,7.78,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.25 in Billed Charges at 63.5% = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE PPO,10.41,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 637 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,HUMANA,HUMANA NATIIONAL POS HMO,7.78,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.25 in Billed Charges at 63.5% = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.94,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.25,,,,,,,5.9500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.13,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.25 in Billed Charges for Rev 637 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.29,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 637 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.19,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.25 in Billed Charges for Rev 637 = $9.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.27,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.25 in Billed Charges for Rev 637 = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.25 in Billed Charges for Rev 637 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 637 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.77,,,,,,,5.9500,12.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.25 in Billed Charges for Rev 637 = $6.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,6.77,,,,,,,5.9500,12.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.25 in Billed Charges for Rev 637 = $6.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,6.77,,,,,,,5.9500,12.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.25 in Billed Charges for Rev 637 = $6.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,UNITY HEALTH PLAN,UNITY HOSPICE,12.25,,,,,,,5.9500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 637 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.60,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.25 in Billed Charges for Rev 637 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 637 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 637 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,71399-7401-5,CDM,,,,,,both,50.000000,ML,12.2500,8.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,AETNA,AETNA HSHS,9.01,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $13.95 in Billed Charges for Rev 637 = $9.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,AETNA,ALL COMMERCIAL AETNA,13.95,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.95 in Billed Charges for Rev 637 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,ANTHEM,ANTHEM POS/HMO,9.49,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $13.95 in Billed Charges for Rev 637 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,ANTHEM,ANTHEM PPO,9.49,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $13.95 in Billed Charges for Rev 637 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13.95,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.95 in Billed Charges for Rev 637 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,CENPATICO,ALL MEDICAID CENPATICO,13.95,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.95 in Billed Charges for Rev 637 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11.86,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.95 in Billed Charges for Rev 637 = $11.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,CIGNA,ALL COMMERCIAL CIGNA,9.77,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $13.95 in Billed Charges for Rev 637 = $9.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,COFINITY,COFINITY,13.95,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.95 in Billed Charges for Rev 637 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13.25,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $13.95 in Billed Charges for Rev 637 = $13.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,11.72,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.95 in Billed Charges for Rev 637 = $11.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9.90,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $13.95 in Billed Charges for Rev 637 = $9.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.18,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.95 in Billed Charges for Rev 637 = $10.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,6.78,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $13.95 in Billed Charges for Rev 637 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11.86,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.95 in Billed Charges for Rev 637 = $11.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,HUMANA,HUMANA CHOICE CARE HMO,8.86,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $13.95 in Billed Charges at 63.5% = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,HUMANA,HUMANA CHOICE CARE PPO,11.86,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.95 in Billed Charges for Rev 637 = $11.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,HUMANA,HUMANA NATIIONAL POS HMO,8.86,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $13.95 in Billed Charges at 63.5% = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.18,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.95 in Billed Charges for Rev 637 = $10.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,13.95,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.95 in Billed Charges for Rev 637 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.95,,,,,,,6.7800,13.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.98,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $13.95 in Billed Charges for Rev 637 = $6.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11.72,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.95 in Billed Charges for Rev 637 = $11.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.46,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $13.95 in Billed Charges for Rev 637 = $10.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12.83,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $13.95 in Billed Charges for Rev 637 = $12.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.37,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.95 in Billed Charges for Rev 637 = $8.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.37,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.95 in Billed Charges for Rev 637 = $8.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,PREVEA HEALTH NETWORK,PREVEA360,8.37,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.95 in Billed Charges for Rev 637 = $8.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.37,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.95 in Billed Charges for Rev 637 = $8.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.90,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $13.95 in Billed Charges for Rev 637 = $8.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.04,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.95 in Billed Charges for Rev 637 = $10.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.71,,,,,,,6.7800,13.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.95 in Billed Charges for Rev 637 = $7.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,UNITED HEALTHCARE,UHC ONEIDA NATION,7.71,,,,,,,6.7800,13.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.95 in Billed Charges for Rev 637 = $7.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,UNITED HEALTHCARE,UNITED HEALTHCARE,7.71,,,,,,,6.7800,13.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.95 in Billed Charges for Rev 637 = $7.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,UNITY HEALTH PLAN,UNITY HOSPICE,13.95,,,,,,,6.7800,13.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.04,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.95 in Billed Charges for Rev 637 = $10.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.65,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $13.95 in Billed Charges for Rev 637 = $8.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.04,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.95 in Billed Charges for Rev 637 = $10.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.04,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.95 in Billed Charges for Rev 637 = $10.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,0536-1343-80,CDM,,,,,,both,50.000000,ML,13.9500,9.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.37,,,,,,,6.7800,13.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.95 in Billed Charges for Rev 637 = $8.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,AETNA,AETNA HSHS,7.36,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $11.40 in Billed Charges for Rev 637 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,AETNA,ALL COMMERCIAL AETNA,11.40,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.40 in Billed Charges for Rev 637 = $11.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,ANTHEM,ANTHEM POS/HMO,7.75,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.40 in Billed Charges for Rev 637 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,ANTHEM,ANTHEM PPO,7.75,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.40 in Billed Charges for Rev 637 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11.40,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.40 in Billed Charges for Rev 637 = $11.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,CENPATICO,ALL MEDICAID CENPATICO,11.40,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.40 in Billed Charges for Rev 637 = $11.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.69,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.40 in Billed Charges for Rev 637 = $9.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,CIGNA,ALL COMMERCIAL CIGNA,7.98,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $11.40 in Billed Charges for Rev 637 = $7.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,COFINITY,COFINITY,11.40,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.40 in Billed Charges for Rev 637 = $11.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.83,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $11.40 in Billed Charges for Rev 637 = $10.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,9.58,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.40 in Billed Charges for Rev 637 = $9.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.09,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $11.40 in Billed Charges for Rev 637 = $8.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.32,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.40 in Billed Charges for Rev 637 = $8.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,5.54,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $11.40 in Billed Charges for Rev 637 = $5.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.69,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.40 in Billed Charges for Rev 637 = $9.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,HUMANA,HUMANA CHOICE CARE HMO,7.24,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.40 in Billed Charges at 63.5% = $7.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,HUMANA,HUMANA CHOICE CARE PPO,9.69,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.40 in Billed Charges for Rev 637 = $9.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,HUMANA,HUMANA NATIIONAL POS HMO,7.24,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.40 in Billed Charges at 63.5% = $7.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.32,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.40 in Billed Charges for Rev 637 = $8.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,11.40,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.40 in Billed Charges for Rev 637 = $11.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.40,,,,,,,5.5400,11.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.70,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $11.40 in Billed Charges for Rev 637 = $5.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.58,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.40 in Billed Charges for Rev 637 = $9.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.55,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $11.40 in Billed Charges for Rev 637 = $8.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.49,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $11.40 in Billed Charges for Rev 637 = $10.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.84,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.40 in Billed Charges for Rev 637 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.84,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.40 in Billed Charges for Rev 637 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,PREVEA HEALTH NETWORK,PREVEA360,6.84,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.40 in Billed Charges for Rev 637 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.84,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.40 in Billed Charges for Rev 637 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.28,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $11.40 in Billed Charges for Rev 637 = $7.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.21,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.40 in Billed Charges for Rev 637 = $8.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.30,,,,,,,5.5400,11.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.40 in Billed Charges for Rev 637 = $6.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,6.30,,,,,,,5.5400,11.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.40 in Billed Charges for Rev 637 = $6.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,6.30,,,,,,,5.5400,11.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.40 in Billed Charges for Rev 637 = $6.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,UNITY HEALTH PLAN,UNITY HOSPICE,11.40,,,,,,,5.5400,11.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.21,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.40 in Billed Charges for Rev 637 = $8.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.07,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $11.40 in Billed Charges for Rev 637 = $7.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.21,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.40 in Billed Charges for Rev 637 = $8.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.21,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.40 in Billed Charges for Rev 637 = $8.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLESTYRAMINE LIGHT 4 G PACK,637,RC,42806-270-98,CDM,,,,,,both,1.000000,EA,11.4000,7.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.84,,,,,,,5.5400,11.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.40 in Billed Charges for Rev 637 = $6.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,AETNA,AETNA HSHS,41.73,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $64.60 in Billed Charges for Rev 637 = $41.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,AETNA,ALL COMMERCIAL AETNA,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 637 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,ANTHEM,ANTHEM POS/HMO,43.93,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $64.60 in Billed Charges for Rev 637 = $43.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,ANTHEM,ANTHEM PPO,43.93,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $64.60 in Billed Charges for Rev 637 = $43.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 637 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,CENPATICO,ALL MEDICAID CENPATICO,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 637 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 637 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,CIGNA,ALL COMMERCIAL CIGNA,45.22,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $64.60 in Billed Charges for Rev 637 = $45.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,COFINITY,COFINITY,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 637 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,61.37,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $64.60 in Billed Charges for Rev 637 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,54.26,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $64.60 in Billed Charges for Rev 637 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,45.87,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $64.60 in Billed Charges for Rev 637 = $45.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,47.16,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $64.60 in Billed Charges for Rev 637 = $47.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,31.40,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $64.60 in Billed Charges for Rev 637 = $31.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 637 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,HUMANA,HUMANA CHOICE CARE HMO,41.02,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $64.60 in Billed Charges at 63.5% = $41.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,HUMANA,HUMANA CHOICE CARE PPO,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 637 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,HUMANA,HUMANA NATIIONAL POS HMO,41.02,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $64.60 in Billed Charges at 63.5% = $41.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,47.16,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $64.60 in Billed Charges for Rev 637 = $47.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 637 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,64.60,,,,,,,31.4000,64.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,32.30,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $64.60 in Billed Charges for Rev 637 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,54.26,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $64.60 in Billed Charges for Rev 637 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,48.45,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $64.60 in Billed Charges for Rev 637 = $48.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,59.43,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $64.60 in Billed Charges for Rev 637 = $59.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 637 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 637 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA360,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 637 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 637 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,41.23,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $64.60 in Billed Charges for Rev 637 = $41.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 637 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 637 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 637 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 637 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,UNITY HEALTH PLAN,UNITY HOSPICE,64.60,,,,,,,31.4000,64.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 637 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,40.05,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $64.60 in Billed Charges for Rev 637 = $40.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 637 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 637 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,42571-315-01,CDM,,,,,,both,1.000000,EA,64.6000,42.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 637 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,AETNA,AETNA HSHS,1008.02,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,560.40 in Billed Charges for Rev 637 = $1,008.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,AETNA,ALL COMMERCIAL AETNA,1560.40,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,560.40 in Billed Charges for Rev 637 = $1,560.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,ANTHEM,ANTHEM POS/HMO,1061.07,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,560.40 in Billed Charges for Rev 637 = $1,061.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,ANTHEM,ANTHEM PPO,1061.07,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,560.40 in Billed Charges for Rev 637 = $1,061.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1560.40,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,560.40 in Billed Charges for Rev 637 = $1,560.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,CENPATICO,ALL MEDICAID CENPATICO,1560.40,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,560.40 in Billed Charges for Rev 637 = $1,560.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1326.34,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,560.40 in Billed Charges for Rev 637 = $1,326.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,CIGNA,ALL COMMERCIAL CIGNA,1092.28,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,560.40 in Billed Charges for Rev 637 = $1,092.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,COFINITY,COFINITY,1560.40,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,560.40 in Billed Charges for Rev 637 = $1,560.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1482.38,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,560.40 in Billed Charges for Rev 637 = $1,482.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,1310.74,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,560.40 in Billed Charges for Rev 637 = $1,310.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1107.88,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,560.40 in Billed Charges for Rev 637 = $1,107.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1139.09,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,560.40 in Billed Charges for Rev 637 = $1,139.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,758.35,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,560.40 in Billed Charges for Rev 637 = $758.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1326.34,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,560.40 in Billed Charges for Rev 637 = $1,326.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,HUMANA,HUMANA CHOICE CARE HMO,990.85,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,560.40 in Billed Charges at 63.5% = $990.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,HUMANA,HUMANA CHOICE CARE PPO,1326.34,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,560.40 in Billed Charges for Rev 637 = $1,326.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,HUMANA,HUMANA NATIIONAL POS HMO,990.85,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,560.40 in Billed Charges at 63.5% = $990.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1139.09,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,560.40 in Billed Charges for Rev 637 = $1,139.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1560.40,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,560.40 in Billed Charges for Rev 637 = $1,560.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1560.40,,,,,,,758.3500,1560.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,780.20,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,560.40 in Billed Charges for Rev 637 = $780.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1310.74,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,560.40 in Billed Charges for Rev 637 = $1,310.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1170.30,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,560.40 in Billed Charges for Rev 637 = $1,170.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1435.57,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,560.40 in Billed Charges for Rev 637 = $1,435.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,936.24,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,560.40 in Billed Charges for Rev 637 = $936.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,936.24,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,560.40 in Billed Charges for Rev 637 = $936.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,PREVEA HEALTH NETWORK,PREVEA360,936.24,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,560.40 in Billed Charges for Rev 637 = $936.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,936.24,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,560.40 in Billed Charges for Rev 637 = $936.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,996.00,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,560.40 in Billed Charges for Rev 637 = $996.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1123.49,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,560.40 in Billed Charges for Rev 637 = $1,123.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,862.90,,,,,,,758.3500,1560.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,560.40 in Billed Charges for Rev 637 = $862.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,862.90,,,,,,,758.3500,1560.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,560.40 in Billed Charges for Rev 637 = $862.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,862.90,,,,,,,758.3500,1560.4000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,560.40 in Billed Charges for Rev 637 = $862.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,UNITY HEALTH PLAN,UNITY HOSPICE,1560.40,,,,,,,758.3500,1560.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1123.49,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,560.40 in Billed Charges for Rev 637 = $1,123.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,967.45,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,560.40 in Billed Charges for Rev 637 = $967.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1123.49,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,560.40 in Billed Charges for Rev 637 = $1,123.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1123.49,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,560.40 in Billed Charges for Rev 637 = $1,123.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 60 G TUBE,637,RC,21922-016-07,CDM,,,,,,both,60.000000,GR,1560.4000,1029.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,936.24,,,,,,,758.3500,1560.4000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,560.40 in Billed Charges for Rev 637 = $936.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,AETNA,AETNA HSHS,72.77,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $112.65 in Billed Charges for Rev 637 = $72.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,AETNA,ALL COMMERCIAL AETNA,112.65,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.65 in Billed Charges for Rev 637 = $112.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,ANTHEM,ANTHEM POS/HMO,76.60,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $112.65 in Billed Charges for Rev 637 = $76.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,ANTHEM,ANTHEM PPO,76.60,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $112.65 in Billed Charges for Rev 637 = $76.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,112.65,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.65 in Billed Charges for Rev 637 = $112.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,CENPATICO,ALL MEDICAID CENPATICO,112.65,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.65 in Billed Charges for Rev 637 = $112.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,95.75,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.65 in Billed Charges for Rev 637 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,CIGNA,ALL COMMERCIAL CIGNA,78.86,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $112.65 in Billed Charges for Rev 637 = $78.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,COFINITY,COFINITY,112.65,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.65 in Billed Charges for Rev 637 = $112.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,107.02,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $112.65 in Billed Charges for Rev 637 = $107.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,94.63,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $112.65 in Billed Charges for Rev 637 = $94.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,79.98,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $112.65 in Billed Charges for Rev 637 = $79.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,82.23,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $112.65 in Billed Charges for Rev 637 = $82.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,54.75,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $112.65 in Billed Charges for Rev 637 = $54.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,95.75,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.65 in Billed Charges for Rev 637 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,HUMANA,HUMANA CHOICE CARE HMO,71.53,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $112.65 in Billed Charges at 63.5% = $71.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,HUMANA,HUMANA CHOICE CARE PPO,95.75,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.65 in Billed Charges for Rev 637 = $95.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,HUMANA,HUMANA NATIIONAL POS HMO,71.53,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $112.65 in Billed Charges at 63.5% = $71.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,82.23,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $112.65 in Billed Charges for Rev 637 = $82.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,112.65,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.65 in Billed Charges for Rev 637 = $112.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,112.65,,,,,,,54.7500,112.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,56.33,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $112.65 in Billed Charges for Rev 637 = $56.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,94.63,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $112.65 in Billed Charges for Rev 637 = $94.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,84.49,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $112.65 in Billed Charges for Rev 637 = $84.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,103.64,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $112.65 in Billed Charges for Rev 637 = $103.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,67.59,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.65 in Billed Charges for Rev 637 = $67.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,67.59,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.65 in Billed Charges for Rev 637 = $67.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,PREVEA HEALTH NETWORK,PREVEA360,67.59,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.65 in Billed Charges for Rev 637 = $67.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,67.59,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.65 in Billed Charges for Rev 637 = $67.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,71.90,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $112.65 in Billed Charges for Rev 637 = $71.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,81.11,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.65 in Billed Charges for Rev 637 = $81.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,62.30,,,,,,,54.7500,112.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $112.65 in Billed Charges for Rev 637 = $62.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,UNITED HEALTHCARE,UHC ONEIDA NATION,62.30,,,,,,,54.7500,112.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $112.65 in Billed Charges for Rev 637 = $62.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,UNITED HEALTHCARE,UNITED HEALTHCARE,62.30,,,,,,,54.7500,112.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $112.65 in Billed Charges for Rev 637 = $62.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,UNITY HEALTH PLAN,UNITY HOSPICE,112.65,,,,,,,54.7500,112.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,81.11,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.65 in Billed Charges for Rev 637 = $81.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,69.84,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $112.65 in Billed Charges for Rev 637 = $69.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,81.11,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.65 in Billed Charges for Rev 637 = $81.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,81.11,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.65 in Billed Charges for Rev 637 = $81.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,0591-3508-54,CDM,,,,,,both,1.000000,EA,112.6500,74.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,67.59,,,,,,,54.7500,112.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.65 in Billed Charges for Rev 637 = $67.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,AETNA,AETNA HSHS,122.51,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $189.65 in Billed Charges for Rev 637 = $122.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,AETNA,ALL COMMERCIAL AETNA,189.65,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.65 in Billed Charges for Rev 637 = $189.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,ANTHEM,ANTHEM POS/HMO,128.96,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $189.65 in Billed Charges for Rev 637 = $128.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,ANTHEM,ANTHEM PPO,128.96,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $189.65 in Billed Charges for Rev 637 = $128.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,189.65,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.65 in Billed Charges for Rev 637 = $189.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,CENPATICO,ALL MEDICAID CENPATICO,189.65,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.65 in Billed Charges for Rev 637 = $189.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,161.20,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.65 in Billed Charges for Rev 637 = $161.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,CIGNA,ALL COMMERCIAL CIGNA,132.76,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $189.65 in Billed Charges for Rev 637 = $132.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,COFINITY,COFINITY,189.65,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.65 in Billed Charges for Rev 637 = $189.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,180.17,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $189.65 in Billed Charges for Rev 637 = $180.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,HEALTH CARE ALLIANCE,THE ALLIANCE,159.31,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $189.65 in Billed Charges for Rev 637 = $159.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,134.65,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $189.65 in Billed Charges for Rev 637 = $134.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,138.44,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $189.65 in Billed Charges for Rev 637 = $138.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,HSHS EMPLOYEES,HSHS EMPLOYEES,92.17,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $189.65 in Billed Charges for Rev 637 = $92.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,161.20,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.65 in Billed Charges for Rev 637 = $161.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,HUMANA,HUMANA CHOICE CARE HMO,120.43,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $189.65 in Billed Charges at 63.5% = $120.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,HUMANA,HUMANA CHOICE CARE PPO,161.20,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.65 in Billed Charges for Rev 637 = $161.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,HUMANA,HUMANA NATIIONAL POS HMO,120.43,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $189.65 in Billed Charges at 63.5% = $120.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,138.44,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $189.65 in Billed Charges for Rev 637 = $138.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,LIVE360,LIVE360 HSHS HEALTHY PLAN,189.65,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.65 in Billed Charges for Rev 637 = $189.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,189.65,,,,,,,92.1700,189.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,94.83,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $189.65 in Billed Charges for Rev 637 = $94.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,159.31,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $189.65 in Billed Charges for Rev 637 = $159.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,142.24,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $189.65 in Billed Charges for Rev 637 = $142.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,174.48,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $189.65 in Billed Charges for Rev 637 = $174.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,113.79,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.65 in Billed Charges for Rev 637 = $113.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,113.79,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.65 in Billed Charges for Rev 637 = $113.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,PREVEA HEALTH NETWORK,PREVEA360,113.79,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.65 in Billed Charges for Rev 637 = $113.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,113.79,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.65 in Billed Charges for Rev 637 = $113.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,121.05,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $189.65 in Billed Charges for Rev 637 = $121.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,136.55,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.65 in Billed Charges for Rev 637 = $136.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,104.88,,,,,,,92.1700,189.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.65 in Billed Charges for Rev 637 = $104.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,UNITED HEALTHCARE,UHC ONEIDA NATION,104.88,,,,,,,92.1700,189.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.65 in Billed Charges for Rev 637 = $104.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,UNITED HEALTHCARE,UNITED HEALTHCARE,104.88,,,,,,,92.1700,189.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.65 in Billed Charges for Rev 637 = $104.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,UNITY HEALTH PLAN,UNITY HOSPICE,189.65,,,,,,,92.1700,189.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,136.55,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.65 in Billed Charges for Rev 637 = $136.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,117.58,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $189.65 in Billed Charges for Rev 637 = $117.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,136.55,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.65 in Billed Charges for Rev 637 = $136.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,136.55,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.65 in Billed Charges for Rev 637 = $136.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,0591-3509-54,CDM,,,,,,both,1.000000,EA,189.6500,125.1700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,113.79,,,,,,,92.1700,189.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.65 in Billed Charges for Rev 637 = $113.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,AETNA,AETNA HSHS,122.64,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $189.85 in Billed Charges for Rev 637 = $122.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,AETNA,ALL COMMERCIAL AETNA,189.85,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.85 in Billed Charges for Rev 637 = $189.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,ANTHEM,ANTHEM POS/HMO,129.10,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $189.85 in Billed Charges for Rev 637 = $129.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,ANTHEM,ANTHEM PPO,129.10,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $189.85 in Billed Charges for Rev 637 = $129.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,189.85,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.85 in Billed Charges for Rev 637 = $189.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,CENPATICO,ALL MEDICAID CENPATICO,189.85,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.85 in Billed Charges for Rev 637 = $189.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,161.37,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.85 in Billed Charges for Rev 637 = $161.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,CIGNA,ALL COMMERCIAL CIGNA,132.90,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $189.85 in Billed Charges for Rev 637 = $132.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,COFINITY,COFINITY,189.85,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.85 in Billed Charges for Rev 637 = $189.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,180.36,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $189.85 in Billed Charges for Rev 637 = $180.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,159.47,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $189.85 in Billed Charges for Rev 637 = $159.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,134.79,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $189.85 in Billed Charges for Rev 637 = $134.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,138.59,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $189.85 in Billed Charges for Rev 637 = $138.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,92.27,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $189.85 in Billed Charges for Rev 637 = $92.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,161.37,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.85 in Billed Charges for Rev 637 = $161.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,HUMANA,HUMANA CHOICE CARE HMO,120.55,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $189.85 in Billed Charges at 63.5% = $120.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,HUMANA,HUMANA CHOICE CARE PPO,161.37,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.85 in Billed Charges for Rev 637 = $161.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,HUMANA,HUMANA NATIIONAL POS HMO,120.55,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $189.85 in Billed Charges at 63.5% = $120.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,138.59,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $189.85 in Billed Charges for Rev 637 = $138.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,189.85,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.85 in Billed Charges for Rev 637 = $189.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,189.85,,,,,,,92.2700,189.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,94.93,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $189.85 in Billed Charges for Rev 637 = $94.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,159.47,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $189.85 in Billed Charges for Rev 637 = $159.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,142.39,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $189.85 in Billed Charges for Rev 637 = $142.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,174.66,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $189.85 in Billed Charges for Rev 637 = $174.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,113.91,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.85 in Billed Charges for Rev 637 = $113.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,113.91,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.85 in Billed Charges for Rev 637 = $113.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,PREVEA HEALTH NETWORK,PREVEA360,113.91,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.85 in Billed Charges for Rev 637 = $113.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,113.91,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.85 in Billed Charges for Rev 637 = $113.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,121.18,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $189.85 in Billed Charges for Rev 637 = $121.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,136.69,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.85 in Billed Charges for Rev 637 = $136.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,104.99,,,,,,,92.2700,189.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.85 in Billed Charges for Rev 637 = $104.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,104.99,,,,,,,92.2700,189.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.85 in Billed Charges for Rev 637 = $104.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,104.99,,,,,,,92.2700,189.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.85 in Billed Charges for Rev 637 = $104.99 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,UNITY HEALTH PLAN,UNITY HOSPICE,189.85,,,,,,,92.2700,189.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,136.69,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.85 in Billed Charges for Rev 637 = $136.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,117.71,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $189.85 in Billed Charges for Rev 637 = $117.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,136.69,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.85 in Billed Charges for Rev 637 = $136.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,136.69,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.85 in Billed Charges for Rev 637 = $136.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.2 MG/24HR PTWK,637,RC,75907-024-11,CDM,,,,,,both,1.000000,EA,189.8500,125.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,113.91,,,,,,,92.2700,189.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.85 in Billed Charges for Rev 637 = $113.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,AETNA,AETNA HSHS,13.23,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.48 in Billed Charges for Rev 637 = $13.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,AETNA,ALL COMMERCIAL AETNA,20.48,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.48 in Billed Charges for Rev 637 = $20.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,ANTHEM,ANTHEM POS/HMO,13.93,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $20.48 in Billed Charges for Rev 637 = $13.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,ANTHEM,ANTHEM PPO,13.93,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $20.48 in Billed Charges for Rev 637 = $13.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.48,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.48 in Billed Charges for Rev 637 = $20.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,CENPATICO,ALL MEDICAID CENPATICO,20.48,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.48 in Billed Charges for Rev 637 = $20.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.41,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.48 in Billed Charges for Rev 637 = $17.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,CIGNA,ALL COMMERCIAL CIGNA,14.34,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.48 in Billed Charges for Rev 637 = $14.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,COFINITY,COFINITY,20.48,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.48 in Billed Charges for Rev 637 = $20.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.46,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.48 in Billed Charges for Rev 637 = $19.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,HEALTH CARE ALLIANCE,THE ALLIANCE,17.20,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.48 in Billed Charges for Rev 637 = $17.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.54,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.48 in Billed Charges for Rev 637 = $14.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.95,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.48 in Billed Charges for Rev 637 = $14.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,HSHS EMPLOYEES,HSHS EMPLOYEES,9.95,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.48 in Billed Charges for Rev 637 = $9.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.41,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.48 in Billed Charges for Rev 637 = $17.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,HUMANA,HUMANA CHOICE CARE HMO,13.00,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $20.48 in Billed Charges at 63.5% = $13.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,HUMANA,HUMANA CHOICE CARE PPO,17.41,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.48 in Billed Charges for Rev 637 = $17.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,HUMANA,HUMANA NATIIONAL POS HMO,13.00,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $20.48 in Billed Charges at 63.5% = $13.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.95,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.48 in Billed Charges for Rev 637 = $14.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.48,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.48 in Billed Charges for Rev 637 = $20.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,20.48,,,,,,,9.9500,20.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.24,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.48 in Billed Charges for Rev 637 = $10.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.20,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.48 in Billed Charges for Rev 637 = $17.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.36,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.48 in Billed Charges for Rev 637 = $15.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.84,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.48 in Billed Charges for Rev 637 = $18.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.29,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.48 in Billed Charges for Rev 637 = $12.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.29,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.48 in Billed Charges for Rev 637 = $12.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,PREVEA HEALTH NETWORK,PREVEA360,12.29,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.48 in Billed Charges for Rev 637 = $12.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.29,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.48 in Billed Charges for Rev 637 = $12.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.07,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.48 in Billed Charges for Rev 637 = $13.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.75,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.48 in Billed Charges for Rev 637 = $14.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.33,,,,,,,9.9500,20.4800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.48 in Billed Charges for Rev 637 = $11.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,UNITED HEALTHCARE,UHC ONEIDA NATION,11.33,,,,,,,9.9500,20.4800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.48 in Billed Charges for Rev 637 = $11.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,UNITED HEALTHCARE,UNITED HEALTHCARE,11.33,,,,,,,9.9500,20.4800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.48 in Billed Charges for Rev 637 = $11.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,UNITY HEALTH PLAN,UNITY HOSPICE,20.48,,,,,,,9.9500,20.4800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.75,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.48 in Billed Charges for Rev 637 = $14.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.70,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.48 in Billed Charges for Rev 637 = $12.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.75,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.48 in Billed Charges for Rev 637 = $14.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.75,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.48 in Billed Charges for Rev 637 = $14.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLARITHROMYCIN 250 MG TABS,637,RC,0781-1961-60,CDM,,,,,,both,1.000000,EA,20.4800,13.5200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.29,,,,,,,9.9500,20.4800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.48 in Billed Charges for Rev 637 = $12.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,AETNA,AETNA HSHS,7.01,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.85 in Billed Charges for Rev 637 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,AETNA,ALL COMMERCIAL AETNA,10.85,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.85 in Billed Charges for Rev 637 = $10.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,ANTHEM,ANTHEM POS/HMO,7.38,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $10.85 in Billed Charges for Rev 637 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,ANTHEM,ANTHEM PPO,7.38,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $10.85 in Billed Charges for Rev 637 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.85,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.85 in Billed Charges for Rev 637 = $10.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,CENPATICO,ALL MEDICAID CENPATICO,10.85,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.85 in Billed Charges for Rev 637 = $10.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.22,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.85 in Billed Charges for Rev 637 = $9.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,CIGNA,ALL COMMERCIAL CIGNA,7.60,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.85 in Billed Charges for Rev 637 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,COFINITY,COFINITY,10.85,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.85 in Billed Charges for Rev 637 = $10.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.31,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.85 in Billed Charges for Rev 637 = $10.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,9.11,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.85 in Billed Charges for Rev 637 = $9.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.70,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.85 in Billed Charges for Rev 637 = $7.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.92,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.85 in Billed Charges for Rev 637 = $7.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,5.27,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.85 in Billed Charges for Rev 637 = $5.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.22,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.85 in Billed Charges for Rev 637 = $9.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,HUMANA,HUMANA CHOICE CARE HMO,6.89,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $10.85 in Billed Charges at 63.5% = $6.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,HUMANA,HUMANA CHOICE CARE PPO,9.22,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.85 in Billed Charges for Rev 637 = $9.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,HUMANA,HUMANA NATIIONAL POS HMO,6.89,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $10.85 in Billed Charges at 63.5% = $6.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.92,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.85 in Billed Charges for Rev 637 = $7.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.85,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.85 in Billed Charges for Rev 637 = $10.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.85,,,,,,,5.2700,10.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.43,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.85 in Billed Charges for Rev 637 = $5.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.11,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.85 in Billed Charges for Rev 637 = $9.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.14,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.85 in Billed Charges for Rev 637 = $8.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.98,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.85 in Billed Charges for Rev 637 = $9.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.51,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.85 in Billed Charges for Rev 637 = $6.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.51,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.85 in Billed Charges for Rev 637 = $6.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,PREVEA HEALTH NETWORK,PREVEA360,6.51,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.85 in Billed Charges for Rev 637 = $6.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.51,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.85 in Billed Charges for Rev 637 = $6.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.93,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.85 in Billed Charges for Rev 637 = $6.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.81,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.85 in Billed Charges for Rev 637 = $7.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.00,,,,,,,5.2700,10.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.85 in Billed Charges for Rev 637 = $6.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,6.00,,,,,,,5.2700,10.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.85 in Billed Charges for Rev 637 = $6.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,6.00,,,,,,,5.2700,10.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.85 in Billed Charges for Rev 637 = $6.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,UNITY HEALTH PLAN,UNITY HOSPICE,10.85,,,,,,,5.2700,10.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.81,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.85 in Billed Charges for Rev 637 = $7.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.73,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.85 in Billed Charges for Rev 637 = $6.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.81,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.85 in Billed Charges for Rev 637 = $7.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.81,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.85 in Billed Charges for Rev 637 = $7.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG TABS,637,RC,68084-070-11,CDM,,,,,,both,1.000000,EA,10.8500,7.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.51,,,,,,,5.2700,10.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.85 in Billed Charges for Rev 637 = $6.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,AETNA,AETNA HSHS,5.35,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.28 in Billed Charges for Rev 637 = $5.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,AETNA,ALL COMMERCIAL AETNA,8.28,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.28 in Billed Charges for Rev 637 = $8.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,ANTHEM,ANTHEM POS/HMO,5.63,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.28 in Billed Charges for Rev 637 = $5.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,ANTHEM,ANTHEM PPO,5.63,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.28 in Billed Charges for Rev 637 = $5.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.28,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.28 in Billed Charges for Rev 637 = $8.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,CENPATICO,ALL MEDICAID CENPATICO,8.28,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.28 in Billed Charges for Rev 637 = $8.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.04,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.28 in Billed Charges for Rev 637 = $7.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,CIGNA,ALL COMMERCIAL CIGNA,5.80,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.28 in Billed Charges for Rev 637 = $5.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,COFINITY,COFINITY,8.28,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.28 in Billed Charges for Rev 637 = $8.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.87,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.28 in Billed Charges for Rev 637 = $7.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,6.96,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.28 in Billed Charges for Rev 637 = $6.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.88,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.28 in Billed Charges for Rev 637 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.04,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.28 in Billed Charges for Rev 637 = $6.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,4.02,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.28 in Billed Charges for Rev 637 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.04,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.28 in Billed Charges for Rev 637 = $7.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,HUMANA,HUMANA CHOICE CARE HMO,5.26,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.28 in Billed Charges at 63.5% = $5.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,HUMANA,HUMANA CHOICE CARE PPO,7.04,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.28 in Billed Charges for Rev 637 = $7.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,HUMANA,HUMANA NATIIONAL POS HMO,5.26,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.28 in Billed Charges at 63.5% = $5.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.04,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.28 in Billed Charges for Rev 637 = $6.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.28,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.28 in Billed Charges for Rev 637 = $8.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.28,,,,,,,4.0200,8.2800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.14,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.28 in Billed Charges for Rev 637 = $4.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.96,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.28 in Billed Charges for Rev 637 = $6.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.21,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.28 in Billed Charges for Rev 637 = $6.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.62,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.28 in Billed Charges for Rev 637 = $7.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.97,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.28 in Billed Charges for Rev 637 = $4.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.97,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.28 in Billed Charges for Rev 637 = $4.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,PREVEA HEALTH NETWORK,PREVEA360,4.97,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.28 in Billed Charges for Rev 637 = $4.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.97,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.28 in Billed Charges for Rev 637 = $4.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.29,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.28 in Billed Charges for Rev 637 = $5.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.96,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.28 in Billed Charges for Rev 637 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.58,,,,,,,4.0200,8.2800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.28 in Billed Charges for Rev 637 = $4.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,4.58,,,,,,,4.0200,8.2800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.28 in Billed Charges for Rev 637 = $4.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,4.58,,,,,,,4.0200,8.2800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.28 in Billed Charges for Rev 637 = $4.58 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,UNITY HEALTH PLAN,UNITY HOSPICE,8.28,,,,,,,4.0200,8.2800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.96,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.28 in Billed Charges for Rev 637 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.13,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.28 in Billed Charges for Rev 637 = $5.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.96,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.28 in Billed Charges for Rev 637 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.96,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.28 in Billed Charges for Rev 637 = $5.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 10 MG TABS,637,RC,0904-6084-61,CDM,,,,,,both,1.000000,EA,8.2800,5.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.97,,,,,,,4.0200,8.2800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.28 in Billed Charges for Rev 637 = $4.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,AETNA,AETNA HSHS,5.65,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.75 in Billed Charges for Rev 637 = $5.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,AETNA,ALL COMMERCIAL AETNA,8.75,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.75 in Billed Charges for Rev 637 = $8.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,ANTHEM,ANTHEM POS/HMO,5.95,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.75 in Billed Charges for Rev 637 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,ANTHEM,ANTHEM PPO,5.95,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.75 in Billed Charges for Rev 637 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.75,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.75 in Billed Charges for Rev 637 = $8.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,CENPATICO,ALL MEDICAID CENPATICO,8.75,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.75 in Billed Charges for Rev 637 = $8.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.44,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.75 in Billed Charges for Rev 637 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,CIGNA,ALL COMMERCIAL CIGNA,6.13,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.75 in Billed Charges for Rev 637 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,COFINITY,COFINITY,8.75,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.75 in Billed Charges for Rev 637 = $8.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.31,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.75 in Billed Charges for Rev 637 = $8.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,7.35,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.75 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.21,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.75 in Billed Charges for Rev 637 = $6.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.39,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.75 in Billed Charges for Rev 637 = $6.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,4.25,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.75 in Billed Charges for Rev 637 = $4.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.44,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.75 in Billed Charges for Rev 637 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,HUMANA,HUMANA CHOICE CARE HMO,5.56,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.75 in Billed Charges at 63.5% = $5.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,HUMANA,HUMANA CHOICE CARE PPO,7.44,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.75 in Billed Charges for Rev 637 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,HUMANA,HUMANA NATIIONAL POS HMO,5.56,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.75 in Billed Charges at 63.5% = $5.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.39,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.75 in Billed Charges for Rev 637 = $6.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.75,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.75 in Billed Charges for Rev 637 = $8.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.75,,,,,,,4.2500,8.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.38,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.75 in Billed Charges for Rev 637 = $4.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.35,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.75 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.56,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.75 in Billed Charges for Rev 637 = $6.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.05,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.75 in Billed Charges for Rev 637 = $8.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.25,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.75 in Billed Charges for Rev 637 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.25,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.75 in Billed Charges for Rev 637 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,PREVEA HEALTH NETWORK,PREVEA360,5.25,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.75 in Billed Charges for Rev 637 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.25,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.75 in Billed Charges for Rev 637 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.59,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.75 in Billed Charges for Rev 637 = $5.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.30,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.75 in Billed Charges for Rev 637 = $6.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.84,,,,,,,4.2500,8.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.75 in Billed Charges for Rev 637 = $4.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.84,,,,,,,4.2500,8.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.75 in Billed Charges for Rev 637 = $4.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.84,,,,,,,4.2500,8.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.75 in Billed Charges for Rev 637 = $4.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,UNITY HEALTH PLAN,UNITY HOSPICE,8.75,,,,,,,4.2500,8.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.30,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.75 in Billed Charges for Rev 637 = $6.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.43,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.75 in Billed Charges for Rev 637 = $5.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.30,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.75 in Billed Charges for Rev 637 = $6.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.30,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.75 in Billed Charges for Rev 637 = $6.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITALOPRAM 20 MG TABS,637,RC,13668-010-05,CDM,,,,,,both,1.000000,EA,8.7500,5.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.25,,,,,,,4.2500,8.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.75 in Billed Charges for Rev 637 = $5.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,AETNA,AETNA HSHS,13.92,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $21.55 in Billed Charges for Rev 637 = $13.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,AETNA,ALL COMMERCIAL AETNA,21.55,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.55 in Billed Charges for Rev 637 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,ANTHEM,ANTHEM POS/HMO,14.65,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $21.55 in Billed Charges for Rev 637 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,ANTHEM,ANTHEM PPO,14.65,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $21.55 in Billed Charges for Rev 637 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,21.55,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.55 in Billed Charges for Rev 637 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,CENPATICO,ALL MEDICAID CENPATICO,21.55,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.55 in Billed Charges for Rev 637 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18.32,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.55 in Billed Charges for Rev 637 = $18.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,CIGNA,ALL COMMERCIAL CIGNA,15.09,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $21.55 in Billed Charges for Rev 637 = $15.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,COFINITY,COFINITY,21.55,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.55 in Billed Charges for Rev 637 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,20.47,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $21.55 in Billed Charges for Rev 637 = $20.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,18.10,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $21.55 in Billed Charges for Rev 637 = $18.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15.30,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $21.55 in Billed Charges for Rev 637 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15.73,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $21.55 in Billed Charges for Rev 637 = $15.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,10.47,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $21.55 in Billed Charges for Rev 637 = $10.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18.32,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.55 in Billed Charges for Rev 637 = $18.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,HUMANA,HUMANA CHOICE CARE HMO,13.68,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $21.55 in Billed Charges at 63.5% = $13.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,HUMANA,HUMANA CHOICE CARE PPO,18.32,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.55 in Billed Charges for Rev 637 = $18.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,HUMANA,HUMANA NATIIONAL POS HMO,13.68,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $21.55 in Billed Charges at 63.5% = $13.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15.73,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $21.55 in Billed Charges for Rev 637 = $15.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,21.55,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.55 in Billed Charges for Rev 637 = $21.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,21.55,,,,,,,10.4700,21.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.78,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $21.55 in Billed Charges for Rev 637 = $10.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18.10,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $21.55 in Billed Charges for Rev 637 = $18.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16.16,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $21.55 in Billed Charges for Rev 637 = $16.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,19.83,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $21.55 in Billed Charges for Rev 637 = $19.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.93,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.55 in Billed Charges for Rev 637 = $12.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.93,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.55 in Billed Charges for Rev 637 = $12.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,PREVEA HEALTH NETWORK,PREVEA360,12.93,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.55 in Billed Charges for Rev 637 = $12.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.93,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.55 in Billed Charges for Rev 637 = $12.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.76,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $21.55 in Billed Charges for Rev 637 = $13.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15.52,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.55 in Billed Charges for Rev 637 = $15.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.92,,,,,,,10.4700,21.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $21.55 in Billed Charges for Rev 637 = $11.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,11.92,,,,,,,10.4700,21.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $21.55 in Billed Charges for Rev 637 = $11.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,11.92,,,,,,,10.4700,21.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $21.55 in Billed Charges for Rev 637 = $11.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,UNITY HEALTH PLAN,UNITY HOSPICE,21.55,,,,,,,10.4700,21.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15.52,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.55 in Billed Charges for Rev 637 = $15.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13.36,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $21.55 in Billed Charges for Rev 637 = $13.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15.52,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.55 in Billed Charges for Rev 637 = $15.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15.52,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.55 in Billed Charges for Rev 637 = $15.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CITRIC ACID-SODIUM CITRATE 500-334 MG/5ML SOLN,637,RC,0121-1190-30,CDM,,,,,,both,30.000000,ML,21.5500,14.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.93,,,,,,,10.4700,21.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.55 in Billed Charges for Rev 637 = $12.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,AETNA,AETNA HSHS,14.81,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $22.93 in Billed Charges for Rev 637 = $14.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,AETNA,ALL COMMERCIAL AETNA,22.93,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.93 in Billed Charges for Rev 637 = $22.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,ANTHEM,ANTHEM POS/HMO,15.59,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $22.93 in Billed Charges for Rev 637 = $15.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,ANTHEM,ANTHEM PPO,15.59,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $22.93 in Billed Charges for Rev 637 = $15.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,22.93,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.93 in Billed Charges for Rev 637 = $22.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,CENPATICO,ALL MEDICAID CENPATICO,22.93,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.93 in Billed Charges for Rev 637 = $22.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,19.49,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.93 in Billed Charges for Rev 637 = $19.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,CIGNA,ALL COMMERCIAL CIGNA,16.05,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $22.93 in Billed Charges for Rev 637 = $16.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,COFINITY,COFINITY,22.93,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.93 in Billed Charges for Rev 637 = $22.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,21.78,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $22.93 in Billed Charges for Rev 637 = $21.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,HEALTH CARE ALLIANCE,THE ALLIANCE,19.26,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.93 in Billed Charges for Rev 637 = $19.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,16.28,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $22.93 in Billed Charges for Rev 637 = $16.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16.74,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.93 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,HSHS EMPLOYEES,HSHS EMPLOYEES,11.14,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $22.93 in Billed Charges for Rev 637 = $11.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,19.49,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.93 in Billed Charges for Rev 637 = $19.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,HUMANA,HUMANA CHOICE CARE HMO,14.56,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $22.93 in Billed Charges at 63.5% = $14.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,HUMANA,HUMANA CHOICE CARE PPO,19.49,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $22.93 in Billed Charges for Rev 637 = $19.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,HUMANA,HUMANA NATIIONAL POS HMO,14.56,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $22.93 in Billed Charges at 63.5% = $14.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16.74,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $22.93 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,LIVE360,LIVE360 HSHS HEALTHY PLAN,22.93,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $22.93 in Billed Charges for Rev 637 = $22.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,22.93,,,,,,,11.1400,22.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.47,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $22.93 in Billed Charges for Rev 637 = $11.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,19.26,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $22.93 in Billed Charges for Rev 637 = $19.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,17.20,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $22.93 in Billed Charges for Rev 637 = $17.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,21.10,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $22.93 in Billed Charges for Rev 637 = $21.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.76,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.93 in Billed Charges for Rev 637 = $13.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.76,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.93 in Billed Charges for Rev 637 = $13.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,PREVEA HEALTH NETWORK,PREVEA360,13.76,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.93 in Billed Charges for Rev 637 = $13.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.76,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.93 in Billed Charges for Rev 637 = $13.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14.64,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $22.93 in Billed Charges for Rev 637 = $14.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,16.51,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.93 in Billed Charges for Rev 637 = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.68,,,,,,,11.1400,22.9300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $22.93 in Billed Charges for Rev 637 = $12.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,UNITED HEALTHCARE,UHC ONEIDA NATION,12.68,,,,,,,11.1400,22.9300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $22.93 in Billed Charges for Rev 637 = $12.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,UNITED HEALTHCARE,UNITED HEALTHCARE,12.68,,,,,,,11.1400,22.9300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $22.93 in Billed Charges for Rev 637 = $12.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,UNITY HEALTH PLAN,UNITY HOSPICE,22.93,,,,,,,11.1400,22.9300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,16.51,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.93 in Billed Charges for Rev 637 = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.22,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $22.93 in Billed Charges for Rev 637 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,16.51,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.93 in Billed Charges for Rev 637 = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,16.51,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $22.93 in Billed Charges for Rev 637 = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,31722-899-30,CDM,,,,,,both,1.000000,EA,22.9300,15.1300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.76,,,,,,,11.1400,22.9300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $22.93 in Billed Charges for Rev 637 = $13.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,AETNA,AETNA HSHS,11.00,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $17.03 in Billed Charges for Rev 637 = $11.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,AETNA,ALL COMMERCIAL AETNA,17.03,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.03 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,ANTHEM,ANTHEM POS/HMO,11.58,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $17.03 in Billed Charges for Rev 637 = $11.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,ANTHEM,ANTHEM PPO,11.58,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $17.03 in Billed Charges for Rev 637 = $11.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17.03,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.03 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,CENPATICO,ALL MEDICAID CENPATICO,17.03,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.03 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.48,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.03 in Billed Charges for Rev 637 = $14.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,CIGNA,ALL COMMERCIAL CIGNA,11.92,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $17.03 in Billed Charges for Rev 637 = $11.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,COFINITY,COFINITY,17.03,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.03 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16.18,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $17.03 in Billed Charges for Rev 637 = $16.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,14.31,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.03 in Billed Charges for Rev 637 = $14.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12.09,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $17.03 in Billed Charges for Rev 637 = $12.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.43,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.03 in Billed Charges for Rev 637 = $12.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,8.28,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $17.03 in Billed Charges for Rev 637 = $8.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.48,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.03 in Billed Charges for Rev 637 = $14.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,HUMANA,HUMANA CHOICE CARE HMO,10.81,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $17.03 in Billed Charges at 63.5% = $10.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,HUMANA,HUMANA CHOICE CARE PPO,14.48,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.03 in Billed Charges for Rev 637 = $14.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,HUMANA,HUMANA NATIIONAL POS HMO,10.81,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $17.03 in Billed Charges at 63.5% = $10.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.43,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.03 in Billed Charges for Rev 637 = $12.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,17.03,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.03 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.03,,,,,,,8.2800,17.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.52,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $17.03 in Billed Charges for Rev 637 = $8.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.31,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.03 in Billed Charges for Rev 637 = $14.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.77,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $17.03 in Billed Charges for Rev 637 = $12.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.67,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $17.03 in Billed Charges for Rev 637 = $15.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.22,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.03 in Billed Charges for Rev 637 = $10.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.22,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.03 in Billed Charges for Rev 637 = $10.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,PREVEA HEALTH NETWORK,PREVEA360,10.22,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.03 in Billed Charges for Rev 637 = $10.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.22,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.03 in Billed Charges for Rev 637 = $10.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.87,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $17.03 in Billed Charges for Rev 637 = $10.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.26,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.03 in Billed Charges for Rev 637 = $12.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.42,,,,,,,8.2800,17.0300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.03 in Billed Charges for Rev 637 = $9.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,9.42,,,,,,,8.2800,17.0300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.03 in Billed Charges for Rev 637 = $9.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,9.42,,,,,,,8.2800,17.0300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.03 in Billed Charges for Rev 637 = $9.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,UNITY HEALTH PLAN,UNITY HOSPICE,17.03,,,,,,,8.2800,17.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.26,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.03 in Billed Charges for Rev 637 = $12.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.56,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $17.03 in Billed Charges for Rev 637 = $10.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.26,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.03 in Billed Charges for Rev 637 = $12.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.26,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.03 in Billed Charges for Rev 637 = $12.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLESTIPOL 1 G TABS,637,RC,60687-715-11,CDM,,,,,,both,1.000000,EA,17.0300,11.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.22,,,,,,,8.2800,17.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.03 in Billed Charges for Rev 637 = $10.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,AETNA,AETNA HSHS,5.30,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.20 in Billed Charges for Rev 637 = $5.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,AETNA,ALL COMMERCIAL AETNA,8.20,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.20 in Billed Charges for Rev 637 = $8.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,ANTHEM,ANTHEM POS/HMO,5.58,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.20 in Billed Charges for Rev 637 = $5.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,ANTHEM,ANTHEM PPO,5.58,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.20 in Billed Charges for Rev 637 = $5.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.20,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.20 in Billed Charges for Rev 637 = $8.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,CENPATICO,ALL MEDICAID CENPATICO,8.20,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.20 in Billed Charges for Rev 637 = $8.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.97,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.20 in Billed Charges for Rev 637 = $6.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,CIGNA,ALL COMMERCIAL CIGNA,5.74,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.20 in Billed Charges for Rev 637 = $5.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,COFINITY,COFINITY,8.20,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.20 in Billed Charges for Rev 637 = $8.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.79,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.20 in Billed Charges for Rev 637 = $7.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,6.89,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.20 in Billed Charges for Rev 637 = $6.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.82,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.20 in Billed Charges for Rev 637 = $5.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.99,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.20 in Billed Charges for Rev 637 = $5.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,3.99,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.20 in Billed Charges for Rev 637 = $3.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.97,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.20 in Billed Charges for Rev 637 = $6.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,HUMANA,HUMANA CHOICE CARE HMO,5.21,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.20 in Billed Charges at 63.5% = $5.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,HUMANA,HUMANA CHOICE CARE PPO,6.97,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.20 in Billed Charges for Rev 637 = $6.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,HUMANA,HUMANA NATIIONAL POS HMO,5.21,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.20 in Billed Charges at 63.5% = $5.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.99,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.20 in Billed Charges for Rev 637 = $5.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.20,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.20 in Billed Charges for Rev 637 = $8.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.20,,,,,,,3.9900,8.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.10,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.20 in Billed Charges for Rev 637 = $4.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.89,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.20 in Billed Charges for Rev 637 = $6.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.15,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.20 in Billed Charges for Rev 637 = $6.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.54,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.20 in Billed Charges for Rev 637 = $7.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.92,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.20 in Billed Charges for Rev 637 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.92,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.20 in Billed Charges for Rev 637 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,PREVEA HEALTH NETWORK,PREVEA360,4.92,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.20 in Billed Charges for Rev 637 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.92,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.20 in Billed Charges for Rev 637 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.23,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.20 in Billed Charges for Rev 637 = $5.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.90,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.20 in Billed Charges for Rev 637 = $5.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.53,,,,,,,3.9900,8.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.20 in Billed Charges for Rev 637 = $4.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,UNITED HEALTHCARE,UHC ONEIDA NATION,4.53,,,,,,,3.9900,8.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.20 in Billed Charges for Rev 637 = $4.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,UNITED HEALTHCARE,UNITED HEALTHCARE,4.53,,,,,,,3.9900,8.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.20 in Billed Charges for Rev 637 = $4.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,UNITY HEALTH PLAN,UNITY HOSPICE,8.20,,,,,,,3.9900,8.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.90,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.20 in Billed Charges for Rev 637 = $5.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.08,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.20 in Billed Charges for Rev 637 = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.90,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.20 in Billed Charges for Rev 637 = $5.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.90,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.20 in Billed Charges for Rev 637 = $5.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28 G TUBE,637,RC,0536-1265-95,CDM,,,,,,both,28.000000,GR,8.2000,5.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.92,,,,,,,3.9900,8.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.20 in Billed Charges for Rev 637 = $4.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,AETNA,AETNA HSHS,18.86,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $29.20 in Billed Charges for Rev 637 = $18.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,AETNA,ALL COMMERCIAL AETNA,29.20,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.20 in Billed Charges for Rev 637 = $29.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,ANTHEM,ANTHEM POS/HMO,19.86,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $29.20 in Billed Charges for Rev 637 = $19.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,ANTHEM,ANTHEM PPO,19.86,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $29.20 in Billed Charges for Rev 637 = $19.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,29.20,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.20 in Billed Charges for Rev 637 = $29.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,CENPATICO,ALL MEDICAID CENPATICO,29.20,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.20 in Billed Charges for Rev 637 = $29.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,24.82,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.20 in Billed Charges for Rev 637 = $24.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,CIGNA,ALL COMMERCIAL CIGNA,20.44,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $29.20 in Billed Charges for Rev 637 = $20.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,COFINITY,COFINITY,29.20,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.20 in Billed Charges for Rev 637 = $29.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,27.74,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $29.20 in Billed Charges for Rev 637 = $27.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,24.53,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $29.20 in Billed Charges for Rev 637 = $24.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,20.73,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $29.20 in Billed Charges for Rev 637 = $20.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,21.32,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $29.20 in Billed Charges for Rev 637 = $21.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,14.19,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $29.20 in Billed Charges for Rev 637 = $14.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,24.82,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.20 in Billed Charges for Rev 637 = $24.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,HUMANA,HUMANA CHOICE CARE HMO,18.54,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $29.20 in Billed Charges at 63.5% = $18.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,HUMANA,HUMANA CHOICE CARE PPO,24.82,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.20 in Billed Charges for Rev 637 = $24.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,HUMANA,HUMANA NATIIONAL POS HMO,18.54,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $29.20 in Billed Charges at 63.5% = $18.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,21.32,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $29.20 in Billed Charges for Rev 637 = $21.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,29.20,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.20 in Billed Charges for Rev 637 = $29.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,29.20,,,,,,,14.1900,29.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,14.60,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $29.20 in Billed Charges for Rev 637 = $14.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,24.53,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $29.20 in Billed Charges for Rev 637 = $24.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,21.90,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $29.20 in Billed Charges for Rev 637 = $21.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,26.86,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $29.20 in Billed Charges for Rev 637 = $26.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.52,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.20 in Billed Charges for Rev 637 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.52,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.20 in Billed Charges for Rev 637 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,PREVEA HEALTH NETWORK,PREVEA360,17.52,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.20 in Billed Charges for Rev 637 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.52,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.20 in Billed Charges for Rev 637 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,18.64,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $29.20 in Billed Charges for Rev 637 = $18.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,21.02,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.20 in Billed Charges for Rev 637 = $21.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.15,,,,,,,14.1900,29.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $29.20 in Billed Charges for Rev 637 = $16.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,UNITED HEALTHCARE,UHC ONEIDA NATION,16.15,,,,,,,14.1900,29.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $29.20 in Billed Charges for Rev 637 = $16.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,UNITED HEALTHCARE,UNITED HEALTHCARE,16.15,,,,,,,14.1900,29.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $29.20 in Billed Charges for Rev 637 = $16.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,UNITY HEALTH PLAN,UNITY HOSPICE,29.20,,,,,,,14.1900,29.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,21.02,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.20 in Billed Charges for Rev 637 = $21.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,18.10,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $29.20 in Billed Charges for Rev 637 = $18.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,21.02,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.20 in Billed Charges for Rev 637 = $21.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,21.02,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.20 in Billed Charges for Rev 637 = $21.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 28.4 G TUBE,637,RC,68001-475-47,CDM,,,,,,both,28.400000,GR,29.2000,19.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,17.52,,,,,,,14.1900,29.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.20 in Billed Charges for Rev 637 = $17.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,AETNA,AETNA HSHS,76.58,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.55 in Billed Charges for Rev 637 = $76.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,AETNA,ALL COMMERCIAL AETNA,118.55,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.55 in Billed Charges for Rev 637 = $118.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,ANTHEM,ANTHEM POS/HMO,80.61,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $118.55 in Billed Charges for Rev 637 = $80.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,ANTHEM,ANTHEM PPO,80.61,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $118.55 in Billed Charges for Rev 637 = $80.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.55,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.55 in Billed Charges for Rev 637 = $118.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,CENPATICO,ALL MEDICAID CENPATICO,118.55,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.55 in Billed Charges for Rev 637 = $118.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.77,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.55 in Billed Charges for Rev 637 = $100.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,CIGNA,ALL COMMERCIAL CIGNA,82.99,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.55 in Billed Charges for Rev 637 = $82.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,COFINITY,COFINITY,118.55,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.55 in Billed Charges for Rev 637 = $118.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.62,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.55 in Billed Charges for Rev 637 = $112.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,99.58,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.55 in Billed Charges for Rev 637 = $99.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,84.17,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.55 in Billed Charges for Rev 637 = $84.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.54,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.55 in Billed Charges for Rev 637 = $86.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,57.62,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.55 in Billed Charges for Rev 637 = $57.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.77,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.55 in Billed Charges for Rev 637 = $100.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,HUMANA,HUMANA CHOICE CARE HMO,75.28,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $118.55 in Billed Charges at 63.5% = $75.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,HUMANA,HUMANA CHOICE CARE PPO,100.77,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.55 in Billed Charges for Rev 637 = $100.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,HUMANA,HUMANA NATIIONAL POS HMO,75.28,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $118.55 in Billed Charges at 63.5% = $75.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.54,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.55 in Billed Charges for Rev 637 = $86.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.55,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.55 in Billed Charges for Rev 637 = $118.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,118.55,,,,,,,57.6200,118.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.28,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.55 in Billed Charges for Rev 637 = $59.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.58,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.55 in Billed Charges for Rev 637 = $99.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.91,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.55 in Billed Charges for Rev 637 = $88.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,109.07,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.55 in Billed Charges for Rev 637 = $109.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,71.13,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.55 in Billed Charges for Rev 637 = $71.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,71.13,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.55 in Billed Charges for Rev 637 = $71.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,PREVEA HEALTH NETWORK,PREVEA360,71.13,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.55 in Billed Charges for Rev 637 = $71.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,71.13,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.55 in Billed Charges for Rev 637 = $71.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.67,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.55 in Billed Charges for Rev 637 = $75.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,85.36,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.55 in Billed Charges for Rev 637 = $85.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,65.56,,,,,,,57.6200,118.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.55 in Billed Charges for Rev 637 = $65.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,65.56,,,,,,,57.6200,118.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.55 in Billed Charges for Rev 637 = $65.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,65.56,,,,,,,57.6200,118.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.55 in Billed Charges for Rev 637 = $65.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,UNITY HEALTH PLAN,UNITY HOSPICE,118.55,,,,,,,57.6200,118.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,85.36,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.55 in Billed Charges for Rev 637 = $85.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.50,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.55 in Billed Charges for Rev 637 = $73.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,85.36,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.55 in Billed Charges for Rev 637 = $85.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,85.36,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.55 in Billed Charges for Rev 637 = $85.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 1 % CREA 30 G TUBE,637,RC,51672-1275-2,CDM,,,,,,both,30.000000,GR,118.5500,78.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,71.13,,,,,,,57.6200,118.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.55 in Billed Charges for Rev 637 = $71.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,AETNA,AETNA HSHS,7.07,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.95 in Billed Charges for Rev 637 = $7.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,AETNA,ALL COMMERCIAL AETNA,10.95,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.95 in Billed Charges for Rev 637 = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,ANTHEM,ANTHEM POS/HMO,7.45,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $10.95 in Billed Charges for Rev 637 = $7.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,ANTHEM,ANTHEM PPO,7.45,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $10.95 in Billed Charges for Rev 637 = $7.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.95,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.95 in Billed Charges for Rev 637 = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,CENPATICO,ALL MEDICAID CENPATICO,10.95,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.95 in Billed Charges for Rev 637 = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.31,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.95 in Billed Charges for Rev 637 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,CIGNA,ALL COMMERCIAL CIGNA,7.67,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.95 in Billed Charges for Rev 637 = $7.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,COFINITY,COFINITY,10.95,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.95 in Billed Charges for Rev 637 = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.40,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.95 in Billed Charges for Rev 637 = $10.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,9.20,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.95 in Billed Charges for Rev 637 = $9.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.77,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.95 in Billed Charges for Rev 637 = $7.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.99,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.95 in Billed Charges for Rev 637 = $7.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,5.32,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.95 in Billed Charges for Rev 637 = $5.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.31,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.95 in Billed Charges for Rev 637 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,HUMANA,HUMANA CHOICE CARE HMO,6.95,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $10.95 in Billed Charges at 63.5% = $6.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,HUMANA,HUMANA CHOICE CARE PPO,9.31,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.95 in Billed Charges for Rev 637 = $9.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,HUMANA,HUMANA NATIIONAL POS HMO,6.95,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $10.95 in Billed Charges at 63.5% = $6.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.99,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.95 in Billed Charges for Rev 637 = $7.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.95,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.95 in Billed Charges for Rev 637 = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.95,,,,,,,5.3200,10.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.48,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.95 in Billed Charges for Rev 637 = $5.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.20,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.95 in Billed Charges for Rev 637 = $9.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.21,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.95 in Billed Charges for Rev 637 = $8.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.07,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.95 in Billed Charges for Rev 637 = $10.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.57,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.95 in Billed Charges for Rev 637 = $6.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.57,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.95 in Billed Charges for Rev 637 = $6.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,PREVEA HEALTH NETWORK,PREVEA360,6.57,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.95 in Billed Charges for Rev 637 = $6.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.57,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.95 in Billed Charges for Rev 637 = $6.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.99,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.95 in Billed Charges for Rev 637 = $6.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.88,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.95 in Billed Charges for Rev 637 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.06,,,,,,,5.3200,10.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.95 in Billed Charges for Rev 637 = $6.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,UNITED HEALTHCARE,UHC ONEIDA NATION,6.06,,,,,,,5.3200,10.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.95 in Billed Charges for Rev 637 = $6.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,UNITED HEALTHCARE,UNITED HEALTHCARE,6.06,,,,,,,5.3200,10.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.95 in Billed Charges for Rev 637 = $6.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,UNITY HEALTH PLAN,UNITY HOSPICE,10.95,,,,,,,5.3200,10.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.88,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.95 in Billed Charges for Rev 637 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.79,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.95 in Billed Charges for Rev 637 = $6.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.88,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.95 in Billed Charges for Rev 637 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.88,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.95 in Billed Charges for Rev 637 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-4146-22,CDM,,,,,,both,1.000000,EA,10.9500,7.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.57,,,,,,,5.3200,10.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.95 in Billed Charges for Rev 637 = $6.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,AETNA,AETNA HSHS,44.44,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $68.80 in Billed Charges for Rev 637 = $44.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,AETNA,ALL COMMERCIAL AETNA,68.80,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 637 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,ANTHEM,ANTHEM POS/HMO,46.78,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $68.80 in Billed Charges for Rev 637 = $46.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,ANTHEM,ANTHEM PPO,46.78,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $68.80 in Billed Charges for Rev 637 = $46.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,68.80,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 637 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,CENPATICO,ALL MEDICAID CENPATICO,68.80,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 637 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.48,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.80 in Billed Charges for Rev 637 = $58.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,CIGNA,ALL COMMERCIAL CIGNA,48.16,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $68.80 in Billed Charges for Rev 637 = $48.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,COFINITY,COFINITY,68.80,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 637 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.36,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $68.80 in Billed Charges for Rev 637 = $65.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,57.79,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.80 in Billed Charges for Rev 637 = $57.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.85,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $68.80 in Billed Charges for Rev 637 = $48.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.22,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.80 in Billed Charges for Rev 637 = $50.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,33.44,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $68.80 in Billed Charges for Rev 637 = $33.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.48,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.80 in Billed Charges for Rev 637 = $58.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,HUMANA,HUMANA CHOICE CARE HMO,43.69,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $68.80 in Billed Charges at 63.5% = $43.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,HUMANA,HUMANA CHOICE CARE PPO,58.48,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.80 in Billed Charges for Rev 637 = $58.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,HUMANA,HUMANA NATIIONAL POS HMO,43.69,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $68.80 in Billed Charges at 63.5% = $43.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.22,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.80 in Billed Charges for Rev 637 = $50.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,68.80,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.80 in Billed Charges for Rev 637 = $68.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,68.80,,,,,,,33.4400,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.40,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $68.80 in Billed Charges for Rev 637 = $34.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.79,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.80 in Billed Charges for Rev 637 = $57.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.60,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $68.80 in Billed Charges for Rev 637 = $51.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.30,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $68.80 in Billed Charges for Rev 637 = $63.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,41.28,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.80 in Billed Charges for Rev 637 = $41.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,41.28,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.80 in Billed Charges for Rev 637 = $41.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,PREVEA HEALTH NETWORK,PREVEA360,41.28,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.80 in Billed Charges for Rev 637 = $41.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,41.28,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.80 in Billed Charges for Rev 637 = $41.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.92,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $68.80 in Billed Charges for Rev 637 = $43.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.54,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.80 in Billed Charges for Rev 637 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,38.05,,,,,,,33.4400,68.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.80 in Billed Charges for Rev 637 = $38.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,UNITED HEALTHCARE,UHC ONEIDA NATION,38.05,,,,,,,33.4400,68.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.80 in Billed Charges for Rev 637 = $38.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,UNITED HEALTHCARE,UNITED HEALTHCARE,38.05,,,,,,,33.4400,68.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.80 in Billed Charges for Rev 637 = $38.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,UNITY HEALTH PLAN,UNITY HOSPICE,68.80,,,,,,,33.4400,68.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.54,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.80 in Billed Charges for Rev 637 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.66,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $68.80 in Billed Charges for Rev 637 = $42.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.54,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.80 in Billed Charges for Rev 637 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.54,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.80 in Billed Charges for Rev 637 = $49.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0168-0258-15,CDM,,,,,,both,15.000000,GR,68.8000,45.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.28,,,,,,,33.4400,68.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.80 in Billed Charges for Rev 637 = $41.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,AETNA,AETNA HSHS,7.61,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $11.78 in Billed Charges for Rev 637 = $7.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,AETNA,ALL COMMERCIAL AETNA,11.78,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.78 in Billed Charges for Rev 637 = $11.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,ANTHEM,ANTHEM POS/HMO,8.01,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.78 in Billed Charges for Rev 637 = $8.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,ANTHEM,ANTHEM PPO,8.01,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.78 in Billed Charges for Rev 637 = $8.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11.78,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.78 in Billed Charges for Rev 637 = $11.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,CENPATICO,ALL MEDICAID CENPATICO,11.78,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.78 in Billed Charges for Rev 637 = $11.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.01,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.78 in Billed Charges for Rev 637 = $10.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,CIGNA,ALL COMMERCIAL CIGNA,8.25,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $11.78 in Billed Charges for Rev 637 = $8.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,COFINITY,COFINITY,11.78,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.78 in Billed Charges for Rev 637 = $11.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.19,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $11.78 in Billed Charges for Rev 637 = $11.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,9.90,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.78 in Billed Charges for Rev 637 = $9.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.36,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $11.78 in Billed Charges for Rev 637 = $8.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.60,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.78 in Billed Charges for Rev 637 = $8.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,5.73,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $11.78 in Billed Charges for Rev 637 = $5.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.01,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.78 in Billed Charges for Rev 637 = $10.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,HUMANA,HUMANA CHOICE CARE HMO,7.48,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.78 in Billed Charges at 63.5% = $7.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,HUMANA,HUMANA CHOICE CARE PPO,10.01,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.78 in Billed Charges for Rev 637 = $10.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,HUMANA,HUMANA NATIIONAL POS HMO,7.48,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.78 in Billed Charges at 63.5% = $7.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.60,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.78 in Billed Charges for Rev 637 = $8.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,11.78,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.78 in Billed Charges for Rev 637 = $11.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.78,,,,,,,5.7300,11.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.89,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $11.78 in Billed Charges for Rev 637 = $5.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.90,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.78 in Billed Charges for Rev 637 = $9.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.84,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $11.78 in Billed Charges for Rev 637 = $8.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.84,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $11.78 in Billed Charges for Rev 637 = $10.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.07,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.78 in Billed Charges for Rev 637 = $7.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.07,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.78 in Billed Charges for Rev 637 = $7.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,PREVEA HEALTH NETWORK,PREVEA360,7.07,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.78 in Billed Charges for Rev 637 = $7.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.07,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.78 in Billed Charges for Rev 637 = $7.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.52,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $11.78 in Billed Charges for Rev 637 = $7.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.48,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.78 in Billed Charges for Rev 637 = $8.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.51,,,,,,,5.7300,11.7800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.78 in Billed Charges for Rev 637 = $6.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,UNITED HEALTHCARE,UHC ONEIDA NATION,6.51,,,,,,,5.7300,11.7800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.78 in Billed Charges for Rev 637 = $6.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,UNITED HEALTHCARE,UNITED HEALTHCARE,6.51,,,,,,,5.7300,11.7800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.78 in Billed Charges for Rev 637 = $6.51 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,UNITY HEALTH PLAN,UNITY HOSPICE,11.78,,,,,,,5.7300,11.7800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.48,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.78 in Billed Charges for Rev 637 = $8.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.30,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $11.78 in Billed Charges for Rev 637 = $7.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.48,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.78 in Billed Charges for Rev 637 = $8.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.48,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.78 in Billed Charges for Rev 637 = $8.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOZAPINE 100 MG TABS,637,RC,60687-415-11,CDM,,,,,,both,1.000000,EA,11.7800,7.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.07,,,,,,,5.7300,11.7800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.78 in Billed Charges for Rev 637 = $7.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,AETNA,AETNA HSHS,141.31,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $218.75 in Billed Charges for Rev 637 = $141.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,AETNA,ALL COMMERCIAL AETNA,218.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.75 in Billed Charges for Rev 637 = $218.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,ANTHEM,ANTHEM POS/HMO,148.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $218.75 in Billed Charges for Rev 637 = $148.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,ANTHEM,ANTHEM PPO,148.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $218.75 in Billed Charges for Rev 637 = $148.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,218.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.75 in Billed Charges for Rev 637 = $218.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,CENPATICO,ALL MEDICAID CENPATICO,218.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.75 in Billed Charges for Rev 637 = $218.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,185.94,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.75 in Billed Charges for Rev 637 = $185.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,CIGNA,ALL COMMERCIAL CIGNA,153.13,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $218.75 in Billed Charges for Rev 637 = $153.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,COFINITY,COFINITY,218.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.75 in Billed Charges for Rev 637 = $218.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,207.81,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $218.75 in Billed Charges for Rev 637 = $207.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,HEALTH CARE ALLIANCE,THE ALLIANCE,183.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $218.75 in Billed Charges for Rev 637 = $183.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,155.31,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $218.75 in Billed Charges for Rev 637 = $155.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,159.69,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $218.75 in Billed Charges for Rev 637 = $159.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,HSHS EMPLOYEES,HSHS EMPLOYEES,106.31,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $218.75 in Billed Charges for Rev 637 = $106.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,185.94,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.75 in Billed Charges for Rev 637 = $185.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,HUMANA,HUMANA CHOICE CARE HMO,138.91,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $218.75 in Billed Charges at 63.5% = $138.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,HUMANA,HUMANA CHOICE CARE PPO,185.94,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $218.75 in Billed Charges for Rev 637 = $185.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,HUMANA,HUMANA NATIIONAL POS HMO,138.91,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $218.75 in Billed Charges at 63.5% = $138.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,159.69,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $218.75 in Billed Charges for Rev 637 = $159.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,LIVE360,LIVE360 HSHS HEALTHY PLAN,218.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $218.75 in Billed Charges for Rev 637 = $218.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,218.75,,,,,,,106.3100,218.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,109.38,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $218.75 in Billed Charges for Rev 637 = $109.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,183.75,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $218.75 in Billed Charges for Rev 637 = $183.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,164.06,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $218.75 in Billed Charges for Rev 637 = $164.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,201.25,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $218.75 in Billed Charges for Rev 637 = $201.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,131.25,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $218.75 in Billed Charges for Rev 637 = $131.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,131.25,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $218.75 in Billed Charges for Rev 637 = $131.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,PREVEA HEALTH NETWORK,PREVEA360,131.25,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $218.75 in Billed Charges for Rev 637 = $131.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,131.25,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $218.75 in Billed Charges for Rev 637 = $131.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,139.63,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $218.75 in Billed Charges for Rev 637 = $139.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,157.50,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.75 in Billed Charges for Rev 637 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,120.97,,,,,,,106.3100,218.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $218.75 in Billed Charges for Rev 637 = $120.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,UNITED HEALTHCARE,UHC ONEIDA NATION,120.97,,,,,,,106.3100,218.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $218.75 in Billed Charges for Rev 637 = $120.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,UNITED HEALTHCARE,UNITED HEALTHCARE,120.97,,,,,,,106.3100,218.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $218.75 in Billed Charges for Rev 637 = $120.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,UNITY HEALTH PLAN,UNITY HOSPICE,218.75,,,,,,,106.3100,218.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,157.50,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.75 in Billed Charges for Rev 637 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,135.63,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $218.75 in Billed Charges for Rev 637 = $135.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,157.50,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.75 in Billed Charges for Rev 637 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,157.50,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $218.75 in Billed Charges for Rev 637 = $157.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYPROHEPTADINE 2 MG/5ML SYRP,637,RC,64980-504-48,CDM,,,,,,both,473.000000,ML,218.7500,144.3800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,131.25,,,,,,,106.3100,218.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $218.75 in Billed Charges for Rev 637 = $131.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,AETNA,AETNA HSHS,18.02,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $27.90 in Billed Charges for Rev 637 = $18.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,AETNA,ALL COMMERCIAL AETNA,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,ANTHEM,ANTHEM POS/HMO,18.97,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $27.90 in Billed Charges for Rev 637 = $18.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,ANTHEM,ANTHEM PPO,18.97,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $27.90 in Billed Charges for Rev 637 = $18.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,CENPATICO,ALL MEDICAID CENPATICO,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 637 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,CIGNA,ALL COMMERCIAL CIGNA,19.53,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $27.90 in Billed Charges for Rev 637 = $19.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,COFINITY,COFINITY,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,26.51,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $27.90 in Billed Charges for Rev 637 = $26.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,23.44,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.90 in Billed Charges for Rev 637 = $23.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19.81,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $27.90 in Billed Charges for Rev 637 = $19.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,20.37,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.90 in Billed Charges for Rev 637 = $20.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,13.56,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $27.90 in Billed Charges for Rev 637 = $13.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 637 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,HUMANA,HUMANA CHOICE CARE HMO,17.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $27.90 in Billed Charges at 63.5% = $17.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,HUMANA,HUMANA CHOICE CARE PPO,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 637 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,HUMANA,HUMANA NATIIONAL POS HMO,17.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $27.90 in Billed Charges at 63.5% = $17.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,20.37,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.90 in Billed Charges for Rev 637 = $20.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,27.90,,,,,,,13.5600,27.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.95,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $27.90 in Billed Charges for Rev 637 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,23.44,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.90 in Billed Charges for Rev 637 = $23.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20.93,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $27.90 in Billed Charges for Rev 637 = $20.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,25.67,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $27.90 in Billed Charges for Rev 637 = $25.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,PREVEA HEALTH NETWORK,PREVEA360,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.81,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $27.90 in Billed Charges for Rev 637 = $17.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 637 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.43,,,,,,,13.5600,27.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.90 in Billed Charges for Rev 637 = $15.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,UNITED HEALTHCARE,UHC ONEIDA NATION,15.43,,,,,,,13.5600,27.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.90 in Billed Charges for Rev 637 = $15.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,UNITED HEALTHCARE,UNITED HEALTHCARE,15.43,,,,,,,13.5600,27.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.90 in Billed Charges for Rev 637 = $15.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,UNITY HEALTH PLAN,UNITY HOSPICE,27.90,,,,,,,13.5600,27.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 637 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.30,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $27.90 in Billed Charges for Rev 637 = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 637 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 637 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYANOCOBALAMIN 5000 MCG/ML LIQD,637,RC,74312-18187,CDM,,,,,,both,59.000000,ML,27.9000,18.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,AETNA,AETNA HSHS,8.29,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.83 in Billed Charges for Rev 637 = $8.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,AETNA,ALL COMMERCIAL AETNA,12.83,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.83 in Billed Charges for Rev 637 = $12.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,ANTHEM,ANTHEM POS/HMO,8.72,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.83 in Billed Charges for Rev 637 = $8.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,ANTHEM,ANTHEM PPO,8.72,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.83 in Billed Charges for Rev 637 = $8.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.83,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.83 in Billed Charges for Rev 637 = $12.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,CENPATICO,ALL MEDICAID CENPATICO,12.83,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.83 in Billed Charges for Rev 637 = $12.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.91,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.83 in Billed Charges for Rev 637 = $10.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,CIGNA,ALL COMMERCIAL CIGNA,8.98,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.83 in Billed Charges for Rev 637 = $8.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,COFINITY,COFINITY,12.83,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.83 in Billed Charges for Rev 637 = $12.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12.19,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.83 in Billed Charges for Rev 637 = $12.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,10.78,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.83 in Billed Charges for Rev 637 = $10.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9.11,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.83 in Billed Charges for Rev 637 = $9.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.37,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.83 in Billed Charges for Rev 637 = $9.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,6.24,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.83 in Billed Charges for Rev 637 = $6.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.91,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.83 in Billed Charges for Rev 637 = $10.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,HUMANA,HUMANA CHOICE CARE HMO,8.15,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.83 in Billed Charges at 63.5% = $8.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,HUMANA,HUMANA CHOICE CARE PPO,10.91,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.83 in Billed Charges for Rev 637 = $10.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,HUMANA,HUMANA NATIIONAL POS HMO,8.15,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.83 in Billed Charges at 63.5% = $8.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.37,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.83 in Billed Charges for Rev 637 = $9.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.83,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.83 in Billed Charges for Rev 637 = $12.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.83,,,,,,,6.2400,12.8300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.42,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.83 in Billed Charges for Rev 637 = $6.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.78,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.83 in Billed Charges for Rev 637 = $10.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.62,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.83 in Billed Charges for Rev 637 = $9.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.80,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.83 in Billed Charges for Rev 637 = $11.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.70,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.83 in Billed Charges for Rev 637 = $7.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.70,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.83 in Billed Charges for Rev 637 = $7.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,PREVEA HEALTH NETWORK,PREVEA360,7.70,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.83 in Billed Charges for Rev 637 = $7.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.70,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.83 in Billed Charges for Rev 637 = $7.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.19,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.83 in Billed Charges for Rev 637 = $8.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.24,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.83 in Billed Charges for Rev 637 = $9.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.10,,,,,,,6.2400,12.8300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.83 in Billed Charges for Rev 637 = $7.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,7.10,,,,,,,6.2400,12.8300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.83 in Billed Charges for Rev 637 = $7.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,7.10,,,,,,,6.2400,12.8300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.83 in Billed Charges for Rev 637 = $7.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,UNITY HEALTH PLAN,UNITY HOSPICE,12.83,,,,,,,6.2400,12.8300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.24,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.83 in Billed Charges for Rev 637 = $9.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.95,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.83 in Billed Charges for Rev 637 = $7.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.24,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.83 in Billed Charges for Rev 637 = $9.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.24,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.83 in Billed Charges for Rev 637 = $9.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,0378-0265-91,CDM,,,,,,both,1.000000,EA,12.8300,8.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.70,,,,,,,6.2400,12.8300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.83 in Billed Charges for Rev 637 = $7.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,AETNA,AETNA HSHS,1214.67,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,880.30 in Billed Charges for Rev 637 = $1,214.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,AETNA,ALL COMMERCIAL AETNA,1880.30,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,880.30 in Billed Charges for Rev 637 = $1,880.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,ANTHEM,ANTHEM POS/HMO,1278.60,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,880.30 in Billed Charges for Rev 637 = $1,278.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,ANTHEM,ANTHEM PPO,1278.60,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,880.30 in Billed Charges for Rev 637 = $1,278.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1880.30,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,880.30 in Billed Charges for Rev 637 = $1,880.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,CENPATICO,ALL MEDICAID CENPATICO,1880.30,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,880.30 in Billed Charges for Rev 637 = $1,880.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1598.26,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,880.30 in Billed Charges for Rev 637 = $1,598.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,CIGNA,ALL COMMERCIAL CIGNA,1316.21,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,880.30 in Billed Charges for Rev 637 = $1,316.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,COFINITY,COFINITY,1880.30,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,880.30 in Billed Charges for Rev 637 = $1,880.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1786.29,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,880.30 in Billed Charges for Rev 637 = $1,786.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,1579.45,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,880.30 in Billed Charges for Rev 637 = $1,579.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1335.01,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,880.30 in Billed Charges for Rev 637 = $1,335.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1372.62,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,880.30 in Billed Charges for Rev 637 = $1,372.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,913.83,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,880.30 in Billed Charges for Rev 637 = $913.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1598.26,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,880.30 in Billed Charges for Rev 637 = $1,598.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,HUMANA,HUMANA CHOICE CARE HMO,1193.99,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,880.30 in Billed Charges at 63.5% = $1,193.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,HUMANA,HUMANA CHOICE CARE PPO,1598.26,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,880.30 in Billed Charges for Rev 637 = $1,598.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,HUMANA,HUMANA NATIIONAL POS HMO,1193.99,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,880.30 in Billed Charges at 63.5% = $1,193.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1372.62,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,880.30 in Billed Charges for Rev 637 = $1,372.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1880.30,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,880.30 in Billed Charges for Rev 637 = $1,880.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1880.30,,,,,,,913.8300,1880.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,940.15,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,880.30 in Billed Charges for Rev 637 = $940.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1579.45,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,880.30 in Billed Charges for Rev 637 = $1,579.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1410.23,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,880.30 in Billed Charges for Rev 637 = $1,410.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1729.88,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,880.30 in Billed Charges for Rev 637 = $1,729.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1128.18,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,880.30 in Billed Charges for Rev 637 = $1,128.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1128.18,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,880.30 in Billed Charges for Rev 637 = $1,128.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,PREVEA HEALTH NETWORK,PREVEA360,1128.18,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,880.30 in Billed Charges for Rev 637 = $1,128.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1128.18,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,880.30 in Billed Charges for Rev 637 = $1,128.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1200.20,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,880.30 in Billed Charges for Rev 637 = $1,200.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1353.82,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,880.30 in Billed Charges for Rev 637 = $1,353.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1039.81,,,,,,,913.8300,1880.3000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,880.30 in Billed Charges for Rev 637 = $1,039.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,1039.81,,,,,,,913.8300,1880.3000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,880.30 in Billed Charges for Rev 637 = $1,039.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,1039.81,,,,,,,913.8300,1880.3000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,880.30 in Billed Charges for Rev 637 = $1,039.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,UNITY HEALTH PLAN,UNITY HOSPICE,1880.30,,,,,,,913.8300,1880.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1353.82,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,880.30 in Billed Charges for Rev 637 = $1,353.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1165.79,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,880.30 in Billed Charges for Rev 637 = $1,165.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1353.82,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,880.30 in Billed Charges for Rev 637 = $1,353.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1353.82,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,880.30 in Billed Charges for Rev 637 = $1,353.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CONJUGATED ESTROGENS 0.625 MG/GM CREA 30 G TUBE,637,RC,0046-0872-21,CDM,,,,,,both,30.000000,GR,1880.3000,1241.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1128.18,,,,,,,913.8300,1880.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,880.30 in Billed Charges for Rev 637 = $1,128.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,AETNA,AETNA HSHS,12.50,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $19.35 in Billed Charges for Rev 637 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,AETNA,ALL COMMERCIAL AETNA,19.35,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.35 in Billed Charges for Rev 637 = $19.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,ANTHEM,ANTHEM POS/HMO,13.16,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $19.35 in Billed Charges for Rev 637 = $13.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,ANTHEM,ANTHEM PPO,13.16,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $19.35 in Billed Charges for Rev 637 = $13.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,19.35,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.35 in Billed Charges for Rev 637 = $19.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,CENPATICO,ALL MEDICAID CENPATICO,19.35,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.35 in Billed Charges for Rev 637 = $19.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,16.45,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.35 in Billed Charges for Rev 637 = $16.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,CIGNA,ALL COMMERCIAL CIGNA,13.55,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $19.35 in Billed Charges for Rev 637 = $13.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,COFINITY,COFINITY,19.35,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.35 in Billed Charges for Rev 637 = $19.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,18.38,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $19.35 in Billed Charges for Rev 637 = $18.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,16.25,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.35 in Billed Charges for Rev 637 = $16.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.74,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $19.35 in Billed Charges for Rev 637 = $13.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.13,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.35 in Billed Charges for Rev 637 = $14.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,9.40,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $19.35 in Billed Charges for Rev 637 = $9.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,16.45,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.35 in Billed Charges for Rev 637 = $16.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,HUMANA,HUMANA CHOICE CARE HMO,12.29,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $19.35 in Billed Charges at 63.5% = $12.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,HUMANA,HUMANA CHOICE CARE PPO,16.45,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.35 in Billed Charges for Rev 637 = $16.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,HUMANA,HUMANA NATIIONAL POS HMO,12.29,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $19.35 in Billed Charges at 63.5% = $12.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.13,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.35 in Billed Charges for Rev 637 = $14.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,19.35,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.35 in Billed Charges for Rev 637 = $19.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,19.35,,,,,,,9.4000,19.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.68,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $19.35 in Billed Charges for Rev 637 = $9.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,16.25,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.35 in Billed Charges for Rev 637 = $16.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.51,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $19.35 in Billed Charges for Rev 637 = $14.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,17.80,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $19.35 in Billed Charges for Rev 637 = $17.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.61,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.35 in Billed Charges for Rev 637 = $11.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.61,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.35 in Billed Charges for Rev 637 = $11.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,PREVEA HEALTH NETWORK,PREVEA360,11.61,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.35 in Billed Charges for Rev 637 = $11.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.61,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.35 in Billed Charges for Rev 637 = $11.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.35,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $19.35 in Billed Charges for Rev 637 = $12.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.93,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.35 in Billed Charges for Rev 637 = $13.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.70,,,,,,,9.4000,19.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.35 in Billed Charges for Rev 637 = $10.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,UNITED HEALTHCARE,UHC ONEIDA NATION,10.70,,,,,,,9.4000,19.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.35 in Billed Charges for Rev 637 = $10.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,UNITED HEALTHCARE,UNITED HEALTHCARE,10.70,,,,,,,9.4000,19.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.35 in Billed Charges for Rev 637 = $10.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,UNITY HEALTH PLAN,UNITY HOSPICE,19.35,,,,,,,9.4000,19.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.93,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.35 in Billed Charges for Rev 637 = $13.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.00,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $19.35 in Billed Charges for Rev 637 = $12.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.93,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.35 in Billed Charges for Rev 637 = $13.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.93,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.35 in Billed Charges for Rev 637 = $13.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,67877-215-60,CDM,,,,,,both,1.000000,EA,19.3500,12.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.61,,,,,,,9.4000,19.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.35 in Billed Charges for Rev 637 = $11.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,AETNA,AETNA HSHS,9.06,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $14.03 in Billed Charges for Rev 637 = $9.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,AETNA,ALL COMMERCIAL AETNA,14.03,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.03 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,ANTHEM,ANTHEM POS/HMO,9.54,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $14.03 in Billed Charges for Rev 637 = $9.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,ANTHEM,ANTHEM PPO,9.54,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $14.03 in Billed Charges for Rev 637 = $9.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14.03,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.03 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,CENPATICO,ALL MEDICAID CENPATICO,14.03,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.03 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11.93,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.03 in Billed Charges for Rev 637 = $11.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,CIGNA,ALL COMMERCIAL CIGNA,9.82,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $14.03 in Billed Charges for Rev 637 = $9.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,COFINITY,COFINITY,14.03,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.03 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13.33,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $14.03 in Billed Charges for Rev 637 = $13.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,11.79,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.03 in Billed Charges for Rev 637 = $11.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9.96,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $14.03 in Billed Charges for Rev 637 = $9.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.24,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.03 in Billed Charges for Rev 637 = $10.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,6.82,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $14.03 in Billed Charges for Rev 637 = $6.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11.93,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.03 in Billed Charges for Rev 637 = $11.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,HUMANA,HUMANA CHOICE CARE HMO,8.91,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $14.03 in Billed Charges at 63.5% = $8.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,HUMANA,HUMANA CHOICE CARE PPO,11.93,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.03 in Billed Charges for Rev 637 = $11.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,HUMANA,HUMANA NATIIONAL POS HMO,8.91,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $14.03 in Billed Charges at 63.5% = $8.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.24,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.03 in Billed Charges for Rev 637 = $10.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,14.03,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.03 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.03,,,,,,,6.8200,14.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.02,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $14.03 in Billed Charges for Rev 637 = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11.79,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.03 in Billed Charges for Rev 637 = $11.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.52,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $14.03 in Billed Charges for Rev 637 = $10.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12.91,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $14.03 in Billed Charges for Rev 637 = $12.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.42,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.03 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.42,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.03 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,PREVEA HEALTH NETWORK,PREVEA360,8.42,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.03 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.42,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.03 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.96,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $14.03 in Billed Charges for Rev 637 = $8.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.10,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.03 in Billed Charges for Rev 637 = $10.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.76,,,,,,,6.8200,14.0300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.03 in Billed Charges for Rev 637 = $7.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,7.76,,,,,,,6.8200,14.0300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.03 in Billed Charges for Rev 637 = $7.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,7.76,,,,,,,6.8200,14.0300,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.03 in Billed Charges for Rev 637 = $7.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,UNITY HEALTH PLAN,UNITY HOSPICE,14.03,,,,,,,6.8200,14.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.10,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.03 in Billed Charges for Rev 637 = $10.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.70,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $14.03 in Billed Charges for Rev 637 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.10,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.03 in Billed Charges for Rev 637 = $10.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.10,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.03 in Billed Charges for Rev 637 = $10.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,60687-272-11,CDM,,,,,,both,1.000000,EA,14.0300,9.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.42,,,,,,,6.8200,14.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.03 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,AETNA,AETNA HSHS,489.15,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $757.20 in Billed Charges for Rev 637 = $489.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,AETNA,ALL COMMERCIAL AETNA,757.20,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $757.20 in Billed Charges for Rev 637 = $757.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,ANTHEM,ANTHEM POS/HMO,514.90,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $757.20 in Billed Charges for Rev 637 = $514.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,ANTHEM,ANTHEM PPO,514.90,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $757.20 in Billed Charges for Rev 637 = $514.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,757.20,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $757.20 in Billed Charges for Rev 637 = $757.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,CENPATICO,ALL MEDICAID CENPATICO,757.20,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $757.20 in Billed Charges for Rev 637 = $757.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,643.62,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $757.20 in Billed Charges for Rev 637 = $643.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,CIGNA,ALL COMMERCIAL CIGNA,530.04,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $757.20 in Billed Charges for Rev 637 = $530.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,COFINITY,COFINITY,757.20,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $757.20 in Billed Charges for Rev 637 = $757.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,719.34,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $757.20 in Billed Charges for Rev 637 = $719.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,636.05,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $757.20 in Billed Charges for Rev 637 = $636.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,537.61,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $757.20 in Billed Charges for Rev 637 = $537.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,552.76,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $757.20 in Billed Charges for Rev 637 = $552.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,368.00,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $757.20 in Billed Charges for Rev 637 = $368.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,643.62,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $757.20 in Billed Charges for Rev 637 = $643.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,HUMANA,HUMANA CHOICE CARE HMO,480.82,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $757.20 in Billed Charges at 63.5% = $480.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,HUMANA,HUMANA CHOICE CARE PPO,643.62,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $757.20 in Billed Charges for Rev 637 = $643.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,HUMANA,HUMANA NATIIONAL POS HMO,480.82,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $757.20 in Billed Charges at 63.5% = $480.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,552.76,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $757.20 in Billed Charges for Rev 637 = $552.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,757.20,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $757.20 in Billed Charges for Rev 637 = $757.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,757.20,,,,,,,368.0000,757.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,378.60,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $757.20 in Billed Charges for Rev 637 = $378.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,636.05,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $757.20 in Billed Charges for Rev 637 = $636.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,567.90,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $757.20 in Billed Charges for Rev 637 = $567.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,696.62,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $757.20 in Billed Charges for Rev 637 = $696.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,454.32,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $757.20 in Billed Charges for Rev 637 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,454.32,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $757.20 in Billed Charges for Rev 637 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,PREVEA HEALTH NETWORK,PREVEA360,454.32,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $757.20 in Billed Charges for Rev 637 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,454.32,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $757.20 in Billed Charges for Rev 637 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,483.32,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $757.20 in Billed Charges for Rev 637 = $483.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,545.18,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $757.20 in Billed Charges for Rev 637 = $545.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,418.73,,,,,,,368.0000,757.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $757.20 in Billed Charges for Rev 637 = $418.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,UNITED HEALTHCARE,UHC ONEIDA NATION,418.73,,,,,,,368.0000,757.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $757.20 in Billed Charges for Rev 637 = $418.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,UNITED HEALTHCARE,UNITED HEALTHCARE,418.73,,,,,,,368.0000,757.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $757.20 in Billed Charges for Rev 637 = $418.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,UNITY HEALTH PLAN,UNITY HOSPICE,757.20,,,,,,,368.0000,757.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,545.18,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $757.20 in Billed Charges for Rev 637 = $545.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,469.46,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $757.20 in Billed Charges for Rev 637 = $469.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,545.18,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $757.20 in Billed Charges for Rev 637 = $545.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,545.18,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $757.20 in Billed Charges for Rev 637 = $545.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFIXIME 100 MG/5ML SUSR,637,RC,65862-751-50,CDM,,,,,,both,50.000000,ML,757.2000,499.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,454.32,,,,,,,368.0000,757.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $757.20 in Billed Charges for Rev 637 = $454.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,AETNA,AETNA HSHS,53.64,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $53.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,AETNA,AETNA MEDICARE,3.52,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,AETNA,ALL COMMERCIAL AETNA,83.03,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $83.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,ANTHEM,ANTEHM MEDICAID,16.45,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.52,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,ANTHEM,ANTHEM POS/HMO,7.67,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 170% = $7.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,ANTHEM,ANTHEM PPO,9.47,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 210% = $9.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,83.03,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $83.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,CENPATICO,ALL MEDICAID CENPATICO,83.03,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $83.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,70.58,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $70.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,CIGNA,ALL COMMERCIAL CIGNA,58.12,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $58.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,COFINITY,COFINITY,83.03,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $83.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.45,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.45,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,78.88,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $78.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,69.75,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $69.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,58.95,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $58.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,60.61,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $60.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,40.35,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $40.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,70.58,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $70.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HUMANA,HUMANA CHOICE CARE HMO,18.60,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule 005543_170 for Rev 636 Proc J1327 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HUMANA,HUMANA CHOICE CARE PPO,70.58,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $70.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,3.52,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,HUMANA,HUMANA NATIIONAL POS HMO,18.60,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule 005543_170 for Rev 636 Proc J1327 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,60.61,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $60.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,83.03,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $83.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.45,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.52,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.45,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,17.44,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45... $16.45 at 106% = $17.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,3.52,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,41.52,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $41.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,69.75,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $69.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,7.92,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,62.27,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $62.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,76.39,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $76.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.07,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.07,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,PREVEA HEALTH NETWORK,PREVEA360,8.07,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.07,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,53.00,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.56,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,59.78,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $59.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,TRIOLOGY,TRILOGY MEDICAID,17.44,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 106% = $17.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.81,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,5.81,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.52,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,5.81,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,UNITY HEALTH PLAN,UNITY HOSPICE,3.52,,,,,,,3.5200,83.0300,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,59.78,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $59.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,51.48,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $51.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,59.78,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $59.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,59.78,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $59.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,55150-219-10,CDM,,,,both,5.000000,ME,83.0300,54.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,49.82,,,,,,,3.5200,83.0300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $83.03 in Billed Charges for Rev 636 Proc J1327 = $49.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,AETNA,AETNA HSHS,186.27,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $186.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,AETNA,AETNA MEDICARE,3.52,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,AETNA,ALL COMMERCIAL AETNA,288.35,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $288.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,ANTHEM,ANTEHM MEDICAID,16.45,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.52,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,ANTHEM,ANTHEM POS/HMO,7.67,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 170% = $7.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,ANTHEM,ANTHEM PPO,9.47,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 210% = $9.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,288.35,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $288.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,CENPATICO,ALL MEDICAID CENPATICO,288.35,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $288.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,245.10,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $245.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,CIGNA,ALL COMMERCIAL CIGNA,201.85,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $201.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,COFINITY,COFINITY,288.35,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $288.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.45,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.45,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,273.93,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $273.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HEALTH CARE ALLIANCE,THE ALLIANCE,242.21,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $242.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,204.73,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $204.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,210.50,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $210.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HSHS EMPLOYEES,HSHS EMPLOYEES,140.14,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $140.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,245.10,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $245.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HUMANA,HUMANA CHOICE CARE HMO,18.60,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule 005543_170 for Rev 636 Proc J1327 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HUMANA,HUMANA CHOICE CARE PPO,245.10,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $245.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HUMANA,HUMANA MEDICARE ADVANTAGE,3.52,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,HUMANA,HUMANA NATIIONAL POS HMO,18.60,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule 005543_170 for Rev 636 Proc J1327 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,210.50,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $210.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,LIVE360,LIVE360 HSHS HEALTHY PLAN,288.35,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $288.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.45,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.52,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.45,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,MOLINA HEALTHCARE,MOLINA MEDICAID,17.44,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45... $16.45 at 106% = $17.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,MOLINA HEALTHCARE,MOLINA MEDICARE,3.52,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,144.18,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $144.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,242.21,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $242.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,NAPHCARE,ALL COMMERICAL NAPHCARE,7.92,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,216.26,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $216.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,265.28,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $265.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.07,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.07,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,PREVEA HEALTH NETWORK,PREVEA360,8.07,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.07,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,184.05,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $184.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.56,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,207.61,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $207.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,TRIOLOGY,TRILOGY MEDICAID,17.44,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 106% = $17.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.81,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,UNITED HEALTHCARE,UHC ONEIDA NATION,5.81,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.52,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,UNITED HEALTHCARE,UNITED HEALTHCARE,5.81,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,UNITY HEALTH PLAN,UNITY HOSPICE,3.52,,,,,,,3.5200,288.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,207.61,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $207.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,178.78,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $178.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,207.61,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $207.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,207.61,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $207.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 20 MG/10ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-629-10,CDM,,,,both,5.000000,ME,288.3500,190.3100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,173.01,,,,,,,3.5200,288.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $288.35 in Billed Charges for Rev 636 Proc J1327 = $173.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,AETNA,AETNA HSHS,60.27,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $60.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,AETNA,AETNA MEDICARE,3.52,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,AETNA,ALL COMMERCIAL AETNA,93.29,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $93.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,ANTHEM,ANTEHM MEDICAID,16.45,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,3.52,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,ANTHEM,ANTHEM POS/HMO,7.67,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 170% = $7.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,ANTHEM,ANTHEM PPO,9.47,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 210% = $9.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,93.29,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $93.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,CENPATICO,ALL MEDICAID CENPATICO,93.29,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $93.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.30,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $79.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,CIGNA,ALL COMMERCIAL CIGNA,65.30,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $65.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,COFINITY,COFINITY,93.29,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $93.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,16.45,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,16.45,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,88.63,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $88.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,78.36,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $78.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.24,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $66.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,68.10,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $68.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,45.34,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $45.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.30,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $79.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HUMANA,HUMANA CHOICE CARE HMO,18.60,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule 005543_170 for Rev 636 Proc J1327 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HUMANA,HUMANA CHOICE CARE PPO,79.30,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $79.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HUMANA,HUMANA MEDICARE ADVANTAGE,3.52,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,HUMANA,HUMANA NATIIONAL POS HMO,18.60,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $18.60 from Fee Schedule 005543_170 for Rev 636 Proc J1327 * Qty 1 = $18.60 at 100% = $18.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,68.10,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $68.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,93.29,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $93.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,16.45,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3.52,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,16.45,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,MOLINA HEALTHCARE,MOLINA MEDICAID,17.44,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 100% = $16.45... $16.45 at 106% = $17.44 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,MOLINA HEALTHCARE,MOLINA MEDICARE,3.52,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.65,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $46.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.36,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $78.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,NAPHCARE,ALL COMMERICAL NAPHCARE,7.92,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,69.97,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $69.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,85.83,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $85.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.07,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.07,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,PREVEA HEALTH NETWORK,PREVEA360,8.07,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.07,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $4.51 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1327 * Qty 1 = $4.51 at 179% = $8.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,59.55,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $59.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,3.56,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,67.17,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $67.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,TRIOLOGY,TRILOGY MEDICAID,17.44,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00431 Proc J1327 at $125.60 (Base Rate) * 0.131 (Relative Weight) = $16.45 (Total Line Payment) at 106% = $17.44. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.81,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,UNITED HEALTHCARE,UHC ONEIDA NATION,5.81,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,3.52,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,UNITED HEALTHCARE,UNITED HEALTHCARE,5.81,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). $5.81 from Fee Schedule UHC_31190C for Rev 636 Proc J1327 * Qty 1 = $5.81 at 100% = $5.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,UNITY HEALTH PLAN,UNITY HOSPICE,3.52,,,,,,,3.5200,93.2900,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,67.17,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $67.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,57.84,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $57.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,67.17,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $67.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,67.17,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $67.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPTIFIBATIDE 200 MG/100ML SOLN per 5 mg,J1327,HCPCS,636,RC,67457-630-10,CDM,,,,both,5.000000,ME,93.2900,61.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.97,,,,,,,3.5200,93.2900,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.29 in Billed Charges for Rev 636 Proc J1327 = $55.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,AETNA,AETNA HSHS,160.85,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $160.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,AETNA,ALL COMMERCIAL AETNA,249.00,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $249.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,ANTHEM,ANTHEM POS/HMO,15.57,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 170% = $15.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,ANTHEM,ANTHEM PPO,19.24,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 210% = $19.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,249.00,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $249.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,CENPATICO,ALL MEDICAID CENPATICO,249.00,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $249.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,211.65,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $211.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,CIGNA,ALL COMMERCIAL CIGNA,174.30,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $174.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,COFINITY,COFINITY,249.00,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $249.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,236.55,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $236.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,209.16,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $209.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,176.79,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $176.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,181.77,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $181.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,121.01,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $121.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,211.65,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $211.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,HUMANA,HUMANA CHOICE CARE HMO,18.26,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.26 from Fee Schedule 005543_170 for Rev 636 Proc J1335 * Qty 1 = $18.26 at 100% = $18.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,HUMANA,HUMANA CHOICE CARE PPO,211.65,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $211.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,HUMANA,HUMANA NATIIONAL POS HMO,18.26,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $18.26 from Fee Schedule 005543_170 for Rev 636 Proc J1335 * Qty 1 = $18.26 at 100% = $18.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,181.77,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $181.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,249.00,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $249.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,124.50,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $124.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,209.16,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $209.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,186.75,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $186.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,229.08,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $229.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.40,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.40,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,PREVEA HEALTH NETWORK,PREVEA360,16.40,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.40,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,158.94,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $158.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,179.28,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $179.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.11,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,15.11,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,15.11,,,,,,,15.1100,249.0000,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,179.28,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $179.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,154.38,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $154.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,179.28,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $179.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,179.28,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $179.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM 1 G SOLR 1 EACH VIAL per 500 mg,J1335,HCPCS,636,RC,43598-901-11,CDM,,,,both,500.000000,ME,249.0000,164.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,149.40,,,,,,,15.1100,249.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $249.00 in Billed Charges for Rev 636 Proc J1335 = $149.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,AETNA,AETNA HSHS,223.28,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $223.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,AETNA,ALL COMMERCIAL AETNA,345.63,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $345.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,ANTHEM,ANTHEM POS/HMO,15.57,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 170% = $15.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,ANTHEM,ANTHEM PPO,19.24,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 210% = $19.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,345.63,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $345.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,CENPATICO,ALL MEDICAID CENPATICO,345.63,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $345.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,293.79,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $293.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,CIGNA,ALL COMMERCIAL CIGNA,241.94,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $241.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,COFINITY,COFINITY,345.63,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $345.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,328.35,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $328.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,290.33,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $290.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,245.40,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $245.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,252.31,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $252.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,167.98,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $167.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,293.79,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $293.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,HUMANA,HUMANA CHOICE CARE HMO,18.26,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $18.26 from Fee Schedule 005543_170 for Rev 636 Proc J1335 * Qty 1 = $18.26 at 100% = $18.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,HUMANA,HUMANA CHOICE CARE PPO,293.79,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $293.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,HUMANA,HUMANA NATIIONAL POS HMO,18.26,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $18.26 from Fee Schedule 005543_170 for Rev 636 Proc J1335 * Qty 1 = $18.26 at 100% = $18.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,252.31,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $252.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,345.63,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $345.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,172.82,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $172.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,290.33,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $290.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,259.22,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $259.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,317.98,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $317.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.40,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.40,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,PREVEA HEALTH NETWORK,PREVEA360,16.40,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.40,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $9.16 from Fee Schedule MEDCR_ASP for Rev 636 Proc J1335 * Qty 1 = $9.16 at 179% = $16.40 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,220.62,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $220.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,248.85,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $248.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.11,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,15.11,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,15.11,,,,,,,15.1100,345.6300,fee schedule,ST VINCENT HOSPITAL (ACU). $15.11 from Fee Schedule UHC_31190C for Rev 636 Proc J1335 * Qty 1 = $15.11 at 100% = $15.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,248.85,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $248.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,214.29,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $214.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,248.85,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $248.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,248.85,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $248.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ERTAPENEM INJECTION,J1335,HCPCS,636,RC,44567-820-01,CDM,,,,both,500.000000,ME,345.6300,228.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,207.38,,,,,,,15.1100,345.6300,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $345.63 in Billed Charges for Rev 636 Proc J1335 = $207.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 637 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.00 in Billed Charges for Rev 637 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.00 in Billed Charges for Rev 637 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 637 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 637 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 637 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 637 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 637 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 637 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.00,,,,,,,3.8900,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 637 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 637 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 637 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 637 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,UNITY HEALTH PLAN,UNITY HOSPICE,8.00,,,,,,,3.8900,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 637 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROXYZINE 25 MG CAPS,637,RC,68084-847-11,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,AETNA,AETNA HSHS,8.79,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $13.60 in Billed Charges for Rev 637 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,AETNA,ALL COMMERCIAL AETNA,13.60,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.60 in Billed Charges for Rev 637 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,ANTHEM,ANTHEM POS/HMO,9.25,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $13.60 in Billed Charges for Rev 637 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,ANTHEM,ANTHEM PPO,9.25,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $13.60 in Billed Charges for Rev 637 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13.60,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.60 in Billed Charges for Rev 637 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,CENPATICO,ALL MEDICAID CENPATICO,13.60,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.60 in Billed Charges for Rev 637 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11.56,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.60 in Billed Charges for Rev 637 = $11.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,CIGNA,ALL COMMERCIAL CIGNA,9.52,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $13.60 in Billed Charges for Rev 637 = $9.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,COFINITY,COFINITY,13.60,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.60 in Billed Charges for Rev 637 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12.92,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $13.60 in Billed Charges for Rev 637 = $12.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,11.42,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.60 in Billed Charges for Rev 637 = $11.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9.66,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $13.60 in Billed Charges for Rev 637 = $9.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.93,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.60 in Billed Charges for Rev 637 = $9.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,6.61,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $13.60 in Billed Charges for Rev 637 = $6.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11.56,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.60 in Billed Charges for Rev 637 = $11.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,HUMANA,HUMANA CHOICE CARE HMO,8.64,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $13.60 in Billed Charges at 63.5% = $8.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,HUMANA,HUMANA CHOICE CARE PPO,11.56,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.60 in Billed Charges for Rev 637 = $11.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,HUMANA,HUMANA NATIIONAL POS HMO,8.64,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $13.60 in Billed Charges at 63.5% = $8.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.93,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.60 in Billed Charges for Rev 637 = $9.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,13.60,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.60 in Billed Charges for Rev 637 = $13.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.60,,,,,,,6.6100,13.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.80,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $13.60 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11.42,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.60 in Billed Charges for Rev 637 = $11.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.20,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $13.60 in Billed Charges for Rev 637 = $10.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12.51,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $13.60 in Billed Charges for Rev 637 = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.16,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.60 in Billed Charges for Rev 637 = $8.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.16,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.60 in Billed Charges for Rev 637 = $8.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,PREVEA HEALTH NETWORK,PREVEA360,8.16,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.60 in Billed Charges for Rev 637 = $8.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.16,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.60 in Billed Charges for Rev 637 = $8.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.68,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $13.60 in Billed Charges for Rev 637 = $8.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.79,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.60 in Billed Charges for Rev 637 = $9.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.52,,,,,,,6.6100,13.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.60 in Billed Charges for Rev 637 = $7.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,UNITED HEALTHCARE,UHC ONEIDA NATION,7.52,,,,,,,6.6100,13.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.60 in Billed Charges for Rev 637 = $7.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,UNITED HEALTHCARE,UNITED HEALTHCARE,7.52,,,,,,,6.6100,13.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.60 in Billed Charges for Rev 637 = $7.52 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,UNITY HEALTH PLAN,UNITY HOSPICE,13.60,,,,,,,6.6100,13.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.79,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.60 in Billed Charges for Rev 637 = $9.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.43,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $13.60 in Billed Charges for Rev 637 = $8.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.79,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.60 in Billed Charges for Rev 637 = $9.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.79,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.60 in Billed Charges for Rev 637 = $9.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % CREA 30 G TUBE,637,RC,68001-476-46,CDM,,,,,,both,30.000000,GR,13.6000,8.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.16,,,,,,,6.6100,13.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.60 in Billed Charges for Rev 637 = $8.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,AETNA,AETNA HSHS,19.06,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $29.50 in Billed Charges for Rev 637 = $19.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,AETNA,ALL COMMERCIAL AETNA,29.50,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.50 in Billed Charges for Rev 637 = $29.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,ANTHEM,ANTHEM POS/HMO,20.06,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $29.50 in Billed Charges for Rev 637 = $20.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,ANTHEM,ANTHEM PPO,20.06,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $29.50 in Billed Charges for Rev 637 = $20.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,29.50,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.50 in Billed Charges for Rev 637 = $29.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,CENPATICO,ALL MEDICAID CENPATICO,29.50,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.50 in Billed Charges for Rev 637 = $29.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,25.08,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.50 in Billed Charges for Rev 637 = $25.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,CIGNA,ALL COMMERCIAL CIGNA,20.65,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $29.50 in Billed Charges for Rev 637 = $20.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,COFINITY,COFINITY,29.50,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.50 in Billed Charges for Rev 637 = $29.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,28.03,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $29.50 in Billed Charges for Rev 637 = $28.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,24.78,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $29.50 in Billed Charges for Rev 637 = $24.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,20.95,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $29.50 in Billed Charges for Rev 637 = $20.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,21.54,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $29.50 in Billed Charges for Rev 637 = $21.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,14.34,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $29.50 in Billed Charges for Rev 637 = $14.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,25.08,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.50 in Billed Charges for Rev 637 = $25.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,HUMANA,HUMANA CHOICE CARE HMO,18.73,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $29.50 in Billed Charges at 63.5% = $18.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,HUMANA,HUMANA CHOICE CARE PPO,25.08,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $29.50 in Billed Charges for Rev 637 = $25.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,HUMANA,HUMANA NATIIONAL POS HMO,18.73,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $29.50 in Billed Charges at 63.5% = $18.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,21.54,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $29.50 in Billed Charges for Rev 637 = $21.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,29.50,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $29.50 in Billed Charges for Rev 637 = $29.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,29.50,,,,,,,14.3400,29.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,14.75,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $29.50 in Billed Charges for Rev 637 = $14.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,24.78,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $29.50 in Billed Charges for Rev 637 = $24.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,22.13,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $29.50 in Billed Charges for Rev 637 = $22.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,27.14,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $29.50 in Billed Charges for Rev 637 = $27.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.70,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.50 in Billed Charges for Rev 637 = $17.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.70,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.50 in Billed Charges for Rev 637 = $17.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,PREVEA HEALTH NETWORK,PREVEA360,17.70,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.50 in Billed Charges for Rev 637 = $17.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.70,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.50 in Billed Charges for Rev 637 = $17.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,18.83,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $29.50 in Billed Charges for Rev 637 = $18.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,21.24,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.50 in Billed Charges for Rev 637 = $21.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,16.31,,,,,,,14.3400,29.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $29.50 in Billed Charges for Rev 637 = $16.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,16.31,,,,,,,14.3400,29.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $29.50 in Billed Charges for Rev 637 = $16.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,16.31,,,,,,,14.3400,29.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $29.50 in Billed Charges for Rev 637 = $16.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,UNITY HEALTH PLAN,UNITY HOSPICE,29.50,,,,,,,14.3400,29.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,21.24,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.50 in Billed Charges for Rev 637 = $21.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,18.29,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $29.50 in Billed Charges for Rev 637 = $18.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,21.24,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.50 in Billed Charges for Rev 637 = $21.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,21.24,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $29.50 in Billed Charges for Rev 637 = $21.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 1 % LOTN 114 G BOTTLE,637,RC,0394-0859-32,CDM,,,,,,both,114.000000,GR,29.5000,19.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,17.70,,,,,,,14.3400,29.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $29.50 in Billed Charges for Rev 637 = $17.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,AETNA,AETNA HSHS,56.56,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $87.55 in Billed Charges for Rev 637 = $56.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,AETNA,ALL COMMERCIAL AETNA,87.55,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.55 in Billed Charges for Rev 637 = $87.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,ANTHEM,ANTHEM POS/HMO,59.53,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $87.55 in Billed Charges for Rev 637 = $59.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,ANTHEM,ANTHEM PPO,59.53,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $87.55 in Billed Charges for Rev 637 = $59.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,87.55,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.55 in Billed Charges for Rev 637 = $87.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,CENPATICO,ALL MEDICAID CENPATICO,87.55,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.55 in Billed Charges for Rev 637 = $87.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,74.42,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $87.55 in Billed Charges for Rev 637 = $74.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,CIGNA,ALL COMMERCIAL CIGNA,61.29,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $87.55 in Billed Charges for Rev 637 = $61.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,COFINITY,COFINITY,87.55,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.55 in Billed Charges for Rev 637 = $87.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,83.17,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $87.55 in Billed Charges for Rev 637 = $83.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,HEALTH CARE ALLIANCE,THE ALLIANCE,73.54,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $87.55 in Billed Charges for Rev 637 = $73.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,62.16,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $87.55 in Billed Charges for Rev 637 = $62.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,63.91,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $87.55 in Billed Charges for Rev 637 = $63.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,HSHS EMPLOYEES,HSHS EMPLOYEES,42.55,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $87.55 in Billed Charges for Rev 637 = $42.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,74.42,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $87.55 in Billed Charges for Rev 637 = $74.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,HUMANA,HUMANA CHOICE CARE HMO,55.59,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $87.55 in Billed Charges at 63.5% = $55.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,HUMANA,HUMANA CHOICE CARE PPO,74.42,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $87.55 in Billed Charges for Rev 637 = $74.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,HUMANA,HUMANA NATIIONAL POS HMO,55.59,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $87.55 in Billed Charges at 63.5% = $55.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,63.91,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $87.55 in Billed Charges for Rev 637 = $63.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,LIVE360,LIVE360 HSHS HEALTHY PLAN,87.55,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.55 in Billed Charges for Rev 637 = $87.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,87.55,,,,,,,42.5500,87.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,43.78,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $87.55 in Billed Charges for Rev 637 = $43.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,73.54,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $87.55 in Billed Charges for Rev 637 = $73.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,65.66,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $87.55 in Billed Charges for Rev 637 = $65.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,80.55,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $87.55 in Billed Charges for Rev 637 = $80.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,52.53,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.55 in Billed Charges for Rev 637 = $52.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,52.53,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.55 in Billed Charges for Rev 637 = $52.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,PREVEA HEALTH NETWORK,PREVEA360,52.53,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.55 in Billed Charges for Rev 637 = $52.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,52.53,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.55 in Billed Charges for Rev 637 = $52.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,55.88,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $87.55 in Billed Charges for Rev 637 = $55.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,63.04,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $87.55 in Billed Charges for Rev 637 = $63.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,48.42,,,,,,,42.5500,87.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $87.55 in Billed Charges for Rev 637 = $48.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,UNITED HEALTHCARE,UHC ONEIDA NATION,48.42,,,,,,,42.5500,87.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $87.55 in Billed Charges for Rev 637 = $48.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,UNITED HEALTHCARE,UNITED HEALTHCARE,48.42,,,,,,,42.5500,87.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $87.55 in Billed Charges for Rev 637 = $48.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,UNITY HEALTH PLAN,UNITY HOSPICE,87.55,,,,,,,42.5500,87.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,63.04,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $87.55 in Billed Charges for Rev 637 = $63.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,54.28,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $87.55 in Billed Charges for Rev 637 = $54.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,63.04,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $87.55 in Billed Charges for Rev 637 = $63.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,63.04,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $87.55 in Billed Charges for Rev 637 = $63.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HYDROCORTISONE 100 MG/60ML ENEM,637,RC,62559-138-11,CDM,,,,,,both,60.000000,ML,87.5500,57.7800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,52.53,,,,,,,42.5500,87.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.55 in Billed Charges for Rev 637 = $52.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,AETNA,AETNA HSHS,204.14,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $316.00 in Billed Charges for Rev 637 = $204.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,AETNA,ALL COMMERCIAL AETNA,316.00,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $316.00 in Billed Charges for Rev 637 = $316.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,ANTHEM,ANTHEM POS/HMO,214.88,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $316.00 in Billed Charges for Rev 637 = $214.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,ANTHEM,ANTHEM PPO,214.88,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $316.00 in Billed Charges for Rev 637 = $214.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,316.00,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $316.00 in Billed Charges for Rev 637 = $316.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,CENPATICO,ALL MEDICAID CENPATICO,316.00,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $316.00 in Billed Charges for Rev 637 = $316.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,268.60,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $316.00 in Billed Charges for Rev 637 = $268.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,CIGNA,ALL COMMERCIAL CIGNA,221.20,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $316.00 in Billed Charges for Rev 637 = $221.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,COFINITY,COFINITY,316.00,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $316.00 in Billed Charges for Rev 637 = $316.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,300.20,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $316.00 in Billed Charges for Rev 637 = $300.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,265.44,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $316.00 in Billed Charges for Rev 637 = $265.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,224.36,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $316.00 in Billed Charges for Rev 637 = $224.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,230.68,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $316.00 in Billed Charges for Rev 637 = $230.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,153.58,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $316.00 in Billed Charges for Rev 637 = $153.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,268.60,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $316.00 in Billed Charges for Rev 637 = $268.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,HUMANA,HUMANA CHOICE CARE HMO,200.66,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $316.00 in Billed Charges at 63.5% = $200.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,HUMANA,HUMANA CHOICE CARE PPO,268.60,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $316.00 in Billed Charges for Rev 637 = $268.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,HUMANA,HUMANA NATIIONAL POS HMO,200.66,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $316.00 in Billed Charges at 63.5% = $200.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,230.68,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $316.00 in Billed Charges for Rev 637 = $230.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,316.00,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $316.00 in Billed Charges for Rev 637 = $316.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,316.00,,,,,,,153.5800,316.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,158.00,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $316.00 in Billed Charges for Rev 637 = $158.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,265.44,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $316.00 in Billed Charges for Rev 637 = $265.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,237.00,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $316.00 in Billed Charges for Rev 637 = $237.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,290.72,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $316.00 in Billed Charges for Rev 637 = $290.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,189.60,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $316.00 in Billed Charges for Rev 637 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,189.60,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $316.00 in Billed Charges for Rev 637 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,PREVEA HEALTH NETWORK,PREVEA360,189.60,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $316.00 in Billed Charges for Rev 637 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,189.60,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $316.00 in Billed Charges for Rev 637 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,201.70,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $316.00 in Billed Charges for Rev 637 = $201.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,227.52,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $316.00 in Billed Charges for Rev 637 = $227.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,174.75,,,,,,,153.5800,316.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $316.00 in Billed Charges for Rev 637 = $174.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,174.75,,,,,,,153.5800,316.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $316.00 in Billed Charges for Rev 637 = $174.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,174.75,,,,,,,153.5800,316.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $316.00 in Billed Charges for Rev 637 = $174.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,UNITY HEALTH PLAN,UNITY HOSPICE,316.00,,,,,,,153.5800,316.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,227.52,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $316.00 in Billed Charges for Rev 637 = $227.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,195.92,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $316.00 in Billed Charges for Rev 637 = $195.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,227.52,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $316.00 in Billed Charges for Rev 637 = $227.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,227.52,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $316.00 in Billed Charges for Rev 637 = $227.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOROMETHOLONE 0.1 % SUSP 5 ML BOTTLE,637,RC,60758-880-05,CDM,,,,,,both,5.000000,ML,316.0000,208.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,189.60,,,,,,,153.5800,316.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $316.00 in Billed Charges for Rev 637 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,AETNA,AETNA HSHS,108.46,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $167.90 in Billed Charges for Rev 637 = $108.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,AETNA,ALL COMMERCIAL AETNA,167.90,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.90 in Billed Charges for Rev 637 = $167.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,ANTHEM,ANTHEM POS/HMO,114.17,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $167.90 in Billed Charges for Rev 637 = $114.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,ANTHEM,ANTHEM PPO,114.17,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $167.90 in Billed Charges for Rev 637 = $114.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,167.90,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.90 in Billed Charges for Rev 637 = $167.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,CENPATICO,ALL MEDICAID CENPATICO,167.90,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.90 in Billed Charges for Rev 637 = $167.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,142.72,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $167.90 in Billed Charges for Rev 637 = $142.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,CIGNA,ALL COMMERCIAL CIGNA,117.53,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $167.90 in Billed Charges for Rev 637 = $117.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,COFINITY,COFINITY,167.90,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.90 in Billed Charges for Rev 637 = $167.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,159.51,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $167.90 in Billed Charges for Rev 637 = $159.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,141.04,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $167.90 in Billed Charges for Rev 637 = $141.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,119.21,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $167.90 in Billed Charges for Rev 637 = $119.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,122.57,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $167.90 in Billed Charges for Rev 637 = $122.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,81.60,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $167.90 in Billed Charges for Rev 637 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,142.72,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $167.90 in Billed Charges for Rev 637 = $142.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,HUMANA,HUMANA CHOICE CARE HMO,106.62,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $167.90 in Billed Charges at 63.5% = $106.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,HUMANA,HUMANA CHOICE CARE PPO,142.72,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $167.90 in Billed Charges for Rev 637 = $142.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,HUMANA,HUMANA NATIIONAL POS HMO,106.62,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $167.90 in Billed Charges at 63.5% = $106.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,122.57,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $167.90 in Billed Charges for Rev 637 = $122.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,167.90,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $167.90 in Billed Charges for Rev 637 = $167.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,167.90,,,,,,,81.6000,167.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,83.95,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $167.90 in Billed Charges for Rev 637 = $83.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,141.04,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $167.90 in Billed Charges for Rev 637 = $141.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,125.93,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $167.90 in Billed Charges for Rev 637 = $125.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,154.47,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $167.90 in Billed Charges for Rev 637 = $154.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,100.74,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $167.90 in Billed Charges for Rev 637 = $100.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,100.74,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $167.90 in Billed Charges for Rev 637 = $100.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,PREVEA HEALTH NETWORK,PREVEA360,100.74,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $167.90 in Billed Charges for Rev 637 = $100.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,100.74,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $167.90 in Billed Charges for Rev 637 = $100.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,107.17,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $167.90 in Billed Charges for Rev 637 = $107.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,120.89,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $167.90 in Billed Charges for Rev 637 = $120.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,92.85,,,,,,,81.6000,167.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $167.90 in Billed Charges for Rev 637 = $92.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,UNITED HEALTHCARE,UHC ONEIDA NATION,92.85,,,,,,,81.6000,167.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $167.90 in Billed Charges for Rev 637 = $92.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,UNITED HEALTHCARE,UNITED HEALTHCARE,92.85,,,,,,,81.6000,167.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $167.90 in Billed Charges for Rev 637 = $92.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,UNITY HEALTH PLAN,UNITY HOSPICE,167.90,,,,,,,81.6000,167.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,120.89,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $167.90 in Billed Charges for Rev 637 = $120.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,104.10,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $167.90 in Billed Charges for Rev 637 = $104.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,120.89,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $167.90 in Billed Charges for Rev 637 = $120.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,120.89,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $167.90 in Billed Charges for Rev 637 = $120.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GENTAMICIN 0.1 % CREA 15 G TUBE,637,RC,0713-0683-15,CDM,,,,,,both,15.000000,GR,167.9000,110.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,100.74,,,,,,,81.6000,167.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $167.90 in Billed Charges for Rev 637 = $100.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,AETNA,AETNA HSHS,9.46,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $14.65 in Billed Charges for Rev 637 = $9.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,AETNA,ALL COMMERCIAL AETNA,14.65,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 637 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,ANTHEM,ANTHEM POS/HMO,9.96,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $14.65 in Billed Charges for Rev 637 = $9.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,ANTHEM,ANTHEM PPO,9.96,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $14.65 in Billed Charges for Rev 637 = $9.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14.65,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 637 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,CENPATICO,ALL MEDICAID CENPATICO,14.65,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 637 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.45,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.65 in Billed Charges for Rev 637 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,CIGNA,ALL COMMERCIAL CIGNA,10.26,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $14.65 in Billed Charges for Rev 637 = $10.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,COFINITY,COFINITY,14.65,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 637 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13.92,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $14.65 in Billed Charges for Rev 637 = $13.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,12.31,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.65 in Billed Charges for Rev 637 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.40,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $14.65 in Billed Charges for Rev 637 = $10.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.69,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.65 in Billed Charges for Rev 637 = $10.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,7.12,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $14.65 in Billed Charges for Rev 637 = $7.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.45,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.65 in Billed Charges for Rev 637 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,HUMANA,HUMANA CHOICE CARE HMO,9.30,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $14.65 in Billed Charges at 63.5% = $9.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,HUMANA,HUMANA CHOICE CARE PPO,12.45,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.65 in Billed Charges for Rev 637 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,HUMANA,HUMANA NATIIONAL POS HMO,9.30,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $14.65 in Billed Charges at 63.5% = $9.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.69,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.65 in Billed Charges for Rev 637 = $10.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,14.65,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.65 in Billed Charges for Rev 637 = $14.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.65,,,,,,,7.1200,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.33,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $14.65 in Billed Charges for Rev 637 = $7.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.31,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.65 in Billed Charges for Rev 637 = $12.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.99,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $14.65 in Billed Charges for Rev 637 = $10.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.48,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $14.65 in Billed Charges for Rev 637 = $13.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.79,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.65 in Billed Charges for Rev 637 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.79,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.65 in Billed Charges for Rev 637 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,PREVEA HEALTH NETWORK,PREVEA360,8.79,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.65 in Billed Charges for Rev 637 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.79,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.65 in Billed Charges for Rev 637 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.35,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $14.65 in Billed Charges for Rev 637 = $9.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.55,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.65 in Billed Charges for Rev 637 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.10,,,,,,,7.1200,14.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.65 in Billed Charges for Rev 637 = $8.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,UNITED HEALTHCARE,UHC ONEIDA NATION,8.10,,,,,,,7.1200,14.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.65 in Billed Charges for Rev 637 = $8.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,UNITED HEALTHCARE,UNITED HEALTHCARE,8.10,,,,,,,7.1200,14.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.65 in Billed Charges for Rev 637 = $8.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,UNITY HEALTH PLAN,UNITY HOSPICE,14.65,,,,,,,7.1200,14.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.55,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.65 in Billed Charges for Rev 637 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.08,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $14.65 in Billed Charges for Rev 637 = $9.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.55,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.65 in Billed Charges for Rev 637 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.55,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.65 in Billed Charges for Rev 637 = $10.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUAIFENESIN-CODEINE 100-10 MG/5ML SOLN,637,RC,0121-1775-05,CDM,,,,,,both,5.000000,ML,14.6500,9.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.79,,,,,,,7.1200,14.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.65 in Billed Charges for Rev 637 = $8.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,AETNA,AETNA HSHS,7.30,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $11.30 in Billed Charges for Rev 637 = $7.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,AETNA,ALL COMMERCIAL AETNA,11.30,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.30 in Billed Charges for Rev 637 = $11.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,ANTHEM,ANTHEM POS/HMO,7.68,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.30 in Billed Charges for Rev 637 = $7.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,ANTHEM,ANTHEM PPO,7.68,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.30 in Billed Charges for Rev 637 = $7.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11.30,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.30 in Billed Charges for Rev 637 = $11.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,CENPATICO,ALL MEDICAID CENPATICO,11.30,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.30 in Billed Charges for Rev 637 = $11.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.61,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.30 in Billed Charges for Rev 637 = $9.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,CIGNA,ALL COMMERCIAL CIGNA,7.91,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $11.30 in Billed Charges for Rev 637 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,COFINITY,COFINITY,11.30,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.30 in Billed Charges for Rev 637 = $11.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.74,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $11.30 in Billed Charges for Rev 637 = $10.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,9.49,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.30 in Billed Charges for Rev 637 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.02,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $11.30 in Billed Charges for Rev 637 = $8.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.25,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.30 in Billed Charges for Rev 637 = $8.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,5.49,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $11.30 in Billed Charges for Rev 637 = $5.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.61,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.30 in Billed Charges for Rev 637 = $9.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,HUMANA,HUMANA CHOICE CARE HMO,7.18,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.30 in Billed Charges at 63.5% = $7.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,HUMANA,HUMANA CHOICE CARE PPO,9.61,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.30 in Billed Charges for Rev 637 = $9.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,HUMANA,HUMANA NATIIONAL POS HMO,7.18,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.30 in Billed Charges at 63.5% = $7.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.25,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.30 in Billed Charges for Rev 637 = $8.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,11.30,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.30 in Billed Charges for Rev 637 = $11.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.30,,,,,,,5.4900,11.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.65,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $11.30 in Billed Charges for Rev 637 = $5.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.49,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.30 in Billed Charges for Rev 637 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.48,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $11.30 in Billed Charges for Rev 637 = $8.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.40,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $11.30 in Billed Charges for Rev 637 = $10.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.78,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.30 in Billed Charges for Rev 637 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.78,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.30 in Billed Charges for Rev 637 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,PREVEA HEALTH NETWORK,PREVEA360,6.78,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.30 in Billed Charges for Rev 637 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.78,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.30 in Billed Charges for Rev 637 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.21,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $11.30 in Billed Charges for Rev 637 = $7.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.14,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.30 in Billed Charges for Rev 637 = $8.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.25,,,,,,,5.4900,11.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.30 in Billed Charges for Rev 637 = $6.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,6.25,,,,,,,5.4900,11.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.30 in Billed Charges for Rev 637 = $6.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,6.25,,,,,,,5.4900,11.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.30 in Billed Charges for Rev 637 = $6.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,UNITY HEALTH PLAN,UNITY HOSPICE,11.30,,,,,,,5.4900,11.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.14,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.30 in Billed Charges for Rev 637 = $8.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.01,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $11.30 in Billed Charges for Rev 637 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.14,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.30 in Billed Charges for Rev 637 = $8.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.14,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.30 in Billed Charges for Rev 637 = $8.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE 1 MG TABS,637,RC,60687-710-11,CDM,,,,,,both,1.000000,EA,11.3000,7.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.78,,,,,,,5.4900,11.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.30 in Billed Charges for Rev 637 = $6.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,AETNA,AETNA HSHS,23.05,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $35.68 in Billed Charges for Rev 637 = $23.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,AETNA,ALL COMMERCIAL AETNA,35.68,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.68 in Billed Charges for Rev 637 = $35.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,ANTHEM,ANTHEM POS/HMO,24.26,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $35.68 in Billed Charges for Rev 637 = $24.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,ANTHEM,ANTHEM PPO,24.26,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $35.68 in Billed Charges for Rev 637 = $24.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,35.68,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.68 in Billed Charges for Rev 637 = $35.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,CENPATICO,ALL MEDICAID CENPATICO,35.68,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.68 in Billed Charges for Rev 637 = $35.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,30.33,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.68 in Billed Charges for Rev 637 = $30.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,CIGNA,ALL COMMERCIAL CIGNA,24.98,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $35.68 in Billed Charges for Rev 637 = $24.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,COFINITY,COFINITY,35.68,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.68 in Billed Charges for Rev 637 = $35.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,33.90,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $35.68 in Billed Charges for Rev 637 = $33.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,29.97,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.68 in Billed Charges for Rev 637 = $29.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,25.33,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $35.68 in Billed Charges for Rev 637 = $25.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,26.05,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.68 in Billed Charges for Rev 637 = $26.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,17.34,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $35.68 in Billed Charges for Rev 637 = $17.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,30.33,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.68 in Billed Charges for Rev 637 = $30.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,HUMANA,HUMANA CHOICE CARE HMO,22.66,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $35.68 in Billed Charges at 63.5% = $22.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,HUMANA,HUMANA CHOICE CARE PPO,30.33,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.68 in Billed Charges for Rev 637 = $30.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,HUMANA,HUMANA NATIIONAL POS HMO,22.66,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $35.68 in Billed Charges at 63.5% = $22.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,26.05,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.68 in Billed Charges for Rev 637 = $26.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,35.68,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.68 in Billed Charges for Rev 637 = $35.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.68,,,,,,,17.3400,35.6800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,17.84,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $35.68 in Billed Charges for Rev 637 = $17.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,29.97,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.68 in Billed Charges for Rev 637 = $29.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,26.76,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $35.68 in Billed Charges for Rev 637 = $26.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,32.83,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $35.68 in Billed Charges for Rev 637 = $32.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.41,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.68 in Billed Charges for Rev 637 = $21.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.41,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.68 in Billed Charges for Rev 637 = $21.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,PREVEA HEALTH NETWORK,PREVEA360,21.41,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.68 in Billed Charges for Rev 637 = $21.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.41,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.68 in Billed Charges for Rev 637 = $21.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,22.77,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $35.68 in Billed Charges for Rev 637 = $22.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,25.69,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.68 in Billed Charges for Rev 637 = $25.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.73,,,,,,,17.3400,35.6800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.68 in Billed Charges for Rev 637 = $19.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,UNITED HEALTHCARE,UHC ONEIDA NATION,19.73,,,,,,,17.3400,35.6800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.68 in Billed Charges for Rev 637 = $19.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,UNITED HEALTHCARE,UNITED HEALTHCARE,19.73,,,,,,,17.3400,35.6800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.68 in Billed Charges for Rev 637 = $19.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,UNITY HEALTH PLAN,UNITY HOSPICE,35.68,,,,,,,17.3400,35.6800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,25.69,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.68 in Billed Charges for Rev 637 = $25.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,22.12,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $35.68 in Billed Charges for Rev 637 = $22.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,25.69,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.68 in Billed Charges for Rev 637 = $25.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,25.69,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.68 in Billed Charges for Rev 637 = $25.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GUANFACINE ER 1 MG TB24,637,RC,0228-2850-11,CDM,,,,,,both,1.000000,EA,35.6800,23.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,21.41,,,,,,,17.3400,35.6800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.68 in Billed Charges for Rev 637 = $21.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,AETNA,AETNA HSHS,1184.34,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,833.35 in Billed Charges for Rev 637 = $1,184.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,AETNA,ALL COMMERCIAL AETNA,1833.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,833.35 in Billed Charges for Rev 637 = $1,833.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,ANTHEM,ANTHEM POS/HMO,1246.68,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,833.35 in Billed Charges for Rev 637 = $1,246.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,ANTHEM,ANTHEM PPO,1246.68,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,833.35 in Billed Charges for Rev 637 = $1,246.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1833.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,833.35 in Billed Charges for Rev 637 = $1,833.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,CENPATICO,ALL MEDICAID CENPATICO,1833.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,833.35 in Billed Charges for Rev 637 = $1,833.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1558.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,833.35 in Billed Charges for Rev 637 = $1,558.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,CIGNA,ALL COMMERCIAL CIGNA,1283.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,833.35 in Billed Charges for Rev 637 = $1,283.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,COFINITY,COFINITY,1833.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,833.35 in Billed Charges for Rev 637 = $1,833.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1741.68,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,833.35 in Billed Charges for Rev 637 = $1,741.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,1540.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,833.35 in Billed Charges for Rev 637 = $1,540.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1301.68,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,833.35 in Billed Charges for Rev 637 = $1,301.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1338.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,833.35 in Billed Charges for Rev 637 = $1,338.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,891.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,833.35 in Billed Charges for Rev 637 = $891.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1558.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,833.35 in Billed Charges for Rev 637 = $1,558.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,HUMANA,HUMANA CHOICE CARE HMO,1164.18,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,833.35 in Billed Charges at 63.5% = $1,164.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,HUMANA,HUMANA CHOICE CARE PPO,1558.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,833.35 in Billed Charges for Rev 637 = $1,558.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,HUMANA,HUMANA NATIIONAL POS HMO,1164.18,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,833.35 in Billed Charges at 63.5% = $1,164.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1338.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,833.35 in Billed Charges for Rev 637 = $1,338.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,1833.35,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,833.35 in Billed Charges for Rev 637 = $1,833.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1833.35,,,,,,,891.0100,1833.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,916.68,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,833.35 in Billed Charges for Rev 637 = $916.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1540.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,833.35 in Billed Charges for Rev 637 = $1,540.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1375.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,833.35 in Billed Charges for Rev 637 = $1,375.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1686.68,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,833.35 in Billed Charges for Rev 637 = $1,686.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1100.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,833.35 in Billed Charges for Rev 637 = $1,100.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1100.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,833.35 in Billed Charges for Rev 637 = $1,100.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,PREVEA HEALTH NETWORK,PREVEA360,1100.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,833.35 in Billed Charges for Rev 637 = $1,100.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1100.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,833.35 in Billed Charges for Rev 637 = $1,100.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1170.23,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,833.35 in Billed Charges for Rev 637 = $1,170.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1320.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,833.35 in Billed Charges for Rev 637 = $1,320.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1013.84,,,,,,,891.0100,1833.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,833.35 in Billed Charges for Rev 637 = $1,013.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,UNITED HEALTHCARE,UHC ONEIDA NATION,1013.84,,,,,,,891.0100,1833.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,833.35 in Billed Charges for Rev 637 = $1,013.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,UNITED HEALTHCARE,UNITED HEALTHCARE,1013.84,,,,,,,891.0100,1833.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,833.35 in Billed Charges for Rev 637 = $1,013.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,UNITY HEALTH PLAN,UNITY HOSPICE,1833.35,,,,,,,891.0100,1833.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1320.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,833.35 in Billed Charges for Rev 637 = $1,320.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1136.68,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,833.35 in Billed Charges for Rev 637 = $1,136.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1320.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,833.35 in Billed Charges for Rev 637 = $1,320.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1320.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,833.35 in Billed Charges for Rev 637 = $1,320.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GLYCOPYRROLATE 1 MG/5ML SOLN,637,RC,31722-016-47,CDM,,,,,,both,473.000000,ML,1833.3500,1210.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1100.01,,,,,,,891.0100,1833.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,833.35 in Billed Charges for Rev 637 = $1,100.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,AETNA,AETNA HSHS,5.33,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.25 in Billed Charges for Rev 637 = $5.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,AETNA,ALL COMMERCIAL AETNA,8.25,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.25 in Billed Charges for Rev 637 = $8.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,ANTHEM,ANTHEM POS/HMO,5.61,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.25 in Billed Charges for Rev 637 = $5.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,ANTHEM,ANTHEM PPO,5.61,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.25 in Billed Charges for Rev 637 = $5.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.25,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.25 in Billed Charges for Rev 637 = $8.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,CENPATICO,ALL MEDICAID CENPATICO,8.25,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.25 in Billed Charges for Rev 637 = $8.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.01,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.25 in Billed Charges for Rev 637 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,CIGNA,ALL COMMERCIAL CIGNA,5.78,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.25 in Billed Charges for Rev 637 = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,COFINITY,COFINITY,8.25,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.25 in Billed Charges for Rev 637 = $8.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.84,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.25 in Billed Charges for Rev 637 = $7.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,HEALTH CARE ALLIANCE,THE ALLIANCE,6.93,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.25 in Billed Charges for Rev 637 = $6.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.86,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.25 in Billed Charges for Rev 637 = $5.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.02,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.25 in Billed Charges for Rev 637 = $6.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,HSHS EMPLOYEES,HSHS EMPLOYEES,4.01,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.25 in Billed Charges for Rev 637 = $4.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.01,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.25 in Billed Charges for Rev 637 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,HUMANA,HUMANA CHOICE CARE HMO,5.24,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.25 in Billed Charges at 63.5% = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,HUMANA,HUMANA CHOICE CARE PPO,7.01,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.25 in Billed Charges for Rev 637 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,HUMANA,HUMANA NATIIONAL POS HMO,5.24,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.25 in Billed Charges at 63.5% = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.02,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.25 in Billed Charges for Rev 637 = $6.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.25,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.25 in Billed Charges for Rev 637 = $8.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.25,,,,,,,4.0100,8.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.13,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.25 in Billed Charges for Rev 637 = $4.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.93,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.25 in Billed Charges for Rev 637 = $6.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.19,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.25 in Billed Charges for Rev 637 = $6.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.59,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.25 in Billed Charges for Rev 637 = $7.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.95,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.25 in Billed Charges for Rev 637 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.95,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.25 in Billed Charges for Rev 637 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,PREVEA HEALTH NETWORK,PREVEA360,4.95,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.25 in Billed Charges for Rev 637 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.95,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.25 in Billed Charges for Rev 637 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.27,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.25 in Billed Charges for Rev 637 = $5.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.94,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.25 in Billed Charges for Rev 637 = $5.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.56,,,,,,,4.0100,8.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.25 in Billed Charges for Rev 637 = $4.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,UNITED HEALTHCARE,UHC ONEIDA NATION,4.56,,,,,,,4.0100,8.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.25 in Billed Charges for Rev 637 = $4.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,UNITED HEALTHCARE,UNITED HEALTHCARE,4.56,,,,,,,4.0100,8.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.25 in Billed Charges for Rev 637 = $4.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,UNITY HEALTH PLAN,UNITY HOSPICE,8.25,,,,,,,4.0100,8.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.94,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.25 in Billed Charges for Rev 637 = $5.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.12,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.25 in Billed Charges for Rev 637 = $5.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.94,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.25 in Billed Charges for Rev 637 = $5.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.94,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.25 in Billed Charges for Rev 637 = $5.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 10 MG CAPS,637,RC,0904-5784-61,CDM,,,,,,both,1.000000,EA,8.2500,5.4500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.95,,,,,,,4.0100,8.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.25 in Billed Charges for Rev 637 = $4.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,AETNA,AETNA HSHS,5.88,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.10 in Billed Charges for Rev 637 = $5.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,AETNA,ALL COMMERCIAL AETNA,9.10,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.10 in Billed Charges for Rev 637 = $9.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,ANTHEM,ANTHEM POS/HMO,6.19,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $9.10 in Billed Charges for Rev 637 = $6.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,ANTHEM,ANTHEM PPO,6.19,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $9.10 in Billed Charges for Rev 637 = $6.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.10,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.10 in Billed Charges for Rev 637 = $9.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,CENPATICO,ALL MEDICAID CENPATICO,9.10,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.10 in Billed Charges for Rev 637 = $9.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.74,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.10 in Billed Charges for Rev 637 = $7.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,CIGNA,ALL COMMERCIAL CIGNA,6.37,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.10 in Billed Charges for Rev 637 = $6.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,COFINITY,COFINITY,9.10,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.10 in Billed Charges for Rev 637 = $9.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.65,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.10 in Billed Charges for Rev 637 = $8.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,7.64,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.10 in Billed Charges for Rev 637 = $7.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.46,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.10 in Billed Charges for Rev 637 = $6.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.64,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.10 in Billed Charges for Rev 637 = $6.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,4.42,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.10 in Billed Charges for Rev 637 = $4.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.74,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.10 in Billed Charges for Rev 637 = $7.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,HUMANA,HUMANA CHOICE CARE HMO,5.78,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $9.10 in Billed Charges at 63.5% = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,HUMANA,HUMANA CHOICE CARE PPO,7.74,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.10 in Billed Charges for Rev 637 = $7.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,HUMANA,HUMANA NATIIONAL POS HMO,5.78,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $9.10 in Billed Charges at 63.5% = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.64,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.10 in Billed Charges for Rev 637 = $6.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.10,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.10 in Billed Charges for Rev 637 = $9.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,9.10,,,,,,,4.4200,9.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.55,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.10 in Billed Charges for Rev 637 = $4.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.64,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.10 in Billed Charges for Rev 637 = $7.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.83,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.10 in Billed Charges for Rev 637 = $6.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.37,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.10 in Billed Charges for Rev 637 = $8.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.46,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.10 in Billed Charges for Rev 637 = $5.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.46,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.10 in Billed Charges for Rev 637 = $5.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,PREVEA HEALTH NETWORK,PREVEA360,5.46,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.10 in Billed Charges for Rev 637 = $5.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.46,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.10 in Billed Charges for Rev 637 = $5.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.81,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.10 in Billed Charges for Rev 637 = $5.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.55,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.10 in Billed Charges for Rev 637 = $6.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.03,,,,,,,4.4200,9.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $9.10 in Billed Charges for Rev 637 = $5.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,UNITED HEALTHCARE,UHC ONEIDA NATION,5.03,,,,,,,4.4200,9.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $9.10 in Billed Charges for Rev 637 = $5.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,UNITED HEALTHCARE,UNITED HEALTHCARE,5.03,,,,,,,4.4200,9.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $9.10 in Billed Charges for Rev 637 = $5.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,UNITY HEALTH PLAN,UNITY HOSPICE,9.10,,,,,,,4.4200,9.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.55,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.10 in Billed Charges for Rev 637 = $6.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.64,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.10 in Billed Charges for Rev 637 = $5.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.55,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.10 in Billed Charges for Rev 637 = $6.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.55,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.10 in Billed Charges for Rev 637 = $6.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUOXETINE 20 MG CAPS,637,RC,68001-400-00,CDM,,,,,,both,1.000000,EA,9.1000,6.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.46,,,,,,,4.4200,9.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.10 in Billed Charges for Rev 637 = $5.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,AETNA,AETNA HSHS,512.18,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $792.85 in Billed Charges for Rev 637 = $512.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,AETNA,ALL COMMERCIAL AETNA,792.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.85 in Billed Charges for Rev 637 = $792.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,ANTHEM,ANTHEM POS/HMO,539.14,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $792.85 in Billed Charges for Rev 637 = $539.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,ANTHEM,ANTHEM PPO,539.14,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $792.85 in Billed Charges for Rev 637 = $539.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,792.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.85 in Billed Charges for Rev 637 = $792.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,CENPATICO,ALL MEDICAID CENPATICO,792.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.85 in Billed Charges for Rev 637 = $792.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,673.92,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $792.85 in Billed Charges for Rev 637 = $673.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,CIGNA,ALL COMMERCIAL CIGNA,555.00,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $792.85 in Billed Charges for Rev 637 = $555.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,COFINITY,COFINITY,792.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.85 in Billed Charges for Rev 637 = $792.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,753.21,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $792.85 in Billed Charges for Rev 637 = $753.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,665.99,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $792.85 in Billed Charges for Rev 637 = $665.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,562.92,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $792.85 in Billed Charges for Rev 637 = $562.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,578.78,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $792.85 in Billed Charges for Rev 637 = $578.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,385.33,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $792.85 in Billed Charges for Rev 637 = $385.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,673.92,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $792.85 in Billed Charges for Rev 637 = $673.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,HUMANA,HUMANA CHOICE CARE HMO,503.46,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $792.85 in Billed Charges at 63.5% = $503.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,HUMANA,HUMANA CHOICE CARE PPO,673.92,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $792.85 in Billed Charges for Rev 637 = $673.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,HUMANA,HUMANA NATIIONAL POS HMO,503.46,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $792.85 in Billed Charges at 63.5% = $503.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,578.78,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $792.85 in Billed Charges for Rev 637 = $578.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,792.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $792.85 in Billed Charges for Rev 637 = $792.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,792.85,,,,,,,385.3300,792.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,396.43,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $792.85 in Billed Charges for Rev 637 = $396.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,665.99,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $792.85 in Billed Charges for Rev 637 = $665.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,594.64,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $792.85 in Billed Charges for Rev 637 = $594.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,729.42,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $792.85 in Billed Charges for Rev 637 = $729.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,475.71,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $792.85 in Billed Charges for Rev 637 = $475.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,475.71,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $792.85 in Billed Charges for Rev 637 = $475.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,PREVEA HEALTH NETWORK,PREVEA360,475.71,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $792.85 in Billed Charges for Rev 637 = $475.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,475.71,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $792.85 in Billed Charges for Rev 637 = $475.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,506.08,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $792.85 in Billed Charges for Rev 637 = $506.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,570.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $792.85 in Billed Charges for Rev 637 = $570.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,438.45,,,,,,,385.3300,792.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $792.85 in Billed Charges for Rev 637 = $438.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,438.45,,,,,,,385.3300,792.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $792.85 in Billed Charges for Rev 637 = $438.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,438.45,,,,,,,385.3300,792.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $792.85 in Billed Charges for Rev 637 = $438.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,UNITY HEALTH PLAN,UNITY HOSPICE,792.85,,,,,,,385.3300,792.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,570.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $792.85 in Billed Charges for Rev 637 = $570.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,491.57,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $792.85 in Billed Charges for Rev 637 = $491.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,570.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $792.85 in Billed Charges for Rev 637 = $570.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,570.85,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $792.85 in Billed Charges for Rev 637 = $570.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 44 MCG/ACT AERO,637,RC,66993-078-96,CDM,,,,,,both,10.600000,GR,792.8500,523.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,475.71,,,,,,,385.3300,792.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $792.85 in Billed Charges for Rev 637 = $475.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,AETNA,AETNA HSHS,187.28,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $289.90 in Billed Charges for Rev 637 = $187.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,AETNA,ALL COMMERCIAL AETNA,289.90,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $289.90 in Billed Charges for Rev 637 = $289.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,ANTHEM,ANTHEM POS/HMO,197.13,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $289.90 in Billed Charges for Rev 637 = $197.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,ANTHEM,ANTHEM PPO,197.13,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $289.90 in Billed Charges for Rev 637 = $197.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,289.90,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $289.90 in Billed Charges for Rev 637 = $289.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,CENPATICO,ALL MEDICAID CENPATICO,289.90,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $289.90 in Billed Charges for Rev 637 = $289.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,246.42,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $289.90 in Billed Charges for Rev 637 = $246.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,CIGNA,ALL COMMERCIAL CIGNA,202.93,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $289.90 in Billed Charges for Rev 637 = $202.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,COFINITY,COFINITY,289.90,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $289.90 in Billed Charges for Rev 637 = $289.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,275.41,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $289.90 in Billed Charges for Rev 637 = $275.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,243.52,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $289.90 in Billed Charges for Rev 637 = $243.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,205.83,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $289.90 in Billed Charges for Rev 637 = $205.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,211.63,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $289.90 in Billed Charges for Rev 637 = $211.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,140.89,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $289.90 in Billed Charges for Rev 637 = $140.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,246.42,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $289.90 in Billed Charges for Rev 637 = $246.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,HUMANA,HUMANA CHOICE CARE HMO,184.09,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $289.90 in Billed Charges at 63.5% = $184.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,HUMANA,HUMANA CHOICE CARE PPO,246.42,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $289.90 in Billed Charges for Rev 637 = $246.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,HUMANA,HUMANA NATIIONAL POS HMO,184.09,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $289.90 in Billed Charges at 63.5% = $184.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,211.63,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $289.90 in Billed Charges for Rev 637 = $211.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,289.90,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $289.90 in Billed Charges for Rev 637 = $289.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,289.90,,,,,,,140.8900,289.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,144.95,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $289.90 in Billed Charges for Rev 637 = $144.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,243.52,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $289.90 in Billed Charges for Rev 637 = $243.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,217.43,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $289.90 in Billed Charges for Rev 637 = $217.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,266.71,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $289.90 in Billed Charges for Rev 637 = $266.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,173.94,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $289.90 in Billed Charges for Rev 637 = $173.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,173.94,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $289.90 in Billed Charges for Rev 637 = $173.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,PREVEA HEALTH NETWORK,PREVEA360,173.94,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $289.90 in Billed Charges for Rev 637 = $173.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,173.94,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $289.90 in Billed Charges for Rev 637 = $173.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,185.04,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $289.90 in Billed Charges for Rev 637 = $185.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,208.73,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $289.90 in Billed Charges for Rev 637 = $208.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,160.31,,,,,,,140.8900,289.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $289.90 in Billed Charges for Rev 637 = $160.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,160.31,,,,,,,140.8900,289.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $289.90 in Billed Charges for Rev 637 = $160.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,160.31,,,,,,,140.8900,289.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $289.90 in Billed Charges for Rev 637 = $160.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,UNITY HEALTH PLAN,UNITY HOSPICE,289.90,,,,,,,140.8900,289.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,208.73,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $289.90 in Billed Charges for Rev 637 = $208.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,179.74,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $289.90 in Billed Charges for Rev 637 = $179.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,208.73,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $289.90 in Billed Charges for Rev 637 = $208.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,208.73,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $289.90 in Billed Charges for Rev 637 = $208.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE PROPIONATE 50 MCG/ACT SUSP 16 G BOTTLE,637,RC,60505-0829-1,CDM,,,,,,both,16.000000,GR,289.9000,191.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,173.94,,,,,,,140.8900,289.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $289.90 in Billed Charges for Rev 637 = $173.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,AETNA,AETNA HSHS,1016.00,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,572.75 in Billed Charges for Rev 637 = $1,016.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,AETNA,ALL COMMERCIAL AETNA,1572.75,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,572.75 in Billed Charges for Rev 637 = $1,572.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,ANTHEM,ANTHEM POS/HMO,1069.47,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,572.75 in Billed Charges for Rev 637 = $1,069.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,ANTHEM,ANTHEM PPO,1069.47,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,572.75 in Billed Charges for Rev 637 = $1,069.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1572.75,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,572.75 in Billed Charges for Rev 637 = $1,572.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,CENPATICO,ALL MEDICAID CENPATICO,1572.75,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,572.75 in Billed Charges for Rev 637 = $1,572.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1336.84,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,572.75 in Billed Charges for Rev 637 = $1,336.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,CIGNA,ALL COMMERCIAL CIGNA,1100.93,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,572.75 in Billed Charges for Rev 637 = $1,100.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,COFINITY,COFINITY,1572.75,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,572.75 in Billed Charges for Rev 637 = $1,572.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1494.11,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,572.75 in Billed Charges for Rev 637 = $1,494.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,1321.11,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,572.75 in Billed Charges for Rev 637 = $1,321.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1116.65,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,572.75 in Billed Charges for Rev 637 = $1,116.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1148.11,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,572.75 in Billed Charges for Rev 637 = $1,148.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,764.36,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,572.75 in Billed Charges for Rev 637 = $764.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1336.84,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,572.75 in Billed Charges for Rev 637 = $1,336.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,HUMANA,HUMANA CHOICE CARE HMO,998.70,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,572.75 in Billed Charges at 63.5% = $998.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,HUMANA,HUMANA CHOICE CARE PPO,1336.84,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,572.75 in Billed Charges for Rev 637 = $1,336.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,HUMANA,HUMANA NATIIONAL POS HMO,998.70,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,572.75 in Billed Charges at 63.5% = $998.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1148.11,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,572.75 in Billed Charges for Rev 637 = $1,148.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,1572.75,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,572.75 in Billed Charges for Rev 637 = $1,572.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1572.75,,,,,,,764.3600,1572.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,786.38,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,572.75 in Billed Charges for Rev 637 = $786.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1321.11,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,572.75 in Billed Charges for Rev 637 = $1,321.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1179.56,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,572.75 in Billed Charges for Rev 637 = $1,179.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1446.93,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,572.75 in Billed Charges for Rev 637 = $1,446.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,943.65,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,572.75 in Billed Charges for Rev 637 = $943.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,943.65,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,572.75 in Billed Charges for Rev 637 = $943.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,PREVEA HEALTH NETWORK,PREVEA360,943.65,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,572.75 in Billed Charges for Rev 637 = $943.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,943.65,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,572.75 in Billed Charges for Rev 637 = $943.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1003.89,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,572.75 in Billed Charges for Rev 637 = $1,003.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1132.38,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,572.75 in Billed Charges for Rev 637 = $1,132.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,869.73,,,,,,,764.3600,1572.7500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,572.75 in Billed Charges for Rev 637 = $869.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,869.73,,,,,,,764.3600,1572.7500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,572.75 in Billed Charges for Rev 637 = $869.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,869.73,,,,,,,764.3600,1572.7500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,572.75 in Billed Charges for Rev 637 = $869.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,UNITY HEALTH PLAN,UNITY HOSPICE,1572.75,,,,,,,764.3600,1572.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1132.38,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,572.75 in Billed Charges for Rev 637 = $1,132.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,975.11,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,572.75 in Billed Charges for Rev 637 = $975.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1132.38,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,572.75 in Billed Charges for Rev 637 = $1,132.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1132.38,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,572.75 in Billed Charges for Rev 637 = $1,132.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FLUTICASONE-SALMETEROL 115-21 MCG/ACT AERO,637,RC,66993-087-96,CDM,,,,,,both,12.000000,GR,1572.7500,1038.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,943.65,,,,,,,764.3600,1572.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,572.75 in Billed Charges for Rev 637 = $943.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,AETNA,AETNA HSHS,37.40,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $57.90 in Billed Charges for Rev 637 = $37.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,AETNA,ALL COMMERCIAL AETNA,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 637 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,ANTHEM,ANTHEM POS/HMO,39.37,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $57.90 in Billed Charges for Rev 637 = $39.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,ANTHEM,ANTHEM PPO,39.37,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $57.90 in Billed Charges for Rev 637 = $39.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 637 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,CENPATICO,ALL MEDICAID CENPATICO,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 637 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,49.22,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.90 in Billed Charges for Rev 637 = $49.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,CIGNA,ALL COMMERCIAL CIGNA,40.53,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $57.90 in Billed Charges for Rev 637 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,COFINITY,COFINITY,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 637 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,55.01,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $57.90 in Billed Charges for Rev 637 = $55.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,48.64,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.90 in Billed Charges for Rev 637 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,41.11,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $57.90 in Billed Charges for Rev 637 = $41.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,42.27,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.90 in Billed Charges for Rev 637 = $42.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,28.14,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $57.90 in Billed Charges for Rev 637 = $28.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,49.22,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.90 in Billed Charges for Rev 637 = $49.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,HUMANA,HUMANA CHOICE CARE HMO,36.77,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $57.90 in Billed Charges at 63.5% = $36.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,HUMANA,HUMANA CHOICE CARE PPO,49.22,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.90 in Billed Charges for Rev 637 = $49.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,HUMANA,HUMANA NATIIONAL POS HMO,36.77,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $57.90 in Billed Charges at 63.5% = $36.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,42.27,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.90 in Billed Charges for Rev 637 = $42.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 637 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,57.90,,,,,,,28.1400,57.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,28.95,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $57.90 in Billed Charges for Rev 637 = $28.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,48.64,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.90 in Billed Charges for Rev 637 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,43.43,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $57.90 in Billed Charges for Rev 637 = $43.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,53.27,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $57.90 in Billed Charges for Rev 637 = $53.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 637 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 637 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,PREVEA HEALTH NETWORK,PREVEA360,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 637 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 637 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,36.96,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $57.90 in Billed Charges for Rev 637 = $36.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,41.69,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.90 in Billed Charges for Rev 637 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32.02,,,,,,,28.1400,57.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.90 in Billed Charges for Rev 637 = $32.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,UNITED HEALTHCARE,UHC ONEIDA NATION,32.02,,,,,,,28.1400,57.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.90 in Billed Charges for Rev 637 = $32.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,UNITED HEALTHCARE,UNITED HEALTHCARE,32.02,,,,,,,28.1400,57.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.90 in Billed Charges for Rev 637 = $32.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,UNITY HEALTH PLAN,UNITY HOSPICE,57.90,,,,,,,28.1400,57.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,41.69,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.90 in Billed Charges for Rev 637 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,35.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $57.90 in Billed Charges for Rev 637 = $35.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,41.69,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.90 in Billed Charges for Rev 637 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,41.69,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.90 in Billed Charges for Rev 637 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 220 (44 FE) MG/5ML SOLN,637,RC,54838-001-80,CDM,,,,,,both,473.000000,ML,57.9000,38.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 637 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,AETNA,AETNA HSHS,7.04,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.90 in Billed Charges for Rev 637 = $7.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,AETNA,ALL COMMERCIAL AETNA,10.90,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.90 in Billed Charges for Rev 637 = $10.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,ANTHEM,ANTHEM POS/HMO,7.41,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $10.90 in Billed Charges for Rev 637 = $7.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,ANTHEM,ANTHEM PPO,7.41,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $10.90 in Billed Charges for Rev 637 = $7.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.90,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.90 in Billed Charges for Rev 637 = $10.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,CENPATICO,ALL MEDICAID CENPATICO,10.90,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.90 in Billed Charges for Rev 637 = $10.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.27,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.90 in Billed Charges for Rev 637 = $9.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,CIGNA,ALL COMMERCIAL CIGNA,7.63,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.90 in Billed Charges for Rev 637 = $7.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,COFINITY,COFINITY,10.90,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.90 in Billed Charges for Rev 637 = $10.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.36,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.90 in Billed Charges for Rev 637 = $10.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,9.16,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.90 in Billed Charges for Rev 637 = $9.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.74,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.90 in Billed Charges for Rev 637 = $7.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.96,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.90 in Billed Charges for Rev 637 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.30,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.90 in Billed Charges for Rev 637 = $5.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.27,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.90 in Billed Charges for Rev 637 = $9.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,HUMANA,HUMANA CHOICE CARE HMO,6.92,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $10.90 in Billed Charges at 63.5% = $6.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,HUMANA,HUMANA CHOICE CARE PPO,9.27,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.90 in Billed Charges for Rev 637 = $9.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,HUMANA,HUMANA NATIIONAL POS HMO,6.92,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $10.90 in Billed Charges at 63.5% = $6.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.96,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.90 in Billed Charges for Rev 637 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.90,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.90 in Billed Charges for Rev 637 = $10.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.90,,,,,,,5.3000,10.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.45,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.90 in Billed Charges for Rev 637 = $5.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.16,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.90 in Billed Charges for Rev 637 = $9.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.18,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.90 in Billed Charges for Rev 637 = $8.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.03,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.90 in Billed Charges for Rev 637 = $10.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.54,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.90 in Billed Charges for Rev 637 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.54,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.90 in Billed Charges for Rev 637 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,PREVEA HEALTH NETWORK,PREVEA360,6.54,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.90 in Billed Charges for Rev 637 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.54,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.90 in Billed Charges for Rev 637 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.96,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.90 in Billed Charges for Rev 637 = $6.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.85,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.90 in Billed Charges for Rev 637 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.03,,,,,,,5.3000,10.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.90 in Billed Charges for Rev 637 = $6.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,UNITED HEALTHCARE,UHC ONEIDA NATION,6.03,,,,,,,5.3000,10.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.90 in Billed Charges for Rev 637 = $6.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,UNITED HEALTHCARE,UNITED HEALTHCARE,6.03,,,,,,,5.3000,10.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.90 in Billed Charges for Rev 637 = $6.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,UNITY HEALTH PLAN,UNITY HOSPICE,10.90,,,,,,,5.3000,10.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.85,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.90 in Billed Charges for Rev 637 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.76,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.90 in Billed Charges for Rev 637 = $6.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.85,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.90 in Billed Charges for Rev 637 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.85,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.90 in Billed Charges for Rev 637 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,69618-07059,CDM,,,,,,both,50.000000,ML,10.9000,7.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.54,,,,,,,5.3000,10.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.90 in Billed Charges for Rev 637 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,AETNA,AETNA HSHS,8.69,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $13.45 in Billed Charges for Rev 637 = $8.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,AETNA,ALL COMMERCIAL AETNA,13.45,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.45 in Billed Charges for Rev 637 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,ANTHEM,ANTHEM POS/HMO,9.15,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $13.45 in Billed Charges for Rev 637 = $9.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,ANTHEM,ANTHEM PPO,9.15,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $13.45 in Billed Charges for Rev 637 = $9.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,13.45,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.45 in Billed Charges for Rev 637 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,CENPATICO,ALL MEDICAID CENPATICO,13.45,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.45 in Billed Charges for Rev 637 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,11.43,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.45 in Billed Charges for Rev 637 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,CIGNA,ALL COMMERCIAL CIGNA,9.42,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $13.45 in Billed Charges for Rev 637 = $9.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,COFINITY,COFINITY,13.45,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.45 in Billed Charges for Rev 637 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12.78,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $13.45 in Billed Charges for Rev 637 = $12.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,11.30,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.45 in Billed Charges for Rev 637 = $11.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9.55,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $13.45 in Billed Charges for Rev 637 = $9.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.82,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.45 in Billed Charges for Rev 637 = $9.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,6.54,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $13.45 in Billed Charges for Rev 637 = $6.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,11.43,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.45 in Billed Charges for Rev 637 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,HUMANA,HUMANA CHOICE CARE HMO,8.54,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $13.45 in Billed Charges at 63.5% = $8.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,HUMANA,HUMANA CHOICE CARE PPO,11.43,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $13.45 in Billed Charges for Rev 637 = $11.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,HUMANA,HUMANA NATIIONAL POS HMO,8.54,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $13.45 in Billed Charges at 63.5% = $8.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.82,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $13.45 in Billed Charges for Rev 637 = $9.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,13.45,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $13.45 in Billed Charges for Rev 637 = $13.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,13.45,,,,,,,6.5400,13.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.73,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $13.45 in Billed Charges for Rev 637 = $6.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,11.30,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $13.45 in Billed Charges for Rev 637 = $11.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.09,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $13.45 in Billed Charges for Rev 637 = $10.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,12.37,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $13.45 in Billed Charges for Rev 637 = $12.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.07,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.45 in Billed Charges for Rev 637 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.07,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.45 in Billed Charges for Rev 637 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,PREVEA HEALTH NETWORK,PREVEA360,8.07,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.45 in Billed Charges for Rev 637 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.07,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.45 in Billed Charges for Rev 637 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.59,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $13.45 in Billed Charges for Rev 637 = $8.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.68,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.45 in Billed Charges for Rev 637 = $9.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.44,,,,,,,6.5400,13.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.45 in Billed Charges for Rev 637 = $7.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,7.44,,,,,,,6.5400,13.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.45 in Billed Charges for Rev 637 = $7.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,7.44,,,,,,,6.5400,13.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $13.45 in Billed Charges for Rev 637 = $7.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,UNITY HEALTH PLAN,UNITY HOSPICE,13.45,,,,,,,6.5400,13.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.68,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.45 in Billed Charges for Rev 637 = $9.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.34,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $13.45 in Billed Charges for Rev 637 = $8.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.68,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.45 in Billed Charges for Rev 637 = $9.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.68,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $13.45 in Billed Charges for Rev 637 = $9.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FERROUS SULFATE 75 (15 FE) MG/ML SOLN,637,RC,71399-7480-5,CDM,,,,,,both,50.000000,ML,13.4500,8.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.07,,,,,,,6.5400,13.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $13.45 in Billed Charges for Rev 637 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,AETNA,AETNA HSHS,52.71,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $81.60 in Billed Charges for Rev 637 = $52.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,AETNA,ALL COMMERCIAL AETNA,81.60,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.60 in Billed Charges for Rev 637 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,ANTHEM,ANTHEM POS/HMO,55.49,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $81.60 in Billed Charges for Rev 637 = $55.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,ANTHEM,ANTHEM PPO,55.49,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $81.60 in Billed Charges for Rev 637 = $55.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,81.60,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.60 in Billed Charges for Rev 637 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,CENPATICO,ALL MEDICAID CENPATICO,81.60,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.60 in Billed Charges for Rev 637 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.36,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.60 in Billed Charges for Rev 637 = $69.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,CIGNA,ALL COMMERCIAL CIGNA,57.12,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $81.60 in Billed Charges for Rev 637 = $57.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,COFINITY,COFINITY,81.60,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.60 in Billed Charges for Rev 637 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.52,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $81.60 in Billed Charges for Rev 637 = $77.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,HEALTH CARE ALLIANCE,THE ALLIANCE,68.54,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.60 in Billed Charges for Rev 637 = $68.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,57.94,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $81.60 in Billed Charges for Rev 637 = $57.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.57,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.60 in Billed Charges for Rev 637 = $59.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,HSHS EMPLOYEES,HSHS EMPLOYEES,39.66,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $81.60 in Billed Charges for Rev 637 = $39.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.36,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.60 in Billed Charges for Rev 637 = $69.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,HUMANA,HUMANA CHOICE CARE HMO,51.82,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $81.60 in Billed Charges at 63.5% = $51.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,HUMANA,HUMANA CHOICE CARE PPO,69.36,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.60 in Billed Charges for Rev 637 = $69.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,HUMANA,HUMANA NATIIONAL POS HMO,51.82,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $81.60 in Billed Charges at 63.5% = $51.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.57,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.60 in Billed Charges for Rev 637 = $59.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,LIVE360,LIVE360 HSHS HEALTHY PLAN,81.60,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.60 in Billed Charges for Rev 637 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,81.60,,,,,,,39.6600,81.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,40.80,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $81.60 in Billed Charges for Rev 637 = $40.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.54,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.60 in Billed Charges for Rev 637 = $68.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.20,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $81.60 in Billed Charges for Rev 637 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,75.07,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $81.60 in Billed Charges for Rev 637 = $75.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,48.96,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.60 in Billed Charges for Rev 637 = $48.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,48.96,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.60 in Billed Charges for Rev 637 = $48.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,PREVEA HEALTH NETWORK,PREVEA360,48.96,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.60 in Billed Charges for Rev 637 = $48.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,48.96,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.60 in Billed Charges for Rev 637 = $48.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,52.09,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $81.60 in Billed Charges for Rev 637 = $52.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,58.75,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.60 in Billed Charges for Rev 637 = $58.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,45.12,,,,,,,39.6600,81.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $81.60 in Billed Charges for Rev 637 = $45.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,UNITED HEALTHCARE,UHC ONEIDA NATION,45.12,,,,,,,39.6600,81.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $81.60 in Billed Charges for Rev 637 = $45.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,UNITED HEALTHCARE,UNITED HEALTHCARE,45.12,,,,,,,39.6600,81.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $81.60 in Billed Charges for Rev 637 = $45.12 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,UNITY HEALTH PLAN,UNITY HOSPICE,81.60,,,,,,,39.6600,81.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,58.75,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.60 in Billed Charges for Rev 637 = $58.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.59,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $81.60 in Billed Charges for Rev 637 = $50.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,58.75,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.60 in Billed Charges for Rev 637 = $58.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,58.75,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.60 in Billed Charges for Rev 637 = $58.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUCONAZOLE 100 MG TABS,637,RC,68084-728-11,CDM,,,,,,both,1.000000,EA,81.6000,53.8600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,48.96,,,,,,,39.6600,81.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.60 in Billed Charges for Rev 637 = $48.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,AETNA,AETNA HSHS,858.89,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,329.55 in Billed Charges for Rev 637 = $858.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,AETNA,ALL COMMERCIAL AETNA,1329.55,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,329.55 in Billed Charges for Rev 637 = $1,329.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,ANTHEM,ANTHEM POS/HMO,904.09,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,329.55 in Billed Charges for Rev 637 = $904.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,ANTHEM,ANTHEM PPO,904.09,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $1,329.55 in Billed Charges for Rev 637 = $904.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1329.55,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,329.55 in Billed Charges for Rev 637 = $1,329.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,CENPATICO,ALL MEDICAID CENPATICO,1329.55,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,329.55 in Billed Charges for Rev 637 = $1,329.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1130.12,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,329.55 in Billed Charges for Rev 637 = $1,130.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,CIGNA,ALL COMMERCIAL CIGNA,930.69,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,329.55 in Billed Charges for Rev 637 = $930.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,COFINITY,COFINITY,1329.55,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,329.55 in Billed Charges for Rev 637 = $1,329.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1263.07,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,329.55 in Billed Charges for Rev 637 = $1,263.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,1116.82,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,329.55 in Billed Charges for Rev 637 = $1,116.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,943.98,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,329.55 in Billed Charges for Rev 637 = $943.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,970.57,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,329.55 in Billed Charges for Rev 637 = $970.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,646.16,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,329.55 in Billed Charges for Rev 637 = $646.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1130.12,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,329.55 in Billed Charges for Rev 637 = $1,130.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,HUMANA,HUMANA CHOICE CARE HMO,844.26,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,329.55 in Billed Charges at 63.5% = $844.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,HUMANA,HUMANA CHOICE CARE PPO,1130.12,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,329.55 in Billed Charges for Rev 637 = $1,130.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,HUMANA,HUMANA NATIIONAL POS HMO,844.26,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $1,329.55 in Billed Charges at 63.5% = $844.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,970.57,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,329.55 in Billed Charges for Rev 637 = $970.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1329.55,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,329.55 in Billed Charges for Rev 637 = $1,329.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,1329.55,,,,,,,646.1600,1329.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,664.78,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,329.55 in Billed Charges for Rev 637 = $664.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1116.82,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,329.55 in Billed Charges for Rev 637 = $1,116.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,997.16,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,329.55 in Billed Charges for Rev 637 = $997.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1223.19,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,329.55 in Billed Charges for Rev 637 = $1,223.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,797.73,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,329.55 in Billed Charges for Rev 637 = $797.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,797.73,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,329.55 in Billed Charges for Rev 637 = $797.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,PREVEA HEALTH NETWORK,PREVEA360,797.73,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,329.55 in Billed Charges for Rev 637 = $797.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,797.73,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,329.55 in Billed Charges for Rev 637 = $797.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,848.65,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,329.55 in Billed Charges for Rev 637 = $848.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,957.28,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,329.55 in Billed Charges for Rev 637 = $957.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,735.24,,,,,,,646.1600,1329.5500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,329.55 in Billed Charges for Rev 637 = $735.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,735.24,,,,,,,646.1600,1329.5500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,329.55 in Billed Charges for Rev 637 = $735.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,735.24,,,,,,,646.1600,1329.5500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,329.55 in Billed Charges for Rev 637 = $735.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,UNITY HEALTH PLAN,UNITY HOSPICE,1329.55,,,,,,,646.1600,1329.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,957.28,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,329.55 in Billed Charges for Rev 637 = $957.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,824.32,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,329.55 in Billed Charges for Rev 637 = $824.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,957.28,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,329.55 in Billed Charges for Rev 637 = $957.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,957.28,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,329.55 in Billed Charges for Rev 637 = $957.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
GABAPENTIN 250 MG/5ML SOLN,637,RC,42192-608-16,CDM,,,,,,both,470.000000,ML,1329.5500,877.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,797.73,,,,,,,646.1600,1329.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,329.55 in Billed Charges for Rev 637 = $797.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,AETNA,AETNA HSHS,20.06,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $31.05 in Billed Charges for Rev 637 = $20.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,AETNA,ALL COMMERCIAL AETNA,31.05,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.05 in Billed Charges for Rev 637 = $31.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,ANTHEM,ANTHEM POS/HMO,21.11,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $31.05 in Billed Charges for Rev 637 = $21.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,ANTHEM,ANTHEM PPO,21.11,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $31.05 in Billed Charges for Rev 637 = $21.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,31.05,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.05 in Billed Charges for Rev 637 = $31.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,CENPATICO,ALL MEDICAID CENPATICO,31.05,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.05 in Billed Charges for Rev 637 = $31.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,26.39,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $31.05 in Billed Charges for Rev 637 = $26.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,CIGNA,ALL COMMERCIAL CIGNA,21.74,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $31.05 in Billed Charges for Rev 637 = $21.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,COFINITY,COFINITY,31.05,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.05 in Billed Charges for Rev 637 = $31.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,29.50,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $31.05 in Billed Charges for Rev 637 = $29.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,HEALTH CARE ALLIANCE,THE ALLIANCE,26.08,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $31.05 in Billed Charges for Rev 637 = $26.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,22.05,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $31.05 in Billed Charges for Rev 637 = $22.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,22.67,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $31.05 in Billed Charges for Rev 637 = $22.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,HSHS EMPLOYEES,HSHS EMPLOYEES,15.09,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $31.05 in Billed Charges for Rev 637 = $15.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,26.39,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $31.05 in Billed Charges for Rev 637 = $26.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,HUMANA,HUMANA CHOICE CARE HMO,19.72,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $31.05 in Billed Charges at 63.5% = $19.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,HUMANA,HUMANA CHOICE CARE PPO,26.39,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $31.05 in Billed Charges for Rev 637 = $26.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,HUMANA,HUMANA NATIIONAL POS HMO,19.72,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $31.05 in Billed Charges at 63.5% = $19.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,22.67,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $31.05 in Billed Charges for Rev 637 = $22.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,LIVE360,LIVE360 HSHS HEALTHY PLAN,31.05,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $31.05 in Billed Charges for Rev 637 = $31.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,31.05,,,,,,,15.0900,31.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,15.53,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $31.05 in Billed Charges for Rev 637 = $15.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,26.08,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $31.05 in Billed Charges for Rev 637 = $26.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,23.29,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $31.05 in Billed Charges for Rev 637 = $23.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,28.57,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $31.05 in Billed Charges for Rev 637 = $28.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,18.63,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.05 in Billed Charges for Rev 637 = $18.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,18.63,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.05 in Billed Charges for Rev 637 = $18.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,PREVEA HEALTH NETWORK,PREVEA360,18.63,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.05 in Billed Charges for Rev 637 = $18.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,18.63,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.05 in Billed Charges for Rev 637 = $18.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,19.82,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $31.05 in Billed Charges for Rev 637 = $19.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,22.36,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $31.05 in Billed Charges for Rev 637 = $22.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.17,,,,,,,15.0900,31.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $31.05 in Billed Charges for Rev 637 = $17.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,UNITED HEALTHCARE,UHC ONEIDA NATION,17.17,,,,,,,15.0900,31.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $31.05 in Billed Charges for Rev 637 = $17.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,UNITED HEALTHCARE,UNITED HEALTHCARE,17.17,,,,,,,15.0900,31.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $31.05 in Billed Charges for Rev 637 = $17.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,UNITY HEALTH PLAN,UNITY HOSPICE,31.05,,,,,,,15.0900,31.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,22.36,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $31.05 in Billed Charges for Rev 637 = $22.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,19.25,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $31.05 in Billed Charges for Rev 637 = $19.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,22.36,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $31.05 in Billed Charges for Rev 637 = $22.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,22.36,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $31.05 in Billed Charges for Rev 637 = $22.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FUROSEMIDE 10 MG/ML SOLN,637,RC,0054-3294-46,CDM,,,,,,both,60.000000,ML,31.0500,20.4900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,18.63,,,,,,,15.0900,31.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $31.05 in Billed Charges for Rev 637 = $18.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,AETNA,AETNA HSHS,207.56,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $321.30 in Billed Charges for Rev 637 = $207.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,AETNA,ALL COMMERCIAL AETNA,321.30,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.30 in Billed Charges for Rev 637 = $321.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,ANTHEM,ANTHEM POS/HMO,218.48,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $321.30 in Billed Charges for Rev 637 = $218.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,ANTHEM,ANTHEM PPO,218.48,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $321.30 in Billed Charges for Rev 637 = $218.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,321.30,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.30 in Billed Charges for Rev 637 = $321.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,CENPATICO,ALL MEDICAID CENPATICO,321.30,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.30 in Billed Charges for Rev 637 = $321.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,273.11,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $321.30 in Billed Charges for Rev 637 = $273.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,CIGNA,ALL COMMERCIAL CIGNA,224.91,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $321.30 in Billed Charges for Rev 637 = $224.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,COFINITY,COFINITY,321.30,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.30 in Billed Charges for Rev 637 = $321.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,305.24,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $321.30 in Billed Charges for Rev 637 = $305.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,269.89,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $321.30 in Billed Charges for Rev 637 = $269.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,228.12,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $321.30 in Billed Charges for Rev 637 = $228.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,234.55,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $321.30 in Billed Charges for Rev 637 = $234.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,156.15,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $321.30 in Billed Charges for Rev 637 = $156.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,273.11,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $321.30 in Billed Charges for Rev 637 = $273.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,HUMANA,HUMANA CHOICE CARE HMO,204.03,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $321.30 in Billed Charges at 63.5% = $204.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,HUMANA,HUMANA CHOICE CARE PPO,273.11,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $321.30 in Billed Charges for Rev 637 = $273.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,HUMANA,HUMANA NATIIONAL POS HMO,204.03,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $321.30 in Billed Charges at 63.5% = $204.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,234.55,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $321.30 in Billed Charges for Rev 637 = $234.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,321.30,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $321.30 in Billed Charges for Rev 637 = $321.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,321.30,,,,,,,156.1500,321.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,160.65,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $321.30 in Billed Charges for Rev 637 = $160.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,269.89,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $321.30 in Billed Charges for Rev 637 = $269.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,240.98,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $321.30 in Billed Charges for Rev 637 = $240.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,295.60,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $321.30 in Billed Charges for Rev 637 = $295.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,192.78,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $321.30 in Billed Charges for Rev 637 = $192.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,192.78,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $321.30 in Billed Charges for Rev 637 = $192.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,PREVEA HEALTH NETWORK,PREVEA360,192.78,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $321.30 in Billed Charges for Rev 637 = $192.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,192.78,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $321.30 in Billed Charges for Rev 637 = $192.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,205.09,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $321.30 in Billed Charges for Rev 637 = $205.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,231.34,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $321.30 in Billed Charges for Rev 637 = $231.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,177.68,,,,,,,156.1500,321.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $321.30 in Billed Charges for Rev 637 = $177.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,177.68,,,,,,,156.1500,321.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $321.30 in Billed Charges for Rev 637 = $177.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,177.68,,,,,,,156.1500,321.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $321.30 in Billed Charges for Rev 637 = $177.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,UNITY HEALTH PLAN,UNITY HOSPICE,321.30,,,,,,,156.1500,321.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,231.34,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $321.30 in Billed Charges for Rev 637 = $231.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,199.21,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $321.30 in Billed Charges for Rev 637 = $199.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,231.34,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $321.30 in Billed Charges for Rev 637 = $231.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,231.34,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $321.30 in Billed Charges for Rev 637 = $231.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FOSFOMYCIN 3 G PACK,637,RC,70700-268-94,CDM,,,,,,both,1.000000,EA,321.3000,212.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,192.78,,,,,,,156.1500,321.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $321.30 in Billed Charges for Rev 637 = $192.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,AETNA,AETNA HSHS,14.08,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $21.80 in Billed Charges for Rev 637 = $14.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,AETNA,ALL COMMERCIAL AETNA,21.80,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.80 in Billed Charges for Rev 637 = $21.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,ANTHEM,ANTHEM POS/HMO,14.82,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $21.80 in Billed Charges for Rev 637 = $14.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,ANTHEM,ANTHEM PPO,14.82,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $21.80 in Billed Charges for Rev 637 = $14.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,21.80,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.80 in Billed Charges for Rev 637 = $21.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,CENPATICO,ALL MEDICAID CENPATICO,21.80,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.80 in Billed Charges for Rev 637 = $21.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,18.53,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.80 in Billed Charges for Rev 637 = $18.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,CIGNA,ALL COMMERCIAL CIGNA,15.26,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $21.80 in Billed Charges for Rev 637 = $15.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,COFINITY,COFINITY,21.80,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.80 in Billed Charges for Rev 637 = $21.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,20.71,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $21.80 in Billed Charges for Rev 637 = $20.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,18.31,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $21.80 in Billed Charges for Rev 637 = $18.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,15.48,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $21.80 in Billed Charges for Rev 637 = $15.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15.91,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $21.80 in Billed Charges for Rev 637 = $15.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,10.59,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $21.80 in Billed Charges for Rev 637 = $10.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,18.53,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.80 in Billed Charges for Rev 637 = $18.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,HUMANA,HUMANA CHOICE CARE HMO,13.84,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $21.80 in Billed Charges at 63.5% = $13.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,HUMANA,HUMANA CHOICE CARE PPO,18.53,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $21.80 in Billed Charges for Rev 637 = $18.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,HUMANA,HUMANA NATIIONAL POS HMO,13.84,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $21.80 in Billed Charges at 63.5% = $13.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15.91,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $21.80 in Billed Charges for Rev 637 = $15.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,21.80,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $21.80 in Billed Charges for Rev 637 = $21.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,21.80,,,,,,,10.5900,21.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.90,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $21.80 in Billed Charges for Rev 637 = $10.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,18.31,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $21.80 in Billed Charges for Rev 637 = $18.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,16.35,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $21.80 in Billed Charges for Rev 637 = $16.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,20.06,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $21.80 in Billed Charges for Rev 637 = $20.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.08,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.80 in Billed Charges for Rev 637 = $13.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.08,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.80 in Billed Charges for Rev 637 = $13.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,PREVEA HEALTH NETWORK,PREVEA360,13.08,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.80 in Billed Charges for Rev 637 = $13.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.08,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.80 in Billed Charges for Rev 637 = $13.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.91,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $21.80 in Billed Charges for Rev 637 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15.70,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.80 in Billed Charges for Rev 637 = $15.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.06,,,,,,,10.5900,21.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $21.80 in Billed Charges for Rev 637 = $12.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,UNITED HEALTHCARE,UHC ONEIDA NATION,12.06,,,,,,,10.5900,21.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $21.80 in Billed Charges for Rev 637 = $12.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,UNITED HEALTHCARE,UNITED HEALTHCARE,12.06,,,,,,,10.5900,21.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $21.80 in Billed Charges for Rev 637 = $12.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,UNITY HEALTH PLAN,UNITY HOSPICE,21.80,,,,,,,10.5900,21.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15.70,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.80 in Billed Charges for Rev 637 = $15.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,13.52,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $21.80 in Billed Charges for Rev 637 = $13.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15.70,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.80 in Billed Charges for Rev 637 = $15.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15.70,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $21.80 in Billed Charges for Rev 637 = $15.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETAPHIL LOTN 237 ML BOTTLE,637,RC,0299-3918-08,CDM,,,,,,both,237.000000,ML,21.8000,14.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.08,,,,,,,10.5900,21.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $21.80 in Billed Charges for Rev 637 = $13.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,AETNA,AETNA HSHS,5.49,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.50 in Billed Charges for Rev 637 = $5.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,AETNA,ALL COMMERCIAL AETNA,8.50,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.50 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,ANTHEM,ANTHEM POS/HMO,5.78,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.50 in Billed Charges for Rev 637 = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,ANTHEM,ANTHEM PPO,5.78,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.50 in Billed Charges for Rev 637 = $5.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.50,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.50 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,CENPATICO,ALL MEDICAID CENPATICO,8.50,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.50 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.23,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.50 in Billed Charges for Rev 637 = $7.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,CIGNA,ALL COMMERCIAL CIGNA,5.95,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.50 in Billed Charges for Rev 637 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,COFINITY,COFINITY,8.50,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.50 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.08,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.50 in Billed Charges for Rev 637 = $8.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,7.14,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.50 in Billed Charges for Rev 637 = $7.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.04,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.50 in Billed Charges for Rev 637 = $6.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.21,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.50 in Billed Charges for Rev 637 = $6.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,4.13,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.50 in Billed Charges for Rev 637 = $4.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.23,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.50 in Billed Charges for Rev 637 = $7.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,HUMANA,HUMANA CHOICE CARE HMO,5.40,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.50 in Billed Charges at 63.5% = $5.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,HUMANA,HUMANA CHOICE CARE PPO,7.23,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.50 in Billed Charges for Rev 637 = $7.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,HUMANA,HUMANA NATIIONAL POS HMO,5.40,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.50 in Billed Charges at 63.5% = $5.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.21,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.50 in Billed Charges for Rev 637 = $6.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.50,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.50 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.50,,,,,,,4.1300,8.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.25,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.50 in Billed Charges for Rev 637 = $4.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.14,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.50 in Billed Charges for Rev 637 = $7.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.38,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.50 in Billed Charges for Rev 637 = $6.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.82,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.50 in Billed Charges for Rev 637 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.10,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.50 in Billed Charges for Rev 637 = $5.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.10,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.50 in Billed Charges for Rev 637 = $5.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,PREVEA HEALTH NETWORK,PREVEA360,5.10,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.50 in Billed Charges for Rev 637 = $5.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.10,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.50 in Billed Charges for Rev 637 = $5.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.43,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.50 in Billed Charges for Rev 637 = $5.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.12,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.50 in Billed Charges for Rev 637 = $6.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.70,,,,,,,4.1300,8.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.50 in Billed Charges for Rev 637 = $4.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,4.70,,,,,,,4.1300,8.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.50 in Billed Charges for Rev 637 = $4.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,4.70,,,,,,,4.1300,8.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.50 in Billed Charges for Rev 637 = $4.70 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,UNITY HEALTH PLAN,UNITY HOSPICE,8.50,,,,,,,4.1300,8.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.12,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.50 in Billed Charges for Rev 637 = $6.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.27,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.50 in Billed Charges for Rev 637 = $5.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.12,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.50 in Billed Charges for Rev 637 = $6.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.12,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.50 in Billed Charges for Rev 637 = $6.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CETIRIZINE 10 MG TABS,637,RC,68001-436-16,CDM,,,,,,both,1.000000,EA,8.5000,5.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.10,,,,,,,4.1300,8.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.50 in Billed Charges for Rev 637 = $5.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,AETNA,AETNA HSHS,5.94,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $9.20 in Billed Charges for Rev 637 = $5.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,AETNA,ALL COMMERCIAL AETNA,9.20,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.20 in Billed Charges for Rev 637 = $9.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,ANTHEM,ANTHEM POS/HMO,6.26,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $9.20 in Billed Charges for Rev 637 = $6.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,ANTHEM,ANTHEM PPO,6.26,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $9.20 in Billed Charges for Rev 637 = $6.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,9.20,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.20 in Billed Charges for Rev 637 = $9.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,CENPATICO,ALL MEDICAID CENPATICO,9.20,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.20 in Billed Charges for Rev 637 = $9.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.82,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.20 in Billed Charges for Rev 637 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,CIGNA,ALL COMMERCIAL CIGNA,6.44,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $9.20 in Billed Charges for Rev 637 = $6.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,COFINITY,COFINITY,9.20,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.20 in Billed Charges for Rev 637 = $9.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.74,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $9.20 in Billed Charges for Rev 637 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,HEALTH CARE ALLIANCE,THE ALLIANCE,7.73,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.20 in Billed Charges for Rev 637 = $7.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.53,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $9.20 in Billed Charges for Rev 637 = $6.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.72,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.20 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,HSHS EMPLOYEES,HSHS EMPLOYEES,4.47,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $9.20 in Billed Charges for Rev 637 = $4.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.82,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.20 in Billed Charges for Rev 637 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,HUMANA,HUMANA CHOICE CARE HMO,5.84,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $9.20 in Billed Charges at 63.5% = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,HUMANA,HUMANA CHOICE CARE PPO,7.82,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $9.20 in Billed Charges for Rev 637 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,HUMANA,HUMANA NATIIONAL POS HMO,5.84,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $9.20 in Billed Charges at 63.5% = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.72,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $9.20 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,LIVE360,LIVE360 HSHS HEALTHY PLAN,9.20,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $9.20 in Billed Charges for Rev 637 = $9.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,9.20,,,,,,,4.4700,9.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.60,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $9.20 in Billed Charges for Rev 637 = $4.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.73,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $9.20 in Billed Charges for Rev 637 = $7.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.90,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $9.20 in Billed Charges for Rev 637 = $6.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.46,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $9.20 in Billed Charges for Rev 637 = $8.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.52,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.20 in Billed Charges for Rev 637 = $5.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.52,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.20 in Billed Charges for Rev 637 = $5.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,PREVEA HEALTH NETWORK,PREVEA360,5.52,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.20 in Billed Charges for Rev 637 = $5.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.52,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.20 in Billed Charges for Rev 637 = $5.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.87,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $9.20 in Billed Charges for Rev 637 = $5.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.62,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.20 in Billed Charges for Rev 637 = $6.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.09,,,,,,,4.4700,9.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $9.20 in Billed Charges for Rev 637 = $5.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,UNITED HEALTHCARE,UHC ONEIDA NATION,5.09,,,,,,,4.4700,9.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $9.20 in Billed Charges for Rev 637 = $5.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,UNITED HEALTHCARE,UNITED HEALTHCARE,5.09,,,,,,,4.4700,9.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $9.20 in Billed Charges for Rev 637 = $5.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,UNITY HEALTH PLAN,UNITY HOSPICE,9.20,,,,,,,4.4700,9.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.62,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.20 in Billed Charges for Rev 637 = $6.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.70,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $9.20 in Billed Charges for Rev 637 = $5.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.62,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.20 in Billed Charges for Rev 637 = $6.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.62,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $9.20 in Billed Charges for Rev 637 = $6.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORTHALIDONE 25 MG TABS 1 EACH BLISTER,637,RC,60687-317-11,CDM,,,,,,both,1.000000,EA,9.2000,6.0700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.52,,,,,,,4.4700,9.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $9.20 in Billed Charges for Rev 637 = $5.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,AETNA,AETNA HSHS,54.91,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $85.00 in Billed Charges for Rev 637 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,AETNA,ALL COMMERCIAL AETNA,85.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 637 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,ANTHEM,ANTHEM POS/HMO,57.80,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $85.00 in Billed Charges for Rev 637 = $57.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,ANTHEM,ANTHEM PPO,57.80,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $85.00 in Billed Charges for Rev 637 = $57.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,85.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 637 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,CENPATICO,ALL MEDICAID CENPATICO,85.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 637 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,72.25,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.00 in Billed Charges for Rev 637 = $72.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,CIGNA,ALL COMMERCIAL CIGNA,59.50,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $85.00 in Billed Charges for Rev 637 = $59.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,COFINITY,COFINITY,85.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 637 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,80.75,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $85.00 in Billed Charges for Rev 637 = $80.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,71.40,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.00 in Billed Charges for Rev 637 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,60.35,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $85.00 in Billed Charges for Rev 637 = $60.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,62.05,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.00 in Billed Charges for Rev 637 = $62.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,41.31,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $85.00 in Billed Charges for Rev 637 = $41.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,72.25,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.00 in Billed Charges for Rev 637 = $72.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,HUMANA,HUMANA CHOICE CARE HMO,53.98,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $85.00 in Billed Charges at 63.5% = $53.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,HUMANA,HUMANA CHOICE CARE PPO,72.25,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.00 in Billed Charges for Rev 637 = $72.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,HUMANA,HUMANA NATIIONAL POS HMO,53.98,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $85.00 in Billed Charges at 63.5% = $53.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,62.05,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.00 in Billed Charges for Rev 637 = $62.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,85.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.00 in Billed Charges for Rev 637 = $85.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,85.00,,,,,,,41.3100,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,42.50,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $85.00 in Billed Charges for Rev 637 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,71.40,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.00 in Billed Charges for Rev 637 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,63.75,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $85.00 in Billed Charges for Rev 637 = $63.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,78.20,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $85.00 in Billed Charges for Rev 637 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,51.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.00 in Billed Charges for Rev 637 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,51.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.00 in Billed Charges for Rev 637 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,PREVEA HEALTH NETWORK,PREVEA360,51.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.00 in Billed Charges for Rev 637 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,51.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.00 in Billed Charges for Rev 637 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,54.26,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $85.00 in Billed Charges for Rev 637 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,61.20,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.00 in Billed Charges for Rev 637 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,47.01,,,,,,,41.3100,85.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $85.00 in Billed Charges for Rev 637 = $47.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,47.01,,,,,,,41.3100,85.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $85.00 in Billed Charges for Rev 637 = $47.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,47.01,,,,,,,41.3100,85.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $85.00 in Billed Charges for Rev 637 = $47.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,UNITY HEALTH PLAN,UNITY HOSPICE,85.00,,,,,,,41.3100,85.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,61.20,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.00 in Billed Charges for Rev 637 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,52.70,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $85.00 in Billed Charges for Rev 637 = $52.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,61.20,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.00 in Billed Charges for Rev 637 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,61.20,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.00 in Billed Charges for Rev 637 = $61.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHOLECALCIFEROL 10 MCG/ML LIQD,637,RC,54838-006-50,CDM,,,,,,both,50.000000,ML,85.0000,56.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,51.00,,,,,,,41.3100,85.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.00 in Billed Charges for Rev 637 = $51.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,AETNA,AETNA HSHS,67.35,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $104.25 in Billed Charges for Rev 637 = $67.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,AETNA,ALL COMMERCIAL AETNA,104.25,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.25 in Billed Charges for Rev 637 = $104.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,ANTHEM,ANTHEM POS/HMO,70.89,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $104.25 in Billed Charges for Rev 637 = $70.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,ANTHEM,ANTHEM PPO,70.89,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $104.25 in Billed Charges for Rev 637 = $70.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,104.25,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.25 in Billed Charges for Rev 637 = $104.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,CENPATICO,ALL MEDICAID CENPATICO,104.25,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.25 in Billed Charges for Rev 637 = $104.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,88.61,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.25 in Billed Charges for Rev 637 = $88.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,CIGNA,ALL COMMERCIAL CIGNA,72.98,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $104.25 in Billed Charges for Rev 637 = $72.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,COFINITY,COFINITY,104.25,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.25 in Billed Charges for Rev 637 = $104.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,99.04,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $104.25 in Billed Charges for Rev 637 = $99.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,87.57,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.25 in Billed Charges for Rev 637 = $87.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,74.02,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $104.25 in Billed Charges for Rev 637 = $74.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,76.10,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.25 in Billed Charges for Rev 637 = $76.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,50.67,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $104.25 in Billed Charges for Rev 637 = $50.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,88.61,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.25 in Billed Charges for Rev 637 = $88.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,HUMANA,HUMANA CHOICE CARE HMO,66.20,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $104.25 in Billed Charges at 63.5% = $66.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,HUMANA,HUMANA CHOICE CARE PPO,88.61,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $104.25 in Billed Charges for Rev 637 = $88.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,HUMANA,HUMANA NATIIONAL POS HMO,66.20,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $104.25 in Billed Charges at 63.5% = $66.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,76.10,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $104.25 in Billed Charges for Rev 637 = $76.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,104.25,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $104.25 in Billed Charges for Rev 637 = $104.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,104.25,,,,,,,50.6700,104.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,52.13,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $104.25 in Billed Charges for Rev 637 = $52.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,87.57,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $104.25 in Billed Charges for Rev 637 = $87.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,78.19,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $104.25 in Billed Charges for Rev 637 = $78.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,95.91,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $104.25 in Billed Charges for Rev 637 = $95.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,62.55,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.25 in Billed Charges for Rev 637 = $62.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,62.55,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.25 in Billed Charges for Rev 637 = $62.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,PREVEA HEALTH NETWORK,PREVEA360,62.55,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.25 in Billed Charges for Rev 637 = $62.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,62.55,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.25 in Billed Charges for Rev 637 = $62.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,66.54,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $104.25 in Billed Charges for Rev 637 = $66.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,75.06,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.25 in Billed Charges for Rev 637 = $75.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,57.65,,,,,,,50.6700,104.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $104.25 in Billed Charges for Rev 637 = $57.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,UNITED HEALTHCARE,UHC ONEIDA NATION,57.65,,,,,,,50.6700,104.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $104.25 in Billed Charges for Rev 637 = $57.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,UNITED HEALTHCARE,UNITED HEALTHCARE,57.65,,,,,,,50.6700,104.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $104.25 in Billed Charges for Rev 637 = $57.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,UNITY HEALTH PLAN,UNITY HOSPICE,104.25,,,,,,,50.6700,104.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,75.06,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.25 in Billed Charges for Rev 637 = $75.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,64.64,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $104.25 in Billed Charges for Rev 637 = $64.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,75.06,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.25 in Billed Charges for Rev 637 = $75.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,75.06,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $104.25 in Billed Charges for Rev 637 = $75.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CINACALCET 30 MG TABS,637,RC,16729-440-10,CDM,,,,,,both,1.000000,EA,104.2500,68.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,62.55,,,,,,,50.6700,104.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $104.25 in Billed Charges for Rev 637 = $62.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,AETNA,AETNA HSHS,260.37,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $403.05 in Billed Charges for Rev 637 = $260.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,AETNA,ALL COMMERCIAL AETNA,403.05,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $403.05 in Billed Charges for Rev 637 = $403.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,ANTHEM,ANTHEM POS/HMO,274.07,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $403.05 in Billed Charges for Rev 637 = $274.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,ANTHEM,ANTHEM PPO,274.07,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $403.05 in Billed Charges for Rev 637 = $274.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,403.05,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $403.05 in Billed Charges for Rev 637 = $403.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,CENPATICO,ALL MEDICAID CENPATICO,403.05,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $403.05 in Billed Charges for Rev 637 = $403.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,342.59,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $403.05 in Billed Charges for Rev 637 = $342.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,CIGNA,ALL COMMERCIAL CIGNA,282.14,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $403.05 in Billed Charges for Rev 637 = $282.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,COFINITY,COFINITY,403.05,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $403.05 in Billed Charges for Rev 637 = $403.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,382.90,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $403.05 in Billed Charges for Rev 637 = $382.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,338.56,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $403.05 in Billed Charges for Rev 637 = $338.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,286.17,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $403.05 in Billed Charges for Rev 637 = $286.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,294.23,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $403.05 in Billed Charges for Rev 637 = $294.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,195.88,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $403.05 in Billed Charges for Rev 637 = $195.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,342.59,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $403.05 in Billed Charges for Rev 637 = $342.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,HUMANA,HUMANA CHOICE CARE HMO,255.94,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $403.05 in Billed Charges at 63.5% = $255.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,HUMANA,HUMANA CHOICE CARE PPO,342.59,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $403.05 in Billed Charges for Rev 637 = $342.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,HUMANA,HUMANA NATIIONAL POS HMO,255.94,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $403.05 in Billed Charges at 63.5% = $255.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,294.23,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $403.05 in Billed Charges for Rev 637 = $294.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,403.05,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $403.05 in Billed Charges for Rev 637 = $403.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,403.05,,,,,,,195.8800,403.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,201.53,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $403.05 in Billed Charges for Rev 637 = $201.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,338.56,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $403.05 in Billed Charges for Rev 637 = $338.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,302.29,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $403.05 in Billed Charges for Rev 637 = $302.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,370.81,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $403.05 in Billed Charges for Rev 637 = $370.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,241.83,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $403.05 in Billed Charges for Rev 637 = $241.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,241.83,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $403.05 in Billed Charges for Rev 637 = $241.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,PREVEA HEALTH NETWORK,PREVEA360,241.83,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $403.05 in Billed Charges for Rev 637 = $241.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,241.83,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $403.05 in Billed Charges for Rev 637 = $241.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,257.27,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $403.05 in Billed Charges for Rev 637 = $257.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,290.20,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $403.05 in Billed Charges for Rev 637 = $290.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,222.89,,,,,,,195.8800,403.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $403.05 in Billed Charges for Rev 637 = $222.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,UNITED HEALTHCARE,UHC ONEIDA NATION,222.89,,,,,,,195.8800,403.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $403.05 in Billed Charges for Rev 637 = $222.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,UNITED HEALTHCARE,UNITED HEALTHCARE,222.89,,,,,,,195.8800,403.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $403.05 in Billed Charges for Rev 637 = $222.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,UNITY HEALTH PLAN,UNITY HOSPICE,403.05,,,,,,,195.8800,403.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,290.20,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $403.05 in Billed Charges for Rev 637 = $290.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,249.89,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $403.05 in Billed Charges for Rev 637 = $249.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,290.20,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $403.05 in Billed Charges for Rev 637 = $290.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,290.20,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $403.05 in Billed Charges for Rev 637 = $290.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,637,RC,49884-161-11,CDM,,,,,,both,3.700000,ML,403.0500,266.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,241.83,,,,,,,195.8800,403.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $403.05 in Billed Charges for Rev 637 = $241.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,AETNA,AETNA HSHS,11.24,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $17.40 in Billed Charges for Rev 637 = $11.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,AETNA,ALL COMMERCIAL AETNA,17.40,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.40 in Billed Charges for Rev 637 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,ANTHEM,ANTHEM POS/HMO,11.83,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $17.40 in Billed Charges for Rev 637 = $11.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,ANTHEM,ANTHEM PPO,11.83,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $17.40 in Billed Charges for Rev 637 = $11.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17.40,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.40 in Billed Charges for Rev 637 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,CENPATICO,ALL MEDICAID CENPATICO,17.40,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.40 in Billed Charges for Rev 637 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.79,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.40 in Billed Charges for Rev 637 = $14.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,CIGNA,ALL COMMERCIAL CIGNA,12.18,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $17.40 in Billed Charges for Rev 637 = $12.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,COFINITY,COFINITY,17.40,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.40 in Billed Charges for Rev 637 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16.53,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $17.40 in Billed Charges for Rev 637 = $16.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,14.62,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.40 in Billed Charges for Rev 637 = $14.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12.35,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $17.40 in Billed Charges for Rev 637 = $12.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.70,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.40 in Billed Charges for Rev 637 = $12.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,8.46,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $17.40 in Billed Charges for Rev 637 = $8.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.79,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.40 in Billed Charges for Rev 637 = $14.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,HUMANA,HUMANA CHOICE CARE HMO,11.05,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $17.40 in Billed Charges at 63.5% = $11.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,HUMANA,HUMANA CHOICE CARE PPO,14.79,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.40 in Billed Charges for Rev 637 = $14.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,HUMANA,HUMANA NATIIONAL POS HMO,11.05,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $17.40 in Billed Charges at 63.5% = $11.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.70,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.40 in Billed Charges for Rev 637 = $12.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,17.40,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.40 in Billed Charges for Rev 637 = $17.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.40,,,,,,,8.4600,17.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.70,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $17.40 in Billed Charges for Rev 637 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.62,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.40 in Billed Charges for Rev 637 = $14.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13.05,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $17.40 in Billed Charges for Rev 637 = $13.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,16.01,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $17.40 in Billed Charges for Rev 637 = $16.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.44,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.40 in Billed Charges for Rev 637 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.44,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.40 in Billed Charges for Rev 637 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,PREVEA HEALTH NETWORK,PREVEA360,10.44,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.40 in Billed Charges for Rev 637 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.44,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.40 in Billed Charges for Rev 637 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.11,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $17.40 in Billed Charges for Rev 637 = $11.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.53,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.40 in Billed Charges for Rev 637 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.62,,,,,,,8.4600,17.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.40 in Billed Charges for Rev 637 = $9.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,9.62,,,,,,,8.4600,17.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.40 in Billed Charges for Rev 637 = $9.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,9.62,,,,,,,8.4600,17.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.40 in Billed Charges for Rev 637 = $9.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,UNITY HEALTH PLAN,UNITY HOSPICE,17.40,,,,,,,8.4600,17.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.53,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.40 in Billed Charges for Rev 637 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.79,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $17.40 in Billed Charges for Rev 637 = $10.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.53,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.40 in Billed Charges for Rev 637 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.53,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.40 in Billed Charges for Rev 637 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 300 MG CAPS,637,RC,68001-362-06,CDM,,,,,,both,1.000000,EA,17.4000,11.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.44,,,,,,,8.4600,17.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.40 in Billed Charges for Rev 637 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,AETNA,AETNA HSHS,393.16,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $608.60 in Billed Charges for Rev 637 = $393.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,AETNA,ALL COMMERCIAL AETNA,608.60,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.60 in Billed Charges for Rev 637 = $608.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,ANTHEM,ANTHEM POS/HMO,413.85,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $608.60 in Billed Charges for Rev 637 = $413.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,ANTHEM,ANTHEM PPO,413.85,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $608.60 in Billed Charges for Rev 637 = $413.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,608.60,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.60 in Billed Charges for Rev 637 = $608.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,CENPATICO,ALL MEDICAID CENPATICO,608.60,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.60 in Billed Charges for Rev 637 = $608.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,517.31,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $608.60 in Billed Charges for Rev 637 = $517.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,CIGNA,ALL COMMERCIAL CIGNA,426.02,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $608.60 in Billed Charges for Rev 637 = $426.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,COFINITY,COFINITY,608.60,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.60 in Billed Charges for Rev 637 = $608.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,578.17,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $608.60 in Billed Charges for Rev 637 = $578.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,HEALTH CARE ALLIANCE,THE ALLIANCE,511.22,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $608.60 in Billed Charges for Rev 637 = $511.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,432.11,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $608.60 in Billed Charges for Rev 637 = $432.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,444.28,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $608.60 in Billed Charges for Rev 637 = $444.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,HSHS EMPLOYEES,HSHS EMPLOYEES,295.78,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $608.60 in Billed Charges for Rev 637 = $295.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,517.31,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $608.60 in Billed Charges for Rev 637 = $517.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,HUMANA,HUMANA CHOICE CARE HMO,386.46,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $608.60 in Billed Charges at 63.5% = $386.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,HUMANA,HUMANA CHOICE CARE PPO,517.31,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $608.60 in Billed Charges for Rev 637 = $517.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,HUMANA,HUMANA NATIIONAL POS HMO,386.46,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $608.60 in Billed Charges at 63.5% = $386.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,444.28,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $608.60 in Billed Charges for Rev 637 = $444.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,LIVE360,LIVE360 HSHS HEALTHY PLAN,608.60,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $608.60 in Billed Charges for Rev 637 = $608.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,608.60,,,,,,,295.7800,608.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,304.30,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $608.60 in Billed Charges for Rev 637 = $304.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,511.22,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $608.60 in Billed Charges for Rev 637 = $511.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,456.45,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $608.60 in Billed Charges for Rev 637 = $456.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,559.91,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $608.60 in Billed Charges for Rev 637 = $559.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,365.16,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $608.60 in Billed Charges for Rev 637 = $365.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,365.16,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $608.60 in Billed Charges for Rev 637 = $365.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,PREVEA HEALTH NETWORK,PREVEA360,365.16,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $608.60 in Billed Charges for Rev 637 = $365.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,365.16,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $608.60 in Billed Charges for Rev 637 = $365.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,388.47,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $608.60 in Billed Charges for Rev 637 = $388.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,438.19,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $608.60 in Billed Charges for Rev 637 = $438.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,336.56,,,,,,,295.7800,608.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $608.60 in Billed Charges for Rev 637 = $336.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,UNITED HEALTHCARE,UHC ONEIDA NATION,336.56,,,,,,,295.7800,608.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $608.60 in Billed Charges for Rev 637 = $336.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,UNITED HEALTHCARE,UNITED HEALTHCARE,336.56,,,,,,,295.7800,608.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $608.60 in Billed Charges for Rev 637 = $336.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,UNITY HEALTH PLAN,UNITY HOSPICE,608.60,,,,,,,295.7800,608.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,438.19,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $608.60 in Billed Charges for Rev 637 = $438.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,377.33,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $608.60 in Billed Charges for Rev 637 = $377.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,438.19,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $608.60 in Billed Charges for Rev 637 = $438.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,438.19,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $608.60 in Billed Charges for Rev 637 = $438.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCITRIOL 1 MCG/ML SOLN,637,RC,0054-3120-41,CDM,,,,,,both,15.000000,ML,608.6000,401.6800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,365.16,,,,,,,295.7800,608.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $608.60 in Billed Charges for Rev 637 = $365.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,AETNA,AETNA HSHS,16.70,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $25.85 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,AETNA,ALL COMMERCIAL AETNA,25.85,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.85 in Billed Charges for Rev 637 = $25.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,ANTHEM,ANTHEM POS/HMO,17.58,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $25.85 in Billed Charges for Rev 637 = $17.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,ANTHEM,ANTHEM PPO,17.58,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $25.85 in Billed Charges for Rev 637 = $17.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,25.85,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.85 in Billed Charges for Rev 637 = $25.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,CENPATICO,ALL MEDICAID CENPATICO,25.85,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.85 in Billed Charges for Rev 637 = $25.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,21.97,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.85 in Billed Charges for Rev 637 = $21.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,CIGNA,ALL COMMERCIAL CIGNA,18.10,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $25.85 in Billed Charges for Rev 637 = $18.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,COFINITY,COFINITY,25.85,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.85 in Billed Charges for Rev 637 = $25.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,24.56,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $25.85 in Billed Charges for Rev 637 = $24.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,HEALTH CARE ALLIANCE,THE ALLIANCE,21.71,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.85 in Billed Charges for Rev 637 = $21.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,18.35,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $25.85 in Billed Charges for Rev 637 = $18.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.87,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.85 in Billed Charges for Rev 637 = $18.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,HSHS EMPLOYEES,HSHS EMPLOYEES,12.56,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $25.85 in Billed Charges for Rev 637 = $12.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,21.97,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.85 in Billed Charges for Rev 637 = $21.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,HUMANA,HUMANA CHOICE CARE HMO,16.41,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $25.85 in Billed Charges at 63.5% = $16.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,HUMANA,HUMANA CHOICE CARE PPO,21.97,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.85 in Billed Charges for Rev 637 = $21.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,HUMANA,HUMANA NATIIONAL POS HMO,16.41,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $25.85 in Billed Charges at 63.5% = $16.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.87,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.85 in Billed Charges for Rev 637 = $18.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,LIVE360,LIVE360 HSHS HEALTHY PLAN,25.85,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.85 in Billed Charges for Rev 637 = $25.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,25.85,,,,,,,12.5600,25.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.93,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $25.85 in Billed Charges for Rev 637 = $12.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,21.71,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.85 in Billed Charges for Rev 637 = $21.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,19.39,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $25.85 in Billed Charges for Rev 637 = $19.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,23.78,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $25.85 in Billed Charges for Rev 637 = $23.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.51,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.85 in Billed Charges for Rev 637 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.51,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.85 in Billed Charges for Rev 637 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,PREVEA HEALTH NETWORK,PREVEA360,15.51,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.85 in Billed Charges for Rev 637 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.51,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.85 in Billed Charges for Rev 637 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,16.50,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $25.85 in Billed Charges for Rev 637 = $16.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,18.61,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.85 in Billed Charges for Rev 637 = $18.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.30,,,,,,,12.5600,25.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $25.85 in Billed Charges for Rev 637 = $14.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,UNITED HEALTHCARE,UHC ONEIDA NATION,14.30,,,,,,,12.5600,25.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $25.85 in Billed Charges for Rev 637 = $14.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,UNITED HEALTHCARE,UNITED HEALTHCARE,14.30,,,,,,,12.5600,25.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $25.85 in Billed Charges for Rev 637 = $14.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,UNITY HEALTH PLAN,UNITY HOSPICE,25.85,,,,,,,12.5600,25.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,18.61,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.85 in Billed Charges for Rev 637 = $18.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.03,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $25.85 in Billed Charges for Rev 637 = $16.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,18.61,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.85 in Billed Charges for Rev 637 = $18.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,18.61,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.85 in Billed Charges for Rev 637 = $18.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMIDE PEROXIDE 6.5 % SOLN 15 ML BOTTLE,637,RC,46122-557-05,CDM,,,,,,both,15.000000,ML,25.8500,17.0600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.51,,,,,,,12.5600,25.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.85 in Billed Charges for Rev 637 = $15.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,AETNA,AETNA HSHS,23.06,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $35.70 in Billed Charges for Rev 637 = $23.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,AETNA,ALL COMMERCIAL AETNA,35.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.70 in Billed Charges for Rev 637 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,ANTHEM,ANTHEM POS/HMO,24.28,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $35.70 in Billed Charges for Rev 637 = $24.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,ANTHEM,ANTHEM PPO,24.28,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $35.70 in Billed Charges for Rev 637 = $24.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,35.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.70 in Billed Charges for Rev 637 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,CENPATICO,ALL MEDICAID CENPATICO,35.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.70 in Billed Charges for Rev 637 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,30.35,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.70 in Billed Charges for Rev 637 = $30.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,CIGNA,ALL COMMERCIAL CIGNA,24.99,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $35.70 in Billed Charges for Rev 637 = $24.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,COFINITY,COFINITY,35.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.70 in Billed Charges for Rev 637 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,33.92,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $35.70 in Billed Charges for Rev 637 = $33.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,29.99,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.70 in Billed Charges for Rev 637 = $29.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,25.35,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $35.70 in Billed Charges for Rev 637 = $25.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,26.06,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.70 in Billed Charges for Rev 637 = $26.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,17.35,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $35.70 in Billed Charges for Rev 637 = $17.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,30.35,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.70 in Billed Charges for Rev 637 = $30.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,HUMANA,HUMANA CHOICE CARE HMO,22.67,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $35.70 in Billed Charges at 63.5% = $22.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,HUMANA,HUMANA CHOICE CARE PPO,30.35,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.70 in Billed Charges for Rev 637 = $30.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,HUMANA,HUMANA NATIIONAL POS HMO,22.67,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $35.70 in Billed Charges at 63.5% = $22.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,26.06,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.70 in Billed Charges for Rev 637 = $26.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,35.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.70 in Billed Charges for Rev 637 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,35.70,,,,,,,17.3500,35.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,17.85,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $35.70 in Billed Charges for Rev 637 = $17.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,29.99,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.70 in Billed Charges for Rev 637 = $29.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,26.78,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $35.70 in Billed Charges for Rev 637 = $26.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,32.84,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $35.70 in Billed Charges for Rev 637 = $32.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.42,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.70 in Billed Charges for Rev 637 = $21.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.42,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.70 in Billed Charges for Rev 637 = $21.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,PREVEA HEALTH NETWORK,PREVEA360,21.42,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.70 in Billed Charges for Rev 637 = $21.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.42,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.70 in Billed Charges for Rev 637 = $21.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,22.79,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $35.70 in Billed Charges for Rev 637 = $22.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,25.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.70 in Billed Charges for Rev 637 = $25.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.74,,,,,,,17.3500,35.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.70 in Billed Charges for Rev 637 = $19.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,19.74,,,,,,,17.3500,35.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.70 in Billed Charges for Rev 637 = $19.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,19.74,,,,,,,17.3500,35.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.70 in Billed Charges for Rev 637 = $19.74 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,UNITY HEALTH PLAN,UNITY HOSPICE,35.70,,,,,,,17.3500,35.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,25.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.70 in Billed Charges for Rev 637 = $25.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,22.13,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $35.70 in Billed Charges for Rev 637 = $22.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,25.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.70 in Billed Charges for Rev 637 = $25.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,25.70,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.70 in Billed Charges for Rev 637 = $25.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,42799-123-01,CDM,,,,,,both,1.000000,EA,35.7000,23.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,21.42,,,,,,,17.3500,35.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.70 in Billed Charges for Rev 637 = $21.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,AETNA,AETNA HSHS,48.00,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $74.30 in Billed Charges for Rev 637 = $48.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,AETNA,ALL COMMERCIAL AETNA,74.30,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.30 in Billed Charges for Rev 637 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,ANTHEM,ANTHEM POS/HMO,50.52,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $74.30 in Billed Charges for Rev 637 = $50.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,ANTHEM,ANTHEM PPO,50.52,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $74.30 in Billed Charges for Rev 637 = $50.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,74.30,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.30 in Billed Charges for Rev 637 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,CENPATICO,ALL MEDICAID CENPATICO,74.30,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.30 in Billed Charges for Rev 637 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,63.16,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.30 in Billed Charges for Rev 637 = $63.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,CIGNA,ALL COMMERCIAL CIGNA,52.01,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $74.30 in Billed Charges for Rev 637 = $52.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,COFINITY,COFINITY,74.30,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.30 in Billed Charges for Rev 637 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,70.59,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $74.30 in Billed Charges for Rev 637 = $70.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,62.41,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.30 in Billed Charges for Rev 637 = $62.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.75,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $74.30 in Billed Charges for Rev 637 = $52.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.24,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.30 in Billed Charges for Rev 637 = $54.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,36.11,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $74.30 in Billed Charges for Rev 637 = $36.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,63.16,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.30 in Billed Charges for Rev 637 = $63.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,HUMANA,HUMANA CHOICE CARE HMO,47.18,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $74.30 in Billed Charges at 63.5% = $47.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,HUMANA,HUMANA CHOICE CARE PPO,63.16,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.30 in Billed Charges for Rev 637 = $63.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,HUMANA,HUMANA NATIIONAL POS HMO,47.18,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $74.30 in Billed Charges at 63.5% = $47.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.24,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.30 in Billed Charges for Rev 637 = $54.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,74.30,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.30 in Billed Charges for Rev 637 = $74.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,74.30,,,,,,,36.1100,74.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.15,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $74.30 in Billed Charges for Rev 637 = $37.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,62.41,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.30 in Billed Charges for Rev 637 = $62.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.73,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $74.30 in Billed Charges for Rev 637 = $55.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,68.36,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $74.30 in Billed Charges for Rev 637 = $68.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,44.58,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.30 in Billed Charges for Rev 637 = $44.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,44.58,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.30 in Billed Charges for Rev 637 = $44.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,PREVEA HEALTH NETWORK,PREVEA360,44.58,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.30 in Billed Charges for Rev 637 = $44.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,44.58,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.30 in Billed Charges for Rev 637 = $44.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.43,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $74.30 in Billed Charges for Rev 637 = $47.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.50,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.30 in Billed Charges for Rev 637 = $53.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,41.09,,,,,,,36.1100,74.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.30 in Billed Charges for Rev 637 = $41.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,41.09,,,,,,,36.1100,74.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.30 in Billed Charges for Rev 637 = $41.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,41.09,,,,,,,36.1100,74.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.30 in Billed Charges for Rev 637 = $41.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,UNITY HEALTH PLAN,UNITY HOSPICE,74.30,,,,,,,36.1100,74.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.50,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.30 in Billed Charges for Rev 637 = $53.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,46.07,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $74.30 in Billed Charges for Rev 637 = $46.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.50,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.30 in Billed Charges for Rev 637 = $53.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.50,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.30 in Billed Charges for Rev 637 = $53.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBIDOPA 25 MG TABS,637,RC,59651-146-01,CDM,,,,,,both,1.000000,EA,74.3000,49.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.58,,,,,,,36.1100,74.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.30 in Billed Charges for Rev 637 = $44.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,AETNA,AETNA HSHS,35.59,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $55.10 in Billed Charges for Rev 637 = $35.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,AETNA,ALL COMMERCIAL AETNA,55.10,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.10 in Billed Charges for Rev 637 = $55.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,ANTHEM,ANTHEM POS/HMO,37.47,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $55.10 in Billed Charges for Rev 637 = $37.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,ANTHEM,ANTHEM PPO,37.47,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $55.10 in Billed Charges for Rev 637 = $37.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,55.10,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.10 in Billed Charges for Rev 637 = $55.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,CENPATICO,ALL MEDICAID CENPATICO,55.10,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.10 in Billed Charges for Rev 637 = $55.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,46.84,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.10 in Billed Charges for Rev 637 = $46.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,CIGNA,ALL COMMERCIAL CIGNA,38.57,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $55.10 in Billed Charges for Rev 637 = $38.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,COFINITY,COFINITY,55.10,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.10 in Billed Charges for Rev 637 = $55.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,52.35,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $55.10 in Billed Charges for Rev 637 = $52.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,46.28,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $55.10 in Billed Charges for Rev 637 = $46.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,39.12,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $55.10 in Billed Charges for Rev 637 = $39.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,40.22,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $55.10 in Billed Charges for Rev 637 = $40.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,26.78,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $55.10 in Billed Charges for Rev 637 = $26.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,46.84,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.10 in Billed Charges for Rev 637 = $46.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,HUMANA,HUMANA CHOICE CARE HMO,34.99,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $55.10 in Billed Charges at 63.5% = $34.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,HUMANA,HUMANA CHOICE CARE PPO,46.84,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $55.10 in Billed Charges for Rev 637 = $46.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,HUMANA,HUMANA NATIIONAL POS HMO,34.99,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $55.10 in Billed Charges at 63.5% = $34.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,40.22,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $55.10 in Billed Charges for Rev 637 = $40.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,55.10,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $55.10 in Billed Charges for Rev 637 = $55.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,55.10,,,,,,,26.7800,55.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27.55,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $55.10 in Billed Charges for Rev 637 = $27.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,46.28,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $55.10 in Billed Charges for Rev 637 = $46.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,41.33,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $55.10 in Billed Charges for Rev 637 = $41.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,50.69,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $55.10 in Billed Charges for Rev 637 = $50.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,33.06,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $55.10 in Billed Charges for Rev 637 = $33.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,33.06,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $55.10 in Billed Charges for Rev 637 = $33.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,PREVEA HEALTH NETWORK,PREVEA360,33.06,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $55.10 in Billed Charges for Rev 637 = $33.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,33.06,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $55.10 in Billed Charges for Rev 637 = $33.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,35.17,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $55.10 in Billed Charges for Rev 637 = $35.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,39.67,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.10 in Billed Charges for Rev 637 = $39.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,30.47,,,,,,,26.7800,55.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $55.10 in Billed Charges for Rev 637 = $30.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,UNITED HEALTHCARE,UHC ONEIDA NATION,30.47,,,,,,,26.7800,55.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $55.10 in Billed Charges for Rev 637 = $30.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,UNITED HEALTHCARE,UNITED HEALTHCARE,30.47,,,,,,,26.7800,55.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $55.10 in Billed Charges for Rev 637 = $30.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,UNITY HEALTH PLAN,UNITY HOSPICE,55.10,,,,,,,26.7800,55.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,39.67,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.10 in Billed Charges for Rev 637 = $39.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,34.16,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $55.10 in Billed Charges for Rev 637 = $34.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,39.67,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.10 in Billed Charges for Rev 637 = $39.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,39.67,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $55.10 in Billed Charges for Rev 637 = $39.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE EC 3 MG CPEP,637,RC,60687-596-33,CDM,,,,,,both,1.000000,EA,55.1000,36.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,33.06,,,,,,,26.7800,55.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $55.10 in Billed Charges for Rev 637 = $33.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,AETNA,AETNA HSHS,212.28,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $328.60 in Billed Charges for Rev 637 = $212.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,AETNA,ALL COMMERCIAL AETNA,328.60,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $328.60 in Billed Charges for Rev 637 = $328.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,ANTHEM,ANTHEM POS/HMO,223.45,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $328.60 in Billed Charges for Rev 637 = $223.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,ANTHEM,ANTHEM PPO,223.45,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $328.60 in Billed Charges for Rev 637 = $223.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,328.60,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $328.60 in Billed Charges for Rev 637 = $328.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,CENPATICO,ALL MEDICAID CENPATICO,328.60,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $328.60 in Billed Charges for Rev 637 = $328.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,279.31,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $328.60 in Billed Charges for Rev 637 = $279.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,CIGNA,ALL COMMERCIAL CIGNA,230.02,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $328.60 in Billed Charges for Rev 637 = $230.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,COFINITY,COFINITY,328.60,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $328.60 in Billed Charges for Rev 637 = $328.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,312.17,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $328.60 in Billed Charges for Rev 637 = $312.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,276.02,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $328.60 in Billed Charges for Rev 637 = $276.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,233.31,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $328.60 in Billed Charges for Rev 637 = $233.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,239.88,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $328.60 in Billed Charges for Rev 637 = $239.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,159.70,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $328.60 in Billed Charges for Rev 637 = $159.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,279.31,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $328.60 in Billed Charges for Rev 637 = $279.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,HUMANA,HUMANA CHOICE CARE HMO,208.66,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $328.60 in Billed Charges at 63.5% = $208.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,HUMANA,HUMANA CHOICE CARE PPO,279.31,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $328.60 in Billed Charges for Rev 637 = $279.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,HUMANA,HUMANA NATIIONAL POS HMO,208.66,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $328.60 in Billed Charges at 63.5% = $208.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,239.88,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $328.60 in Billed Charges for Rev 637 = $239.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,328.60,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $328.60 in Billed Charges for Rev 637 = $328.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,328.60,,,,,,,159.7000,328.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,164.30,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $328.60 in Billed Charges for Rev 637 = $164.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,276.02,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $328.60 in Billed Charges for Rev 637 = $276.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,246.45,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $328.60 in Billed Charges for Rev 637 = $246.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,302.31,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $328.60 in Billed Charges for Rev 637 = $302.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,197.16,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $328.60 in Billed Charges for Rev 637 = $197.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,197.16,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $328.60 in Billed Charges for Rev 637 = $197.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,PREVEA HEALTH NETWORK,PREVEA360,197.16,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $328.60 in Billed Charges for Rev 637 = $197.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,197.16,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $328.60 in Billed Charges for Rev 637 = $197.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,209.75,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $328.60 in Billed Charges for Rev 637 = $209.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,236.59,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $328.60 in Billed Charges for Rev 637 = $236.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,181.72,,,,,,,159.7000,328.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $328.60 in Billed Charges for Rev 637 = $181.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,181.72,,,,,,,159.7000,328.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $328.60 in Billed Charges for Rev 637 = $181.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,181.72,,,,,,,159.7000,328.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $328.60 in Billed Charges for Rev 637 = $181.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,UNITY HEALTH PLAN,UNITY HOSPICE,328.60,,,,,,,159.7000,328.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,236.59,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $328.60 in Billed Charges for Rev 637 = $236.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,203.73,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $328.60 in Billed Charges for Rev 637 = $203.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,236.59,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $328.60 in Billed Charges for Rev 637 = $236.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,236.59,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $328.60 in Billed Charges for Rev 637 = $236.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 10 MCG/HR PTWK,637,RC,42858-493-40,CDM,,,,,,both,1.000000,EA,328.6000,216.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,197.16,,,,,,,159.7000,328.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $328.60 in Billed Charges for Rev 637 = $197.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,AETNA,AETNA HSHS,9.88,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $15.30 in Billed Charges for Rev 637 = $9.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,AETNA,ALL COMMERCIAL AETNA,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 637 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,ANTHEM,ANTHEM POS/HMO,10.40,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $15.30 in Billed Charges for Rev 637 = $10.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,ANTHEM,ANTHEM PPO,10.40,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $15.30 in Billed Charges for Rev 637 = $10.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 637 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,CENPATICO,ALL MEDICAID CENPATICO,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 637 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.01,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.30 in Billed Charges for Rev 637 = $13.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,CIGNA,ALL COMMERCIAL CIGNA,10.71,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $15.30 in Billed Charges for Rev 637 = $10.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,COFINITY,COFINITY,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 637 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14.54,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $15.30 in Billed Charges for Rev 637 = $14.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,12.85,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.30 in Billed Charges for Rev 637 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.86,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $15.30 in Billed Charges for Rev 637 = $10.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.17,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.30 in Billed Charges for Rev 637 = $11.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,7.44,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $15.30 in Billed Charges for Rev 637 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.01,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.30 in Billed Charges for Rev 637 = $13.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,HUMANA,HUMANA CHOICE CARE HMO,9.72,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $15.30 in Billed Charges at 63.5% = $9.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,HUMANA,HUMANA CHOICE CARE PPO,13.01,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.30 in Billed Charges for Rev 637 = $13.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,HUMANA,HUMANA NATIIONAL POS HMO,9.72,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $15.30 in Billed Charges at 63.5% = $9.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.17,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.30 in Billed Charges for Rev 637 = $11.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 637 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.30,,,,,,,7.4400,15.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.65,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $15.30 in Billed Charges for Rev 637 = $7.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.85,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.30 in Billed Charges for Rev 637 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.48,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $15.30 in Billed Charges for Rev 637 = $11.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,14.08,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $15.30 in Billed Charges for Rev 637 = $14.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 637 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 637 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,PREVEA HEALTH NETWORK,PREVEA360,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 637 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 637 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.77,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $15.30 in Billed Charges for Rev 637 = $9.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.02,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.30 in Billed Charges for Rev 637 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.46,,,,,,,7.4400,15.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.30 in Billed Charges for Rev 637 = $8.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,8.46,,,,,,,7.4400,15.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.30 in Billed Charges for Rev 637 = $8.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,8.46,,,,,,,7.4400,15.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.30 in Billed Charges for Rev 637 = $8.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,UNITY HEALTH PLAN,UNITY HOSPICE,15.30,,,,,,,7.4400,15.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.02,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.30 in Billed Charges for Rev 637 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.49,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $15.30 in Billed Charges for Rev 637 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.02,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.30 in Billed Charges for Rev 637 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.02,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.30 in Billed Charges for Rev 637 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,0228-3156-03,CDM,,,,,,both,1.000000,EA,15.3000,10.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 637 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,AETNA,AETNA HSHS,141.54,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $219.10 in Billed Charges for Rev 637 = $141.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,AETNA,ALL COMMERCIAL AETNA,219.10,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $219.10 in Billed Charges for Rev 637 = $219.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,ANTHEM,ANTHEM POS/HMO,148.99,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $219.10 in Billed Charges for Rev 637 = $148.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,ANTHEM,ANTHEM PPO,148.99,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $219.10 in Billed Charges for Rev 637 = $148.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,219.10,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $219.10 in Billed Charges for Rev 637 = $219.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,CENPATICO,ALL MEDICAID CENPATICO,219.10,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $219.10 in Billed Charges for Rev 637 = $219.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,186.24,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $219.10 in Billed Charges for Rev 637 = $186.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,CIGNA,ALL COMMERCIAL CIGNA,153.37,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $219.10 in Billed Charges for Rev 637 = $153.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,COFINITY,COFINITY,219.10,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $219.10 in Billed Charges for Rev 637 = $219.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,208.15,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $219.10 in Billed Charges for Rev 637 = $208.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,184.04,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $219.10 in Billed Charges for Rev 637 = $184.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,155.56,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $219.10 in Billed Charges for Rev 637 = $155.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,159.94,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $219.10 in Billed Charges for Rev 637 = $159.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,106.48,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $219.10 in Billed Charges for Rev 637 = $106.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,186.24,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $219.10 in Billed Charges for Rev 637 = $186.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,HUMANA,HUMANA CHOICE CARE HMO,139.13,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $219.10 in Billed Charges at 63.5% = $139.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,HUMANA,HUMANA CHOICE CARE PPO,186.24,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $219.10 in Billed Charges for Rev 637 = $186.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,HUMANA,HUMANA NATIIONAL POS HMO,139.13,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $219.10 in Billed Charges at 63.5% = $139.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,159.94,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $219.10 in Billed Charges for Rev 637 = $159.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,219.10,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $219.10 in Billed Charges for Rev 637 = $219.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,219.10,,,,,,,106.4800,219.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,109.55,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $219.10 in Billed Charges for Rev 637 = $109.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,184.04,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $219.10 in Billed Charges for Rev 637 = $184.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,164.33,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $219.10 in Billed Charges for Rev 637 = $164.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,201.57,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $219.10 in Billed Charges for Rev 637 = $201.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,131.46,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $219.10 in Billed Charges for Rev 637 = $131.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,131.46,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $219.10 in Billed Charges for Rev 637 = $131.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,PREVEA HEALTH NETWORK,PREVEA360,131.46,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $219.10 in Billed Charges for Rev 637 = $131.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,131.46,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $219.10 in Billed Charges for Rev 637 = $131.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,139.85,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $219.10 in Billed Charges for Rev 637 = $139.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,157.75,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $219.10 in Billed Charges for Rev 637 = $157.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,121.16,,,,,,,106.4800,219.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $219.10 in Billed Charges for Rev 637 = $121.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,121.16,,,,,,,106.4800,219.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $219.10 in Billed Charges for Rev 637 = $121.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,121.16,,,,,,,106.4800,219.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $219.10 in Billed Charges for Rev 637 = $121.16 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,UNITY HEALTH PLAN,UNITY HOSPICE,219.10,,,,,,,106.4800,219.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,157.75,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $219.10 in Billed Charges for Rev 637 = $157.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,135.84,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $219.10 in Billed Charges for Rev 637 = $135.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,157.75,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $219.10 in Billed Charges for Rev 637 = $157.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,157.75,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $219.10 in Billed Charges for Rev 637 = $157.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 5 MCG/HR PTWK,637,RC,42858-750-40,CDM,,,,,,both,1.000000,EA,219.1000,144.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,131.46,,,,,,,106.4800,219.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $219.10 in Billed Charges for Rev 637 = $131.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,AETNA,AETNA HSHS,9.24,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $14.30 in Billed Charges for Rev 637 = $9.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,AETNA,ALL COMMERCIAL AETNA,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 637 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,ANTHEM,ANTHEM POS/HMO,9.72,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $14.30 in Billed Charges for Rev 637 = $9.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,ANTHEM,ANTHEM PPO,9.72,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $14.30 in Billed Charges for Rev 637 = $9.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 637 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,CENPATICO,ALL MEDICAID CENPATICO,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 637 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.16,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.30 in Billed Charges for Rev 637 = $12.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,CIGNA,ALL COMMERCIAL CIGNA,10.01,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $14.30 in Billed Charges for Rev 637 = $10.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,COFINITY,COFINITY,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 637 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13.59,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $14.30 in Billed Charges for Rev 637 = $13.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,12.01,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.30 in Billed Charges for Rev 637 = $12.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.15,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $14.30 in Billed Charges for Rev 637 = $10.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.44,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.30 in Billed Charges for Rev 637 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,6.95,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $14.30 in Billed Charges for Rev 637 = $6.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.16,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.30 in Billed Charges for Rev 637 = $12.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,HUMANA,HUMANA CHOICE CARE HMO,9.08,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $14.30 in Billed Charges at 63.5% = $9.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,HUMANA,HUMANA CHOICE CARE PPO,12.16,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.30 in Billed Charges for Rev 637 = $12.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,HUMANA,HUMANA NATIIONAL POS HMO,9.08,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $14.30 in Billed Charges at 63.5% = $9.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.44,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.30 in Billed Charges for Rev 637 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 637 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,14.30,,,,,,,6.9500,14.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.15,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $14.30 in Billed Charges for Rev 637 = $7.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.01,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.30 in Billed Charges for Rev 637 = $12.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.73,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $14.30 in Billed Charges for Rev 637 = $10.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.16,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $14.30 in Billed Charges for Rev 637 = $13.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 637 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 637 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,PREVEA HEALTH NETWORK,PREVEA360,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 637 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 637 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.13,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $14.30 in Billed Charges for Rev 637 = $9.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.30 in Billed Charges for Rev 637 = $10.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.91,,,,,,,6.9500,14.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.30 in Billed Charges for Rev 637 = $7.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,7.91,,,,,,,6.9500,14.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.30 in Billed Charges for Rev 637 = $7.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,7.91,,,,,,,6.9500,14.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.30 in Billed Charges for Rev 637 = $7.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,UNITY HEALTH PLAN,UNITY HOSPICE,14.30,,,,,,,6.9500,14.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.30 in Billed Charges for Rev 637 = $10.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.87,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $14.30 in Billed Charges for Rev 637 = $8.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.30 in Billed Charges for Rev 637 = $10.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.30 in Billed Charges for Rev 637 = $10.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 8 MG SUBL,637,RC,60687-492-11,CDM,,,,,,both,1.000000,EA,14.3000,9.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 637 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,AETNA,AETNA HSHS,11.47,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $17.75 in Billed Charges for Rev 637 = $11.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,AETNA,ALL COMMERCIAL AETNA,17.75,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.75 in Billed Charges for Rev 637 = $17.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,ANTHEM,ANTHEM POS/HMO,12.07,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $17.75 in Billed Charges for Rev 637 = $12.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,ANTHEM,ANTHEM PPO,12.07,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $17.75 in Billed Charges for Rev 637 = $12.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17.75,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.75 in Billed Charges for Rev 637 = $17.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,CENPATICO,ALL MEDICAID CENPATICO,17.75,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.75 in Billed Charges for Rev 637 = $17.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15.09,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.75 in Billed Charges for Rev 637 = $15.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,CIGNA,ALL COMMERCIAL CIGNA,12.43,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $17.75 in Billed Charges for Rev 637 = $12.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,COFINITY,COFINITY,17.75,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.75 in Billed Charges for Rev 637 = $17.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16.86,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $17.75 in Billed Charges for Rev 637 = $16.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,14.91,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.75 in Billed Charges for Rev 637 = $14.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12.60,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $17.75 in Billed Charges for Rev 637 = $12.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.96,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.75 in Billed Charges for Rev 637 = $12.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,8.63,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $17.75 in Billed Charges for Rev 637 = $8.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15.09,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.75 in Billed Charges for Rev 637 = $15.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,HUMANA,HUMANA CHOICE CARE HMO,11.27,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $17.75 in Billed Charges at 63.5% = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,HUMANA,HUMANA CHOICE CARE PPO,15.09,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.75 in Billed Charges for Rev 637 = $15.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,HUMANA,HUMANA NATIIONAL POS HMO,11.27,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $17.75 in Billed Charges at 63.5% = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.96,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.75 in Billed Charges for Rev 637 = $12.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,17.75,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.75 in Billed Charges for Rev 637 = $17.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.75,,,,,,,8.6300,17.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.88,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $17.75 in Billed Charges for Rev 637 = $8.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.91,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.75 in Billed Charges for Rev 637 = $14.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,13.31,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $17.75 in Billed Charges for Rev 637 = $13.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,16.33,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $17.75 in Billed Charges for Rev 637 = $16.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.65,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.75 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.65,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.75 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,PREVEA HEALTH NETWORK,PREVEA360,10.65,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.75 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.65,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.75 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.33,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $17.75 in Billed Charges for Rev 637 = $11.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.78,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.75 in Billed Charges for Rev 637 = $12.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.82,,,,,,,8.6300,17.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.75 in Billed Charges for Rev 637 = $9.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,9.82,,,,,,,8.6300,17.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.75 in Billed Charges for Rev 637 = $9.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,9.82,,,,,,,8.6300,17.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.75 in Billed Charges for Rev 637 = $9.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,UNITY HEALTH PLAN,UNITY HOSPICE,17.75,,,,,,,8.6300,17.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.78,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.75 in Billed Charges for Rev 637 = $12.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.01,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $17.75 in Billed Charges for Rev 637 = $11.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.78,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.75 in Billed Charges for Rev 637 = $12.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.78,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.75 in Billed Charges for Rev 637 = $12.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPROPION XL 150 MG TB24,637,RC,68001-613-04,CDM,,,,,,both,1.000000,EA,17.7500,11.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.65,,,,,,,8.6300,17.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.75 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,AETNA,AETNA HSHS,26.65,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $41.25 in Billed Charges for Rev 637 = $26.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,AETNA,ALL COMMERCIAL AETNA,41.25,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.25 in Billed Charges for Rev 637 = $41.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,ANTHEM,ANTHEM POS/HMO,28.05,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $41.25 in Billed Charges for Rev 637 = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,ANTHEM,ANTHEM PPO,28.05,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $41.25 in Billed Charges for Rev 637 = $28.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,41.25,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.25 in Billed Charges for Rev 637 = $41.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,CENPATICO,ALL MEDICAID CENPATICO,41.25,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.25 in Billed Charges for Rev 637 = $41.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,35.06,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.25 in Billed Charges for Rev 637 = $35.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,CIGNA,ALL COMMERCIAL CIGNA,28.88,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $41.25 in Billed Charges for Rev 637 = $28.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,COFINITY,COFINITY,41.25,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.25 in Billed Charges for Rev 637 = $41.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,39.19,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $41.25 in Billed Charges for Rev 637 = $39.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,HEALTH CARE ALLIANCE,THE ALLIANCE,34.65,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.25 in Billed Charges for Rev 637 = $34.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.29,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $41.25 in Billed Charges for Rev 637 = $29.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,30.11,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.25 in Billed Charges for Rev 637 = $30.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,HSHS EMPLOYEES,HSHS EMPLOYEES,20.05,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $41.25 in Billed Charges for Rev 637 = $20.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,35.06,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.25 in Billed Charges for Rev 637 = $35.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,HUMANA,HUMANA CHOICE CARE HMO,26.19,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $41.25 in Billed Charges at 63.5% = $26.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,HUMANA,HUMANA CHOICE CARE PPO,35.06,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.25 in Billed Charges for Rev 637 = $35.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,HUMANA,HUMANA NATIIONAL POS HMO,26.19,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $41.25 in Billed Charges at 63.5% = $26.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,30.11,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.25 in Billed Charges for Rev 637 = $30.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,LIVE360,LIVE360 HSHS HEALTHY PLAN,41.25,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.25 in Billed Charges for Rev 637 = $41.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,41.25,,,,,,,20.0500,41.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,20.63,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $41.25 in Billed Charges for Rev 637 = $20.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,34.65,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.25 in Billed Charges for Rev 637 = $34.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,30.94,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $41.25 in Billed Charges for Rev 637 = $30.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,37.95,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $41.25 in Billed Charges for Rev 637 = $37.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,24.75,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.25 in Billed Charges for Rev 637 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,24.75,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.25 in Billed Charges for Rev 637 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,PREVEA HEALTH NETWORK,PREVEA360,24.75,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.25 in Billed Charges for Rev 637 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,24.75,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.25 in Billed Charges for Rev 637 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.33,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $41.25 in Billed Charges for Rev 637 = $26.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,29.70,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.25 in Billed Charges for Rev 637 = $29.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,22.81,,,,,,,20.0500,41.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $41.25 in Billed Charges for Rev 637 = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,UNITED HEALTHCARE,UHC ONEIDA NATION,22.81,,,,,,,20.0500,41.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $41.25 in Billed Charges for Rev 637 = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,UNITED HEALTHCARE,UNITED HEALTHCARE,22.81,,,,,,,20.0500,41.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $41.25 in Billed Charges for Rev 637 = $22.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,UNITY HEALTH PLAN,UNITY HOSPICE,41.25,,,,,,,20.0500,41.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,29.70,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.25 in Billed Charges for Rev 637 = $29.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,25.58,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $41.25 in Billed Charges for Rev 637 = $25.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,29.70,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.25 in Billed Charges for Rev 637 = $29.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,29.70,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.25 in Billed Charges for Rev 637 = $29.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APIXABAN 2.5 MG TABS,637,RC,0003-0893-31,CDM,,,,,,both,1.000000,EA,41.2500,27.2300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,24.75,,,,,,,20.0500,41.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.25 in Billed Charges for Rev 637 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,AETNA,AETNA HSHS,24.55,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $38.00 in Billed Charges for Rev 637 = $24.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,AETNA,ALL COMMERCIAL AETNA,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 637 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,ANTHEM,ANTHEM POS/HMO,25.84,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $38.00 in Billed Charges for Rev 637 = $25.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,ANTHEM,ANTHEM PPO,25.84,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $38.00 in Billed Charges for Rev 637 = $25.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 637 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,CENPATICO,ALL MEDICAID CENPATICO,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 637 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,32.30,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 637 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,CIGNA,ALL COMMERCIAL CIGNA,26.60,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $38.00 in Billed Charges for Rev 637 = $26.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,COFINITY,COFINITY,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 637 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,36.10,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $38.00 in Billed Charges for Rev 637 = $36.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,31.92,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.00 in Billed Charges for Rev 637 = $31.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,26.98,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $38.00 in Billed Charges for Rev 637 = $26.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,27.74,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.00 in Billed Charges for Rev 637 = $27.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,18.47,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $38.00 in Billed Charges for Rev 637 = $18.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,32.30,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 637 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,HUMANA,HUMANA CHOICE CARE HMO,24.13,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $38.00 in Billed Charges at 63.5% = $24.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,HUMANA,HUMANA CHOICE CARE PPO,32.30,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 637 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,HUMANA,HUMANA NATIIONAL POS HMO,24.13,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $38.00 in Billed Charges at 63.5% = $24.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,27.74,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.00 in Billed Charges for Rev 637 = $27.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 637 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,38.00,,,,,,,18.4700,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $38.00 in Billed Charges for Rev 637 = $19.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,31.92,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.00 in Billed Charges for Rev 637 = $31.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,28.50,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $38.00 in Billed Charges for Rev 637 = $28.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,34.96,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $38.00 in Billed Charges for Rev 637 = $34.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 637 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 637 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA360,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 637 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 637 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,24.26,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $38.00 in Billed Charges for Rev 637 = $24.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,27.36,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 637 = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,21.01,,,,,,,18.4700,38.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.00 in Billed Charges for Rev 637 = $21.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,21.01,,,,,,,18.4700,38.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.00 in Billed Charges for Rev 637 = $21.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,21.01,,,,,,,18.4700,38.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.00 in Billed Charges for Rev 637 = $21.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,UNITY HEALTH PLAN,UNITY HOSPICE,38.00,,,,,,,18.4700,38.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,27.36,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 637 = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,23.56,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $38.00 in Billed Charges for Rev 637 = $23.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,27.36,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 637 = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,27.36,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 637 = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ANAGRELIDE 0.5 MG CAPS,637,RC,13668-453-01,CDM,,,,,,both,1.000000,EA,38.0000,25.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 637 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,AETNA,AETNA HSHS,13.40,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.75 in Billed Charges for Rev 637 = $13.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,AETNA,ALL COMMERCIAL AETNA,20.75,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.75 in Billed Charges for Rev 637 = $20.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,ANTHEM,ANTHEM POS/HMO,14.11,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $20.75 in Billed Charges for Rev 637 = $14.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,ANTHEM,ANTHEM PPO,14.11,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $20.75 in Billed Charges for Rev 637 = $14.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.75,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.75 in Billed Charges for Rev 637 = $20.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,CENPATICO,ALL MEDICAID CENPATICO,20.75,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.75 in Billed Charges for Rev 637 = $20.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.64,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.75 in Billed Charges for Rev 637 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,CIGNA,ALL COMMERCIAL CIGNA,14.53,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.75 in Billed Charges for Rev 637 = $14.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,COFINITY,COFINITY,20.75,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.75 in Billed Charges for Rev 637 = $20.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.71,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.75 in Billed Charges for Rev 637 = $19.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,HEALTH CARE ALLIANCE,THE ALLIANCE,17.43,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.75 in Billed Charges for Rev 637 = $17.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.73,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.75 in Billed Charges for Rev 637 = $14.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15.15,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.75 in Billed Charges for Rev 637 = $15.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,HSHS EMPLOYEES,HSHS EMPLOYEES,10.08,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.75 in Billed Charges for Rev 637 = $10.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.64,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.75 in Billed Charges for Rev 637 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,HUMANA,HUMANA CHOICE CARE HMO,13.18,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $20.75 in Billed Charges at 63.5% = $13.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,HUMANA,HUMANA CHOICE CARE PPO,17.64,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.75 in Billed Charges for Rev 637 = $17.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,HUMANA,HUMANA NATIIONAL POS HMO,13.18,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $20.75 in Billed Charges at 63.5% = $13.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15.15,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.75 in Billed Charges for Rev 637 = $15.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.75,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.75 in Billed Charges for Rev 637 = $20.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,20.75,,,,,,,10.0800,20.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.38,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.75 in Billed Charges for Rev 637 = $10.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.43,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.75 in Billed Charges for Rev 637 = $17.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.56,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.75 in Billed Charges for Rev 637 = $15.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,19.09,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.75 in Billed Charges for Rev 637 = $19.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.45,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.75 in Billed Charges for Rev 637 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.45,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.75 in Billed Charges for Rev 637 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,PREVEA HEALTH NETWORK,PREVEA360,12.45,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.75 in Billed Charges for Rev 637 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.45,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.75 in Billed Charges for Rev 637 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.24,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.75 in Billed Charges for Rev 637 = $13.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.94,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.75 in Billed Charges for Rev 637 = $14.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.47,,,,,,,10.0800,20.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.75 in Billed Charges for Rev 637 = $11.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,UNITED HEALTHCARE,UHC ONEIDA NATION,11.47,,,,,,,10.0800,20.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.75 in Billed Charges for Rev 637 = $11.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,UNITED HEALTHCARE,UNITED HEALTHCARE,11.47,,,,,,,10.0800,20.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.75 in Billed Charges for Rev 637 = $11.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,UNITY HEALTH PLAN,UNITY HOSPICE,20.75,,,,,,,10.0800,20.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.94,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.75 in Billed Charges for Rev 637 = $14.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.87,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.75 in Billed Charges for Rev 637 = $12.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.94,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.75 in Billed Charges for Rev 637 = $14.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.94,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.75 in Billed Charges for Rev 637 = $14.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 250 MG/5ML SUSR,637,RC,0143-9889-01,CDM,,,,,,both,100.000000,ML,20.7500,13.7000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.45,,,,,,,10.0800,20.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.75 in Billed Charges for Rev 637 = $12.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,AETNA,AETNA HSHS,21.54,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $33.35 in Billed Charges for Rev 637 = $21.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,AETNA,ALL COMMERCIAL AETNA,33.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.35 in Billed Charges for Rev 637 = $33.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,ANTHEM,ANTHEM POS/HMO,22.68,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $33.35 in Billed Charges for Rev 637 = $22.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,ANTHEM,ANTHEM PPO,22.68,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $33.35 in Billed Charges for Rev 637 = $22.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,33.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.35 in Billed Charges for Rev 637 = $33.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,CENPATICO,ALL MEDICAID CENPATICO,33.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.35 in Billed Charges for Rev 637 = $33.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,28.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.35 in Billed Charges for Rev 637 = $28.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,CIGNA,ALL COMMERCIAL CIGNA,23.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $33.35 in Billed Charges for Rev 637 = $23.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,COFINITY,COFINITY,33.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.35 in Billed Charges for Rev 637 = $33.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,31.68,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $33.35 in Billed Charges for Rev 637 = $31.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,28.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.35 in Billed Charges for Rev 637 = $28.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,23.68,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $33.35 in Billed Charges for Rev 637 = $23.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,24.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.35 in Billed Charges for Rev 637 = $24.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,16.21,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $33.35 in Billed Charges for Rev 637 = $16.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,28.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.35 in Billed Charges for Rev 637 = $28.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,HUMANA,HUMANA CHOICE CARE HMO,21.18,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $33.35 in Billed Charges at 63.5% = $21.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,HUMANA,HUMANA CHOICE CARE PPO,28.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.35 in Billed Charges for Rev 637 = $28.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,HUMANA,HUMANA NATIIONAL POS HMO,21.18,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $33.35 in Billed Charges at 63.5% = $21.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,24.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.35 in Billed Charges for Rev 637 = $24.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,33.35,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.35 in Billed Charges for Rev 637 = $33.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,33.35,,,,,,,16.2100,33.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.68,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $33.35 in Billed Charges for Rev 637 = $16.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,28.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.35 in Billed Charges for Rev 637 = $28.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,25.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $33.35 in Billed Charges for Rev 637 = $25.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,30.68,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $33.35 in Billed Charges for Rev 637 = $30.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,20.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.35 in Billed Charges for Rev 637 = $20.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,20.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.35 in Billed Charges for Rev 637 = $20.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,PREVEA HEALTH NETWORK,PREVEA360,20.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.35 in Billed Charges for Rev 637 = $20.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,20.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.35 in Billed Charges for Rev 637 = $20.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,21.29,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $33.35 in Billed Charges for Rev 637 = $21.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,24.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.35 in Billed Charges for Rev 637 = $24.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,18.44,,,,,,,16.2100,33.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $33.35 in Billed Charges for Rev 637 = $18.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,UNITED HEALTHCARE,UHC ONEIDA NATION,18.44,,,,,,,16.2100,33.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $33.35 in Billed Charges for Rev 637 = $18.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,UNITED HEALTHCARE,UNITED HEALTHCARE,18.44,,,,,,,16.2100,33.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $33.35 in Billed Charges for Rev 637 = $18.44 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,UNITY HEALTH PLAN,UNITY HOSPICE,33.35,,,,,,,16.2100,33.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,24.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.35 in Billed Charges for Rev 637 = $24.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,20.68,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $33.35 in Billed Charges for Rev 637 = $20.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,24.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.35 in Billed Charges for Rev 637 = $24.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,24.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.35 in Billed Charges for Rev 637 = $24.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-01,CDM,,,,,,both,100.000000,ML,33.3500,22.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,20.01,,,,,,,16.2100,33.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.35 in Billed Charges for Rev 637 = $20.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,AETNA,AETNA HSHS,54.04,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $83.65 in Billed Charges for Rev 637 = $54.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,AETNA,ALL COMMERCIAL AETNA,83.65,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.65 in Billed Charges for Rev 637 = $83.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,ANTHEM,ANTHEM POS/HMO,56.88,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $83.65 in Billed Charges for Rev 637 = $56.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,ANTHEM,ANTHEM PPO,56.88,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $83.65 in Billed Charges for Rev 637 = $56.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,83.65,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.65 in Billed Charges for Rev 637 = $83.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,CENPATICO,ALL MEDICAID CENPATICO,83.65,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.65 in Billed Charges for Rev 637 = $83.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,71.10,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.65 in Billed Charges for Rev 637 = $71.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,CIGNA,ALL COMMERCIAL CIGNA,58.56,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $83.65 in Billed Charges for Rev 637 = $58.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,COFINITY,COFINITY,83.65,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.65 in Billed Charges for Rev 637 = $83.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,79.47,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $83.65 in Billed Charges for Rev 637 = $79.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,70.27,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $83.65 in Billed Charges for Rev 637 = $70.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,59.39,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $83.65 in Billed Charges for Rev 637 = $59.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,61.06,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $83.65 in Billed Charges for Rev 637 = $61.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,40.65,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $83.65 in Billed Charges for Rev 637 = $40.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,71.10,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.65 in Billed Charges for Rev 637 = $71.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,HUMANA,HUMANA CHOICE CARE HMO,53.12,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $83.65 in Billed Charges at 63.5% = $53.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,HUMANA,HUMANA CHOICE CARE PPO,71.10,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $83.65 in Billed Charges for Rev 637 = $71.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,HUMANA,HUMANA NATIIONAL POS HMO,53.12,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $83.65 in Billed Charges at 63.5% = $53.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,61.06,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $83.65 in Billed Charges for Rev 637 = $61.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,83.65,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $83.65 in Billed Charges for Rev 637 = $83.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,83.65,,,,,,,40.6500,83.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,41.83,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $83.65 in Billed Charges for Rev 637 = $41.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,70.27,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $83.65 in Billed Charges for Rev 637 = $70.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,62.74,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $83.65 in Billed Charges for Rev 637 = $62.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,76.96,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $83.65 in Billed Charges for Rev 637 = $76.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,50.19,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $83.65 in Billed Charges for Rev 637 = $50.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,50.19,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $83.65 in Billed Charges for Rev 637 = $50.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,PREVEA HEALTH NETWORK,PREVEA360,50.19,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $83.65 in Billed Charges for Rev 637 = $50.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,50.19,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $83.65 in Billed Charges for Rev 637 = $50.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,53.39,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $83.65 in Billed Charges for Rev 637 = $53.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,60.23,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.65 in Billed Charges for Rev 637 = $60.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,46.26,,,,,,,40.6500,83.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $83.65 in Billed Charges for Rev 637 = $46.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,UNITED HEALTHCARE,UHC ONEIDA NATION,46.26,,,,,,,40.6500,83.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $83.65 in Billed Charges for Rev 637 = $46.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,UNITED HEALTHCARE,UNITED HEALTHCARE,46.26,,,,,,,40.6500,83.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $83.65 in Billed Charges for Rev 637 = $46.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,UNITY HEALTH PLAN,UNITY HOSPICE,83.65,,,,,,,40.6500,83.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,60.23,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.65 in Billed Charges for Rev 637 = $60.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,51.86,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $83.65 in Billed Charges for Rev 637 = $51.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,60.23,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.65 in Billed Charges for Rev 637 = $60.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,60.23,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $83.65 in Billed Charges for Rev 637 = $60.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 200-28.5 MG/5ML SUSR,637,RC,65862-533-75,CDM,,,,,,both,75.000000,ML,83.6500,55.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,50.19,,,,,,,40.6500,83.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $83.65 in Billed Charges for Rev 637 = $50.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,AETNA,AETNA HSHS,11.14,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $17.25 in Billed Charges for Rev 637 = $11.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,AETNA,ALL COMMERCIAL AETNA,17.25,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.25 in Billed Charges for Rev 637 = $17.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,ANTHEM,ANTHEM POS/HMO,11.73,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $17.25 in Billed Charges for Rev 637 = $11.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,ANTHEM,ANTHEM PPO,11.73,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $17.25 in Billed Charges for Rev 637 = $11.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,17.25,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.25 in Billed Charges for Rev 637 = $17.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,CENPATICO,ALL MEDICAID CENPATICO,17.25,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.25 in Billed Charges for Rev 637 = $17.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.66,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.25 in Billed Charges for Rev 637 = $14.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,CIGNA,ALL COMMERCIAL CIGNA,12.08,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $17.25 in Billed Charges for Rev 637 = $12.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,COFINITY,COFINITY,17.25,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.25 in Billed Charges for Rev 637 = $17.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,16.39,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $17.25 in Billed Charges for Rev 637 = $16.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,14.49,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.25 in Billed Charges for Rev 637 = $14.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,12.25,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $17.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.59,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.25 in Billed Charges for Rev 637 = $12.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,8.38,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $17.25 in Billed Charges for Rev 637 = $8.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.66,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.25 in Billed Charges for Rev 637 = $14.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,HUMANA,HUMANA CHOICE CARE HMO,10.95,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $17.25 in Billed Charges at 63.5% = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,HUMANA,HUMANA CHOICE CARE PPO,14.66,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $17.25 in Billed Charges for Rev 637 = $14.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,HUMANA,HUMANA NATIIONAL POS HMO,10.95,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $17.25 in Billed Charges at 63.5% = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.59,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $17.25 in Billed Charges for Rev 637 = $12.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,17.25,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $17.25 in Billed Charges for Rev 637 = $17.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,17.25,,,,,,,8.3800,17.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.63,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $17.25 in Billed Charges for Rev 637 = $8.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.49,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $17.25 in Billed Charges for Rev 637 = $14.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.94,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $17.25 in Billed Charges for Rev 637 = $12.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.87,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $17.25 in Billed Charges for Rev 637 = $15.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.35,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.25 in Billed Charges for Rev 637 = $10.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.35,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.25 in Billed Charges for Rev 637 = $10.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,PREVEA HEALTH NETWORK,PREVEA360,10.35,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.25 in Billed Charges for Rev 637 = $10.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.35,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.25 in Billed Charges for Rev 637 = $10.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.01,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $17.25 in Billed Charges for Rev 637 = $11.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.42,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.25 in Billed Charges for Rev 637 = $12.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.54,,,,,,,8.3800,17.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.25 in Billed Charges for Rev 637 = $9.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,UNITED HEALTHCARE,UHC ONEIDA NATION,9.54,,,,,,,8.3800,17.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.25 in Billed Charges for Rev 637 = $9.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,UNITED HEALTHCARE,UNITED HEALTHCARE,9.54,,,,,,,8.3800,17.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $17.25 in Billed Charges for Rev 637 = $9.54 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,UNITY HEALTH PLAN,UNITY HOSPICE,17.25,,,,,,,8.3800,17.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.42,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.25 in Billed Charges for Rev 637 = $12.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.70,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $17.25 in Billed Charges for Rev 637 = $10.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.42,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.25 in Billed Charges for Rev 637 = $12.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.42,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $17.25 in Billed Charges for Rev 637 = $12.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,65862-503-20,CDM,,,,,,both,1.000000,EA,17.2500,11.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.35,,,,,,,8.3800,17.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $17.25 in Billed Charges for Rev 637 = $10.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,AETNA,AETNA HSHS,70.28,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $108.80 in Billed Charges for Rev 637 = $70.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,AETNA,ALL COMMERCIAL AETNA,108.80,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.80 in Billed Charges for Rev 637 = $108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,ANTHEM,ANTHEM POS/HMO,73.98,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $108.80 in Billed Charges for Rev 637 = $73.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,ANTHEM,ANTHEM PPO,73.98,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $108.80 in Billed Charges for Rev 637 = $73.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,108.80,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.80 in Billed Charges for Rev 637 = $108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,CENPATICO,ALL MEDICAID CENPATICO,108.80,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.80 in Billed Charges for Rev 637 = $108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,92.48,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $108.80 in Billed Charges for Rev 637 = $92.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,CIGNA,ALL COMMERCIAL CIGNA,76.16,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $108.80 in Billed Charges for Rev 637 = $76.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,COFINITY,COFINITY,108.80,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.80 in Billed Charges for Rev 637 = $108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,103.36,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $108.80 in Billed Charges for Rev 637 = $103.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,91.39,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $108.80 in Billed Charges for Rev 637 = $91.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,77.25,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $108.80 in Billed Charges for Rev 637 = $77.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,79.42,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $108.80 in Billed Charges for Rev 637 = $79.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,52.88,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $108.80 in Billed Charges for Rev 637 = $52.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,92.48,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $108.80 in Billed Charges for Rev 637 = $92.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,HUMANA,HUMANA CHOICE CARE HMO,69.09,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $108.80 in Billed Charges at 63.5% = $69.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,HUMANA,HUMANA CHOICE CARE PPO,92.48,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $108.80 in Billed Charges for Rev 637 = $92.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,HUMANA,HUMANA NATIIONAL POS HMO,69.09,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $108.80 in Billed Charges at 63.5% = $69.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,79.42,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $108.80 in Billed Charges for Rev 637 = $79.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,108.80,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $108.80 in Billed Charges for Rev 637 = $108.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,108.80,,,,,,,52.8800,108.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,54.40,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $108.80 in Billed Charges for Rev 637 = $54.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,91.39,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $108.80 in Billed Charges for Rev 637 = $91.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,81.60,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $108.80 in Billed Charges for Rev 637 = $81.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,100.10,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $108.80 in Billed Charges for Rev 637 = $100.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,65.28,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $108.80 in Billed Charges for Rev 637 = $65.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,65.28,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $108.80 in Billed Charges for Rev 637 = $65.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,PREVEA HEALTH NETWORK,PREVEA360,65.28,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $108.80 in Billed Charges for Rev 637 = $65.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,65.28,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $108.80 in Billed Charges for Rev 637 = $65.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,69.45,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $108.80 in Billed Charges for Rev 637 = $69.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,78.34,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $108.80 in Billed Charges for Rev 637 = $78.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,60.17,,,,,,,52.8800,108.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $108.80 in Billed Charges for Rev 637 = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,UNITED HEALTHCARE,UHC ONEIDA NATION,60.17,,,,,,,52.8800,108.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $108.80 in Billed Charges for Rev 637 = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,UNITED HEALTHCARE,UNITED HEALTHCARE,60.17,,,,,,,52.8800,108.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $108.80 in Billed Charges for Rev 637 = $60.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,UNITY HEALTH PLAN,UNITY HOSPICE,108.80,,,,,,,52.8800,108.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,78.34,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $108.80 in Billed Charges for Rev 637 = $78.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,67.46,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $108.80 in Billed Charges for Rev 637 = $67.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,78.34,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $108.80 in Billed Charges for Rev 637 = $78.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,78.34,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $108.80 in Billed Charges for Rev 637 = $78.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 2 MG TABS,637,RC,62332-097-30,CDM,,,,,,both,1.000000,EA,108.8000,71.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,65.28,,,,,,,52.8800,108.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $108.80 in Billed Charges for Rev 637 = $65.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,AETNA,AETNA HSHS,65.76,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $101.80 in Billed Charges for Rev 637 = $65.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,AETNA,ALL COMMERCIAL AETNA,101.80,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.80 in Billed Charges for Rev 637 = $101.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,ANTHEM,ANTHEM POS/HMO,69.22,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $101.80 in Billed Charges for Rev 637 = $69.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,ANTHEM,ANTHEM PPO,69.22,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $101.80 in Billed Charges for Rev 637 = $69.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,101.80,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.80 in Billed Charges for Rev 637 = $101.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,CENPATICO,ALL MEDICAID CENPATICO,101.80,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.80 in Billed Charges for Rev 637 = $101.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,86.53,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.80 in Billed Charges for Rev 637 = $86.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,CIGNA,ALL COMMERCIAL CIGNA,71.26,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $101.80 in Billed Charges for Rev 637 = $71.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,COFINITY,COFINITY,101.80,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.80 in Billed Charges for Rev 637 = $101.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,96.71,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $101.80 in Billed Charges for Rev 637 = $96.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,85.51,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $101.80 in Billed Charges for Rev 637 = $85.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,72.28,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $101.80 in Billed Charges for Rev 637 = $72.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,74.31,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $101.80 in Billed Charges for Rev 637 = $74.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,49.47,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $101.80 in Billed Charges for Rev 637 = $49.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,86.53,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.80 in Billed Charges for Rev 637 = $86.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,HUMANA,HUMANA CHOICE CARE HMO,64.64,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $101.80 in Billed Charges at 63.5% = $64.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,HUMANA,HUMANA CHOICE CARE PPO,86.53,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.80 in Billed Charges for Rev 637 = $86.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,HUMANA,HUMANA NATIIONAL POS HMO,64.64,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $101.80 in Billed Charges at 63.5% = $64.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,74.31,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $101.80 in Billed Charges for Rev 637 = $74.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,101.80,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.80 in Billed Charges for Rev 637 = $101.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,101.80,,,,,,,49.4700,101.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,50.90,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $101.80 in Billed Charges for Rev 637 = $50.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,85.51,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $101.80 in Billed Charges for Rev 637 = $85.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,76.35,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $101.80 in Billed Charges for Rev 637 = $76.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,93.66,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $101.80 in Billed Charges for Rev 637 = $93.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,61.08,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.80 in Billed Charges for Rev 637 = $61.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,61.08,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.80 in Billed Charges for Rev 637 = $61.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,PREVEA HEALTH NETWORK,PREVEA360,61.08,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.80 in Billed Charges for Rev 637 = $61.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,61.08,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.80 in Billed Charges for Rev 637 = $61.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,64.98,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $101.80 in Billed Charges for Rev 637 = $64.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,73.30,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.80 in Billed Charges for Rev 637 = $73.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,56.30,,,,,,,49.4700,101.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $101.80 in Billed Charges for Rev 637 = $56.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,UNITED HEALTHCARE,UHC ONEIDA NATION,56.30,,,,,,,49.4700,101.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $101.80 in Billed Charges for Rev 637 = $56.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,UNITED HEALTHCARE,UNITED HEALTHCARE,56.30,,,,,,,49.4700,101.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $101.80 in Billed Charges for Rev 637 = $56.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,UNITY HEALTH PLAN,UNITY HOSPICE,101.80,,,,,,,49.4700,101.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,73.30,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.80 in Billed Charges for Rev 637 = $73.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,63.12,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $101.80 in Billed Charges for Rev 637 = $63.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,73.30,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.80 in Billed Charges for Rev 637 = $73.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,73.30,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.80 in Billed Charges for Rev 637 = $73.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARIPIPRAZOLE 5 MG TABS,637,RC,50268-088-11,CDM,,,,,,both,1.000000,EA,101.8000,67.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,61.08,,,,,,,49.4700,101.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $101.80 in Billed Charges for Rev 637 = $61.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,AETNA,AETNA HSHS,231.17,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $357.85 in Billed Charges for Rev 637 = $231.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,AETNA,ALL COMMERCIAL AETNA,357.85,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $357.85 in Billed Charges for Rev 637 = $357.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,ANTHEM,ANTHEM POS/HMO,243.34,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $357.85 in Billed Charges for Rev 637 = $243.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,ANTHEM,ANTHEM PPO,243.34,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $357.85 in Billed Charges for Rev 637 = $243.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,357.85,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $357.85 in Billed Charges for Rev 637 = $357.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,CENPATICO,ALL MEDICAID CENPATICO,357.85,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $357.85 in Billed Charges for Rev 637 = $357.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,304.17,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $357.85 in Billed Charges for Rev 637 = $304.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,CIGNA,ALL COMMERCIAL CIGNA,250.50,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $357.85 in Billed Charges for Rev 637 = $250.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,COFINITY,COFINITY,357.85,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $357.85 in Billed Charges for Rev 637 = $357.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,339.96,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $357.85 in Billed Charges for Rev 637 = $339.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,HEALTH CARE ALLIANCE,THE ALLIANCE,300.59,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $357.85 in Billed Charges for Rev 637 = $300.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,254.07,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $357.85 in Billed Charges for Rev 637 = $254.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,261.23,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $357.85 in Billed Charges for Rev 637 = $261.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,HSHS EMPLOYEES,HSHS EMPLOYEES,173.92,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $357.85 in Billed Charges for Rev 637 = $173.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,304.17,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $357.85 in Billed Charges for Rev 637 = $304.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,HUMANA,HUMANA CHOICE CARE HMO,227.23,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $357.85 in Billed Charges at 63.5% = $227.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,HUMANA,HUMANA CHOICE CARE PPO,304.17,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $357.85 in Billed Charges for Rev 637 = $304.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,HUMANA,HUMANA NATIIONAL POS HMO,227.23,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $357.85 in Billed Charges at 63.5% = $227.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,261.23,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $357.85 in Billed Charges for Rev 637 = $261.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,LIVE360,LIVE360 HSHS HEALTHY PLAN,357.85,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $357.85 in Billed Charges for Rev 637 = $357.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,357.85,,,,,,,173.9200,357.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,178.93,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $357.85 in Billed Charges for Rev 637 = $178.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,300.59,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $357.85 in Billed Charges for Rev 637 = $300.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,268.39,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $357.85 in Billed Charges for Rev 637 = $268.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,329.22,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $357.85 in Billed Charges for Rev 637 = $329.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,214.71,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $357.85 in Billed Charges for Rev 637 = $214.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,214.71,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $357.85 in Billed Charges for Rev 637 = $214.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,PREVEA HEALTH NETWORK,PREVEA360,214.71,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $357.85 in Billed Charges for Rev 637 = $214.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,214.71,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $357.85 in Billed Charges for Rev 637 = $214.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,228.42,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $357.85 in Billed Charges for Rev 637 = $228.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,257.65,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $357.85 in Billed Charges for Rev 637 = $257.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,197.89,,,,,,,173.9200,357.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $357.85 in Billed Charges for Rev 637 = $197.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,UNITED HEALTHCARE,UHC ONEIDA NATION,197.89,,,,,,,173.9200,357.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $357.85 in Billed Charges for Rev 637 = $197.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,UNITED HEALTHCARE,UNITED HEALTHCARE,197.89,,,,,,,173.9200,357.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $357.85 in Billed Charges for Rev 637 = $197.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,UNITY HEALTH PLAN,UNITY HOSPICE,357.85,,,,,,,173.9200,357.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,257.65,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $357.85 in Billed Charges for Rev 637 = $257.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,221.87,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $357.85 in Billed Charges for Rev 637 = $221.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,257.65,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $357.85 in Billed Charges for Rev 637 = $257.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,257.65,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $357.85 in Billed Charges for Rev 637 = $257.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,637,RC,60505-0833-5,CDM,,,,,,both,30.000000,ML,357.8500,236.1800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,214.71,,,,,,,173.9200,357.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $357.85 in Billed Charges for Rev 637 = $214.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,AETNA,AETNA HSHS,76.62,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.60 in Billed Charges for Rev 637 = $76.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,AETNA,ALL COMMERCIAL AETNA,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,ANTHEM,ANTHEM POS/HMO,80.65,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $118.60 in Billed Charges for Rev 637 = $80.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,ANTHEM,ANTHEM PPO,80.65,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $118.60 in Billed Charges for Rev 637 = $80.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,CENPATICO,ALL MEDICAID CENPATICO,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.81,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.60 in Billed Charges for Rev 637 = $100.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,CIGNA,ALL COMMERCIAL CIGNA,83.02,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.60 in Billed Charges for Rev 637 = $83.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,COFINITY,COFINITY,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.67,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.60 in Billed Charges for Rev 637 = $112.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.62,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.60 in Billed Charges for Rev 637 = $99.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,84.21,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.60 in Billed Charges for Rev 637 = $84.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.58,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.60 in Billed Charges for Rev 637 = $86.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.64,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.60 in Billed Charges for Rev 637 = $57.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.81,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.60 in Billed Charges for Rev 637 = $100.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,HUMANA,HUMANA CHOICE CARE HMO,75.31,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $118.60 in Billed Charges at 63.5% = $75.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,HUMANA,HUMANA CHOICE CARE PPO,100.81,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.60 in Billed Charges for Rev 637 = $100.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,HUMANA,HUMANA NATIIONAL POS HMO,75.31,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $118.60 in Billed Charges at 63.5% = $75.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.58,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.60 in Billed Charges for Rev 637 = $86.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,118.60,,,,,,,57.6400,118.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.30,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.60 in Billed Charges for Rev 637 = $59.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.62,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.60 in Billed Charges for Rev 637 = $99.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.95,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.60 in Billed Charges for Rev 637 = $88.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,109.11,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.60 in Billed Charges for Rev 637 = $109.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,PREVEA HEALTH NETWORK,PREVEA360,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.70,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.60 in Billed Charges for Rev 637 = $75.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,85.39,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.60 in Billed Charges for Rev 637 = $85.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,65.59,,,,,,,57.6400,118.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.60 in Billed Charges for Rev 637 = $65.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,65.59,,,,,,,57.6400,118.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.60 in Billed Charges for Rev 637 = $65.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,65.59,,,,,,,57.6400,118.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.60 in Billed Charges for Rev 637 = $65.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,UNITY HEALTH PLAN,UNITY HOSPICE,118.60,,,,,,,57.6400,118.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,85.39,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.60 in Billed Charges for Rev 637 = $85.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.53,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.60 in Billed Charges for Rev 637 = $73.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,85.39,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.60 in Billed Charges for Rev 637 = $85.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,85.39,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.60 in Billed Charges for Rev 637 = $85.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-23,CDM,,,,,,both,15.000000,ML,118.6000,78.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,AETNA,AETNA HSHS,7.91,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.25 in Billed Charges for Rev 637 = $7.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,AETNA,ALL COMMERCIAL AETNA,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,ANTHEM,ANTHEM POS/HMO,8.33,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.25 in Billed Charges for Rev 637 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,ANTHEM,ANTHEM PPO,8.33,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.25 in Billed Charges for Rev 637 = $8.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,CENPATICO,ALL MEDICAID CENPATICO,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.41,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 637 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,CIGNA,ALL COMMERCIAL CIGNA,8.58,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.25 in Billed Charges for Rev 637 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,COFINITY,COFINITY,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.64,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.25 in Billed Charges for Rev 637 = $11.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,10.29,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 637 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.70,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.25 in Billed Charges for Rev 637 = $8.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.94,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,5.95,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.25 in Billed Charges for Rev 637 = $5.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.41,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 637 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE HMO,7.78,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.25 in Billed Charges at 63.5% = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,HUMANA,HUMANA CHOICE CARE PPO,10.41,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.25 in Billed Charges for Rev 637 = $10.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,HUMANA,HUMANA NATIIONAL POS HMO,7.78,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.25 in Billed Charges at 63.5% = $7.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.94,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.25 in Billed Charges for Rev 637 = $8.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.25,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.25 in Billed Charges for Rev 637 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.25,,,,,,,5.9500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.13,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.25 in Billed Charges for Rev 637 = $6.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.29,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.25 in Billed Charges for Rev 637 = $10.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.19,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.25 in Billed Charges for Rev 637 = $9.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.27,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.25 in Billed Charges for Rev 637 = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.25 in Billed Charges for Rev 637 = $7.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 637 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.77,,,,,,,5.9500,12.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.25 in Billed Charges for Rev 637 = $6.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,6.77,,,,,,,5.9500,12.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.25 in Billed Charges for Rev 637 = $6.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,6.77,,,,,,,5.9500,12.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.25 in Billed Charges for Rev 637 = $6.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,UNITY HEALTH PLAN,UNITY HOSPICE,12.25,,,,,,,5.9500,12.2500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 637 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.60,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.25 in Billed Charges for Rev 637 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 637 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.82,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.25 in Billed Charges for Rev 637 = $8.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,637,RC,45802-060-01,CDM,,,,,,both,14.000000,GR,12.2500,8.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.35,,,,,,,5.9500,12.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.25 in Billed Charges for Rev 637 = $7.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,AETNA,AETNA HSHS,7.95,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.30 in Billed Charges for Rev 637 = $7.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,AETNA,ALL COMMERCIAL AETNA,12.30,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.30 in Billed Charges for Rev 637 = $12.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,ANTHEM,ANTHEM POS/HMO,8.36,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.30 in Billed Charges for Rev 637 = $8.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,ANTHEM,ANTHEM PPO,8.36,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.30 in Billed Charges for Rev 637 = $8.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.30,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.30 in Billed Charges for Rev 637 = $12.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,CENPATICO,ALL MEDICAID CENPATICO,12.30,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.30 in Billed Charges for Rev 637 = $12.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.46,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.30 in Billed Charges for Rev 637 = $10.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,CIGNA,ALL COMMERCIAL CIGNA,8.61,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.30 in Billed Charges for Rev 637 = $8.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,COFINITY,COFINITY,12.30,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.30 in Billed Charges for Rev 637 = $12.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.69,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.30 in Billed Charges for Rev 637 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,10.33,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.30 in Billed Charges for Rev 637 = $10.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.73,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.30 in Billed Charges for Rev 637 = $8.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.98,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.30 in Billed Charges for Rev 637 = $8.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,5.98,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.30 in Billed Charges for Rev 637 = $5.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.46,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.30 in Billed Charges for Rev 637 = $10.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,HUMANA,HUMANA CHOICE CARE HMO,7.81,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.30 in Billed Charges at 63.5% = $7.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,HUMANA,HUMANA CHOICE CARE PPO,10.46,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.30 in Billed Charges for Rev 637 = $10.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,HUMANA,HUMANA NATIIONAL POS HMO,7.81,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.30 in Billed Charges at 63.5% = $7.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.98,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.30 in Billed Charges for Rev 637 = $8.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.30,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.30 in Billed Charges for Rev 637 = $12.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.30,,,,,,,5.9800,12.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.15,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.30 in Billed Charges for Rev 637 = $6.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.33,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.30 in Billed Charges for Rev 637 = $10.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.23,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.30 in Billed Charges for Rev 637 = $9.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.32,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.30 in Billed Charges for Rev 637 = $11.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.38,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.30 in Billed Charges for Rev 637 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.38,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.30 in Billed Charges for Rev 637 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,PREVEA HEALTH NETWORK,PREVEA360,7.38,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.30 in Billed Charges for Rev 637 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.38,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.30 in Billed Charges for Rev 637 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.85,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.30 in Billed Charges for Rev 637 = $7.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.86,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.30 in Billed Charges for Rev 637 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.80,,,,,,,5.9800,12.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.30 in Billed Charges for Rev 637 = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,6.80,,,,,,,5.9800,12.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.30 in Billed Charges for Rev 637 = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,6.80,,,,,,,5.9800,12.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.30 in Billed Charges for Rev 637 = $6.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,UNITY HEALTH PLAN,UNITY HOSPICE,12.30,,,,,,,5.9800,12.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.86,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.30 in Billed Charges for Rev 637 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.63,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.30 in Billed Charges for Rev 637 = $7.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.86,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.30 in Billed Charges for Rev 637 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.86,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.30 in Billed Charges for Rev 637 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 14.2 G TUBE,637,RC,68001-477-46,CDM,,,,,,both,14.200000,GR,12.3000,8.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.38,,,,,,,5.9800,12.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.30 in Billed Charges for Rev 637 = $7.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,AETNA,AETNA HSHS,284.85,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $440.95 in Billed Charges for Rev 637 = $284.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,AETNA,ALL COMMERCIAL AETNA,440.95,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $440.95 in Billed Charges for Rev 637 = $440.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,ANTHEM,ANTHEM POS/HMO,299.85,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $440.95 in Billed Charges for Rev 637 = $299.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,ANTHEM,ANTHEM PPO,299.85,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $440.95 in Billed Charges for Rev 637 = $299.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,440.95,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $440.95 in Billed Charges for Rev 637 = $440.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,CENPATICO,ALL MEDICAID CENPATICO,440.95,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $440.95 in Billed Charges for Rev 637 = $440.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,374.81,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $440.95 in Billed Charges for Rev 637 = $374.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,CIGNA,ALL COMMERCIAL CIGNA,308.67,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $440.95 in Billed Charges for Rev 637 = $308.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,COFINITY,COFINITY,440.95,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $440.95 in Billed Charges for Rev 637 = $440.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,418.90,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $440.95 in Billed Charges for Rev 637 = $418.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,HEALTH CARE ALLIANCE,THE ALLIANCE,370.40,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $440.95 in Billed Charges for Rev 637 = $370.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,313.07,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $440.95 in Billed Charges for Rev 637 = $313.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,321.89,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $440.95 in Billed Charges for Rev 637 = $321.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,HSHS EMPLOYEES,HSHS EMPLOYEES,214.30,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $440.95 in Billed Charges for Rev 637 = $214.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,374.81,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $440.95 in Billed Charges for Rev 637 = $374.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,HUMANA,HUMANA CHOICE CARE HMO,280.00,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $440.95 in Billed Charges at 63.5% = $280.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,HUMANA,HUMANA CHOICE CARE PPO,374.81,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $440.95 in Billed Charges for Rev 637 = $374.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,HUMANA,HUMANA NATIIONAL POS HMO,280.00,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $440.95 in Billed Charges at 63.5% = $280.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,321.89,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $440.95 in Billed Charges for Rev 637 = $321.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,LIVE360,LIVE360 HSHS HEALTHY PLAN,440.95,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $440.95 in Billed Charges for Rev 637 = $440.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,440.95,,,,,,,214.3000,440.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,220.48,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $440.95 in Billed Charges for Rev 637 = $220.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,370.40,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $440.95 in Billed Charges for Rev 637 = $370.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,330.71,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $440.95 in Billed Charges for Rev 637 = $330.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,405.67,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $440.95 in Billed Charges for Rev 637 = $405.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,264.57,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $440.95 in Billed Charges for Rev 637 = $264.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,264.57,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $440.95 in Billed Charges for Rev 637 = $264.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,PREVEA HEALTH NETWORK,PREVEA360,264.57,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $440.95 in Billed Charges for Rev 637 = $264.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,264.57,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $440.95 in Billed Charges for Rev 637 = $264.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,281.46,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $440.95 in Billed Charges for Rev 637 = $281.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,317.48,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $440.95 in Billed Charges for Rev 637 = $317.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,243.85,,,,,,,214.3000,440.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $440.95 in Billed Charges for Rev 637 = $243.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,UNITED HEALTHCARE,UHC ONEIDA NATION,243.85,,,,,,,214.3000,440.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $440.95 in Billed Charges for Rev 637 = $243.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,UNITED HEALTHCARE,UNITED HEALTHCARE,243.85,,,,,,,214.3000,440.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $440.95 in Billed Charges for Rev 637 = $243.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,UNITY HEALTH PLAN,UNITY HOSPICE,440.95,,,,,,,214.3000,440.9500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,317.48,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $440.95 in Billed Charges for Rev 637 = $317.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,273.39,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $440.95 in Billed Charges for Rev 637 = $273.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,317.48,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $440.95 in Billed Charges for Rev 637 = $317.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,317.48,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $440.95 in Billed Charges for Rev 637 = $317.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN 500 UNIT/GM OINT 3.5 G TUBE,637,RC,0574-4022-35,CDM,,,,,,both,3.500000,GR,440.9500,291.0300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,264.57,,,,,,,214.3000,440.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $440.95 in Billed Charges for Rev 637 = $264.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,AETNA,AETNA HSHS,62.95,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $97.45 in Billed Charges for Rev 637 = $62.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,AETNA,ALL COMMERCIAL AETNA,97.45,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.45 in Billed Charges for Rev 637 = $97.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,ANTHEM,ANTHEM POS/HMO,66.27,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $97.45 in Billed Charges for Rev 637 = $66.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,ANTHEM,ANTHEM PPO,66.27,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $97.45 in Billed Charges for Rev 637 = $66.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,97.45,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.45 in Billed Charges for Rev 637 = $97.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,CENPATICO,ALL MEDICAID CENPATICO,97.45,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.45 in Billed Charges for Rev 637 = $97.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,82.83,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.45 in Billed Charges for Rev 637 = $82.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,CIGNA,ALL COMMERCIAL CIGNA,68.22,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $97.45 in Billed Charges for Rev 637 = $68.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,COFINITY,COFINITY,97.45,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.45 in Billed Charges for Rev 637 = $97.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,92.58,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $97.45 in Billed Charges for Rev 637 = $92.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,81.86,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $97.45 in Billed Charges for Rev 637 = $81.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,69.19,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $97.45 in Billed Charges for Rev 637 = $69.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,71.14,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $97.45 in Billed Charges for Rev 637 = $71.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,47.36,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $97.45 in Billed Charges for Rev 637 = $47.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,82.83,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.45 in Billed Charges for Rev 637 = $82.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,HUMANA,HUMANA CHOICE CARE HMO,61.88,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $97.45 in Billed Charges at 63.5% = $61.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,HUMANA,HUMANA CHOICE CARE PPO,82.83,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $97.45 in Billed Charges for Rev 637 = $82.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,HUMANA,HUMANA NATIIONAL POS HMO,61.88,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $97.45 in Billed Charges at 63.5% = $61.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,71.14,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $97.45 in Billed Charges for Rev 637 = $71.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,97.45,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $97.45 in Billed Charges for Rev 637 = $97.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,97.45,,,,,,,47.3600,97.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,48.73,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $97.45 in Billed Charges for Rev 637 = $48.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,81.86,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $97.45 in Billed Charges for Rev 637 = $81.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,73.09,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $97.45 in Billed Charges for Rev 637 = $73.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,89.65,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $97.45 in Billed Charges for Rev 637 = $89.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,58.47,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.45 in Billed Charges for Rev 637 = $58.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,58.47,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.45 in Billed Charges for Rev 637 = $58.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,PREVEA HEALTH NETWORK,PREVEA360,58.47,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.45 in Billed Charges for Rev 637 = $58.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,58.47,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.45 in Billed Charges for Rev 637 = $58.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,62.20,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $97.45 in Billed Charges for Rev 637 = $62.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,70.16,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.45 in Billed Charges for Rev 637 = $70.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,53.89,,,,,,,47.3600,97.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $97.45 in Billed Charges for Rev 637 = $53.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,53.89,,,,,,,47.3600,97.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $97.45 in Billed Charges for Rev 637 = $53.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,53.89,,,,,,,47.3600,97.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $97.45 in Billed Charges for Rev 637 = $53.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,UNITY HEALTH PLAN,UNITY HOSPICE,97.45,,,,,,,47.3600,97.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,70.16,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.45 in Billed Charges for Rev 637 = $70.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,60.42,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $97.45 in Billed Charges for Rev 637 = $60.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,70.16,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.45 in Billed Charges for Rev 637 = $70.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,70.16,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $97.45 in Billed Charges for Rev 637 = $70.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,24208-555-55,CDM,,,,,,both,3.500000,GR,97.4500,64.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,58.47,,,,,,,47.3600,97.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $97.45 in Billed Charges for Rev 637 = $58.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,AETNA,AETNA HSHS,1913.52,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,962.10 in Billed Charges for Rev 637 = $1,913.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,AETNA,ALL COMMERCIAL AETNA,2962.10,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.10 in Billed Charges for Rev 637 = $2,962.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,ANTHEM,ANTHEM POS/HMO,2014.23,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,962.10 in Billed Charges for Rev 637 = $2,014.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,ANTHEM,ANTHEM PPO,2014.23,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $2,962.10 in Billed Charges for Rev 637 = $2,014.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2962.10,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.10 in Billed Charges for Rev 637 = $2,962.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,CENPATICO,ALL MEDICAID CENPATICO,2962.10,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.10 in Billed Charges for Rev 637 = $2,962.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2517.79,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,962.10 in Billed Charges for Rev 637 = $2,517.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,CIGNA,ALL COMMERCIAL CIGNA,2073.47,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,962.10 in Billed Charges for Rev 637 = $2,073.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,COFINITY,COFINITY,2962.10,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.10 in Billed Charges for Rev 637 = $2,962.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2814.00,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,962.10 in Billed Charges for Rev 637 = $2,814.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,HEALTH CARE ALLIANCE,THE ALLIANCE,2488.16,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,962.10 in Billed Charges for Rev 637 = $2,488.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2103.09,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,962.10 in Billed Charges for Rev 637 = $2,103.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2162.33,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,962.10 in Billed Charges for Rev 637 = $2,162.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,HSHS EMPLOYEES,HSHS EMPLOYEES,1439.58,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,962.10 in Billed Charges for Rev 637 = $1,439.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2517.79,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,962.10 in Billed Charges for Rev 637 = $2,517.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,HUMANA,HUMANA CHOICE CARE HMO,1880.93,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $2,962.10 in Billed Charges at 63.5% = $1,880.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,HUMANA,HUMANA CHOICE CARE PPO,2517.79,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,962.10 in Billed Charges for Rev 637 = $2,517.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,HUMANA,HUMANA NATIIONAL POS HMO,1880.93,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $2,962.10 in Billed Charges at 63.5% = $1,880.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2162.33,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,962.10 in Billed Charges for Rev 637 = $2,162.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,LIVE360,LIVE360 HSHS HEALTHY PLAN,2962.10,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,962.10 in Billed Charges for Rev 637 = $2,962.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,2962.10,,,,,,,1439.5800,2962.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1481.05,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,962.10 in Billed Charges for Rev 637 = $1,481.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2488.16,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,962.10 in Billed Charges for Rev 637 = $2,488.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2221.58,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,962.10 in Billed Charges for Rev 637 = $2,221.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2725.13,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,962.10 in Billed Charges for Rev 637 = $2,725.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1777.26,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,962.10 in Billed Charges for Rev 637 = $1,777.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1777.26,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,962.10 in Billed Charges for Rev 637 = $1,777.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,PREVEA HEALTH NETWORK,PREVEA360,1777.26,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,962.10 in Billed Charges for Rev 637 = $1,777.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1777.26,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,962.10 in Billed Charges for Rev 637 = $1,777.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1890.71,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,962.10 in Billed Charges for Rev 637 = $1,890.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2132.71,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,962.10 in Billed Charges for Rev 637 = $2,132.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1638.04,,,,,,,1439.5800,2962.1000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,962.10 in Billed Charges for Rev 637 = $1,638.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,UNITED HEALTHCARE,UHC ONEIDA NATION,1638.04,,,,,,,1439.5800,2962.1000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,962.10 in Billed Charges for Rev 637 = $1,638.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,UNITED HEALTHCARE,UNITED HEALTHCARE,1638.04,,,,,,,1439.5800,2962.1000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,962.10 in Billed Charges for Rev 637 = $1,638.04 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,UNITY HEALTH PLAN,UNITY HOSPICE,2962.10,,,,,,,1439.5800,2962.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2132.71,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,962.10 in Billed Charges for Rev 637 = $2,132.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1836.50,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,962.10 in Billed Charges for Rev 637 = $1,836.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2132.71,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,962.10 in Billed Charges for Rev 637 = $2,132.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2132.71,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,962.10 in Billed Charges for Rev 637 = $2,132.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
BACLOFEN 25 MG/5ML SUSP,637,RC,52536-600-11,CDM,,,,,,both,120.000000,ML,2962.1000,1954.9900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1777.26,,,,,,,1439.5800,2962.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,962.10 in Billed Charges for Rev 637 = $1,777.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,AETNA,AETNA HSHS,181.53,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $181.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,AETNA,AETNA MEDICARE,172.41,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,AETNA,ALL COMMERCIAL AETNA,281.00,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $281.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,ANTHEM,ANTEHM MEDICAID,59.28,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00315 Proc 90832 at $125.60 (Base Rate) * 0.472 (Relative Weight) = $59.28 (Total Line Payment) at 100% = $59.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,172.41,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,281.00,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $281.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,CENPATICO,ALL MEDICAID CENPATICO,281.00,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $281.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,238.85,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $238.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,CIGNA,ALL COMMERCIAL CIGNA,196.70,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $196.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,COFINITY,COFINITY,281.00,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $281.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,59.28,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00315 Proc 90832 at $125.60 (Base Rate) * 0.472 (Relative Weight) = $59.28 (Total Line Payment) at 100% = $59.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,59.28,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00315 Proc 90832 at $125.60 (Base Rate) * 0.472 (Relative Weight) = $59.28 (Total Line Payment) at 100% = $59.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,266.95,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $266.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,236.04,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $236.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,199.51,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $199.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,205.13,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $205.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,136.57,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $136.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,238.85,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $238.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HUMANA,HUMANA CHOICE CARE HMO,178.44,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $178.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HUMANA,HUMANA CHOICE CARE PPO,238.85,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $238.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HUMANA,HUMANA MEDICARE ADVANTAGE,172.41,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,HUMANA,HUMANA NATIIONAL POS HMO,178.44,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $178.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,205.13,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $205.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,281.00,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $281.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,59.28,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00315 Proc 90832 at $125.60 (Base Rate) * 0.472 (Relative Weight) = $59.28 (Total Line Payment) at 100% = $59.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,172.41,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,59.28,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00315 Proc 90832 at $125.60 (Base Rate) * 0.472 (Relative Weight) = $59.28 (Total Line Payment) at 100% = $59.28. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,MOLINA HEALTHCARE,MOLINA MEDICAID,62.84,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00315 Proc 90832 at $125.60 (Base Rate) * 0.472 (Relative Weight) = $59.28 (Total Line Payment) at 100% = $59.28... $59.28 at 106% = $62.84 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,MOLINA HEALTHCARE,MOLINA MEDICARE,172.41,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,140.50,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $140.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,236.04,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $236.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,NAPHCARE,ALL COMMERICAL NAPHCARE,387.92,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,210.75,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $210.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,258.52,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $258.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,168.60,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $168.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,168.60,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $168.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,PREVEA HEALTH NETWORK,PREVEA360,168.60,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $168.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,168.60,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $168.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,179.36,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $179.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,174.13,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,202.32,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $202.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,TRIOLOGY,TRILOGY MEDICAID,62.84,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00315 Proc 90832 at $125.60 (Base Rate) * 0.472 (Relative Weight) = $59.28 (Total Line Payment) at 106% = $62.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,172.41,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,UNITY HEALTH PLAN,UNITY HOSPICE,172.41,,,,,,,59.2800,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,202.32,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $202.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,174.22,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $174.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,202.32,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $202.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,202.32,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $202.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 30MIN,90832,CPT,945,RC,94500013,CDM,,,,both,,,281.0000,185.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,168.60,,,,,,,59.2800,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $281.00 in Billed Charges for Rev 945 Proc 90832 = $168.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,AETNA,AETNA HSHS,213.18,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $213.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,AETNA,AETNA MEDICARE,172.41,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,AETNA,ALL COMMERCIAL AETNA,330.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,ANTHEM,ANTEHM MEDICAID,70.84,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00316 Proc 90837 at $125.60 (Base Rate) * 0.564 (Relative Weight) = $70.84 (Total Line Payment) at 100% = $70.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,172.41,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,330.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,CENPATICO,ALL MEDICAID CENPATICO,330.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,280.50,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $280.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,CIGNA,ALL COMMERCIAL CIGNA,231.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $231.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,COFINITY,COFINITY,330.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,70.84,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00316 Proc 90837 at $125.60 (Base Rate) * 0.564 (Relative Weight) = $70.84 (Total Line Payment) at 100% = $70.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,70.84,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00316 Proc 90837 at $125.60 (Base Rate) * 0.564 (Relative Weight) = $70.84 (Total Line Payment) at 100% = $70.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,313.50,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $313.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,277.20,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $277.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,234.30,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $234.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,240.90,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $240.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,160.38,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $160.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,280.50,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $280.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HUMANA,HUMANA CHOICE CARE HMO,209.55,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $209.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HUMANA,HUMANA CHOICE CARE PPO,280.50,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $280.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HUMANA,HUMANA MEDICARE ADVANTAGE,172.41,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,HUMANA,HUMANA NATIIONAL POS HMO,209.55,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $209.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,240.90,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $240.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,330.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,70.84,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00316 Proc 90837 at $125.60 (Base Rate) * 0.564 (Relative Weight) = $70.84 (Total Line Payment) at 100% = $70.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,172.41,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,70.84,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00316 Proc 90837 at $125.60 (Base Rate) * 0.564 (Relative Weight) = $70.84 (Total Line Payment) at 100% = $70.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,MOLINA HEALTHCARE,MOLINA MEDICAID,75.09,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00316 Proc 90837 at $125.60 (Base Rate) * 0.564 (Relative Weight) = $70.84 (Total Line Payment) at 100% = $70.84... $70.84 at 106% = $75.09 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,MOLINA HEALTHCARE,MOLINA MEDICARE,172.41,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,165.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $165.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,277.20,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $277.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,NAPHCARE,ALL COMMERICAL NAPHCARE,387.92,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,247.50,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $247.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,303.60,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $303.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,198.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,198.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,PREVEA HEALTH NETWORK,PREVEA360,198.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,198.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,210.64,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $210.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,174.13,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,237.60,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $237.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,TRIOLOGY,TRILOGY MEDICAID,75.09,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00316 Proc 90837 at $125.60 (Base Rate) * 0.564 (Relative Weight) = $70.84 (Total Line Payment) at 106% = $75.09. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,172.41,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,UNITY HEALTH PLAN,UNITY HOSPICE,172.41,,,,,,,70.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,237.60,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $237.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,204.60,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $204.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,237.60,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $237.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,237.60,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $237.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL THERAPY INDIVIDUAL 60MIN,90837,CPT,945,RC,94500015,CDM,,,,both,,,330.0000,217.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,198.00,,,,,,,70.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $330.00 in Billed Charges for Rev 945 Proc 90837 = $198.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,AETNA,AETNA HSHS,135.01,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $135.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,AETNA,AETNA MEDICARE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,AETNA,ALL COMMERCIAL AETNA,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTEHM MEDICAID,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94625 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM POS/HMO,142.12,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $142.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM PPO,142.12,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $142.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,CENPATICO,ALL MEDICAID CENPATICO,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,177.65,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,CIGNA,ALL COMMERCIAL CIGNA,146.30,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $146.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,COFINITY,COFINITY,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94625 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94625 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,198.55,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $198.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,175.56,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $175.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,148.39,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $148.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,152.57,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $152.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,101.57,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $101.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,177.65,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA CHOICE CARE HMO,132.72,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $132.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA CHOICE CARE PPO,177.65,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA NATIIONAL POS HMO,132.72,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $132.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,152.57,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $152.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94625 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94625 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,16.59,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94625 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65... $15.65 at 106% = $16.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,104.50,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $104.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,175.56,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $175.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,128.93,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,156.75,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $156.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,192.28,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $192.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA360,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,133.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $133.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,57.87,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,150.48,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,TRIOLOGY,TRILOGY MEDICAID,16.59,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94625 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 106% = $16.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,97.39,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 46.6% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $97.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,97.39,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 46.6% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $97.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,97.39,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 46.6% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $97.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,UNITY HEALTH PLAN,UNITY HOSPICE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,150.48,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,129.58,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $129.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,150.48,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,150.48,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/O MNTR,94625,CPT,948,RC,94800001,CDM,,,,both,,,209.0000,137.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94625 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,AETNA,AETNA HSHS,65.25,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $101.00 in Billed Charges for Rev 2 = $65.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,AETNA,ALL COMMERCIAL AETNA,101.00,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 2 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,101.00,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 2 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,85.85,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 2 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,CIGNA,ALL COMMERCIAL CIGNA,70.70,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $101.00 in Billed Charges for Rev 2 = $70.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,COFINITY,COFINITY,101.00,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 2 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,95.95,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $101.00 in Billed Charges for Rev 2 = $95.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,84.84,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $101.00 in Billed Charges for Rev 2 = $84.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,71.71,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $101.00 in Billed Charges for Rev 2 = $71.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,73.73,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $101.00 in Billed Charges for Rev 2 = $73.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,49.09,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $101.00 in Billed Charges for Rev 2 = $49.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,85.85,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 2 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,HUMANA,HUMANA CHOICE CARE PPO,85.85,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $101.00 in Billed Charges for Rev 2 = $85.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,73.73,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $101.00 in Billed Charges for Rev 2 = $73.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,101.00,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $101.00 in Billed Charges for Rev 2 = $101.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,50.50,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $101.00 in Billed Charges for Rev 2 = $50.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,84.84,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $101.00 in Billed Charges for Rev 2 = $84.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,75.75,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $101.00 in Billed Charges for Rev 2 = $75.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,92.92,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $101.00 in Billed Charges for Rev 2 = $92.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,64.47,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $101.00 in Billed Charges for Rev 2 = $64.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,72.72,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 2 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,UNITY HEALTH PLAN,UNITY HOSPICE,101.00,,,,,,,49.0900,101.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 2... Eligible capped at $101.00 (Billed Charges)
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,72.72,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 2 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,62.62,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $101.00 in Billed Charges for Rev 2 = $62.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,72.72,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 2 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL CCS,2,RC,10020003,CDM,,,,,,inpatient,,,101.0000,66.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,72.72,,,,,,,49.0900,101.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $101.00 in Billed Charges for Rev 2 = $72.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,AETNA,AETNA HSHS,199.90,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $309.45 in Billed Charges for Rev 637 = $199.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,AETNA,ALL COMMERCIAL AETNA,309.45,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $309.45 in Billed Charges for Rev 637 = $309.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,ANTHEM,ANTHEM POS/HMO,210.43,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $309.45 in Billed Charges for Rev 637 = $210.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,ANTHEM,ANTHEM PPO,210.43,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $309.45 in Billed Charges for Rev 637 = $210.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,309.45,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $309.45 in Billed Charges for Rev 637 = $309.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,CENPATICO,ALL MEDICAID CENPATICO,309.45,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $309.45 in Billed Charges for Rev 637 = $309.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,263.03,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $309.45 in Billed Charges for Rev 637 = $263.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,CIGNA,ALL COMMERCIAL CIGNA,216.62,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $309.45 in Billed Charges for Rev 637 = $216.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,COFINITY,COFINITY,309.45,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $309.45 in Billed Charges for Rev 637 = $309.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,293.98,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $309.45 in Billed Charges for Rev 637 = $293.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,259.94,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $309.45 in Billed Charges for Rev 637 = $259.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,219.71,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $309.45 in Billed Charges for Rev 637 = $219.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,225.90,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $309.45 in Billed Charges for Rev 637 = $225.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,150.39,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $309.45 in Billed Charges for Rev 637 = $150.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,263.03,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $309.45 in Billed Charges for Rev 637 = $263.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,HUMANA,HUMANA CHOICE CARE HMO,196.50,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $309.45 in Billed Charges at 63.5% = $196.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,HUMANA,HUMANA CHOICE CARE PPO,263.03,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $309.45 in Billed Charges for Rev 637 = $263.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,HUMANA,HUMANA NATIIONAL POS HMO,196.50,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $309.45 in Billed Charges at 63.5% = $196.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,225.90,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $309.45 in Billed Charges for Rev 637 = $225.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,309.45,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $309.45 in Billed Charges for Rev 637 = $309.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,309.45,,,,,,,150.3900,309.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,154.73,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $309.45 in Billed Charges for Rev 637 = $154.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,259.94,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $309.45 in Billed Charges for Rev 637 = $259.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,232.09,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $309.45 in Billed Charges for Rev 637 = $232.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,284.69,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $309.45 in Billed Charges for Rev 637 = $284.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,185.67,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $309.45 in Billed Charges for Rev 637 = $185.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,185.67,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $309.45 in Billed Charges for Rev 637 = $185.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,PREVEA HEALTH NETWORK,PREVEA360,185.67,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $309.45 in Billed Charges for Rev 637 = $185.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,185.67,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $309.45 in Billed Charges for Rev 637 = $185.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,197.52,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $309.45 in Billed Charges for Rev 637 = $197.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,222.80,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $309.45 in Billed Charges for Rev 637 = $222.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,171.13,,,,,,,150.3900,309.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $309.45 in Billed Charges for Rev 637 = $171.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,171.13,,,,,,,150.3900,309.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $309.45 in Billed Charges for Rev 637 = $171.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,171.13,,,,,,,150.3900,309.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $309.45 in Billed Charges for Rev 637 = $171.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,UNITY HEALTH PLAN,UNITY HOSPICE,309.45,,,,,,,150.3900,309.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,222.80,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $309.45 in Billed Charges for Rev 637 = $222.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,191.86,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $309.45 in Billed Charges for Rev 637 = $191.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,222.80,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $309.45 in Billed Charges for Rev 637 = $222.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,222.80,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $309.45 in Billed Charges for Rev 637 = $222.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLOROTHIAZIDE 250 MG/5ML SUSP,637,RC,65649-311-12,CDM,,,,,,both,237.000000,ML,309.4500,204.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,185.67,,,,,,,150.3900,309.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $309.45 in Billed Charges for Rev 637 = $185.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,AETNA,AETNA HSHS,9.75,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $15.10 in Billed Charges for Rev 637 = $9.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,AETNA,ALL COMMERCIAL AETNA,15.10,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.10 in Billed Charges for Rev 637 = $15.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,ANTHEM,ANTHEM POS/HMO,10.27,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $15.10 in Billed Charges for Rev 637 = $10.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,ANTHEM,ANTHEM PPO,10.27,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $15.10 in Billed Charges for Rev 637 = $10.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15.10,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.10 in Billed Charges for Rev 637 = $15.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,CENPATICO,ALL MEDICAID CENPATICO,15.10,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.10 in Billed Charges for Rev 637 = $15.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.84,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.10 in Billed Charges for Rev 637 = $12.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,CIGNA,ALL COMMERCIAL CIGNA,10.57,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $15.10 in Billed Charges for Rev 637 = $10.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,COFINITY,COFINITY,15.10,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.10 in Billed Charges for Rev 637 = $15.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14.35,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $15.10 in Billed Charges for Rev 637 = $14.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,HEALTH CARE ALLIANCE,THE ALLIANCE,12.68,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.10 in Billed Charges for Rev 637 = $12.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.72,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $15.10 in Billed Charges for Rev 637 = $10.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.02,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.10 in Billed Charges for Rev 637 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,HSHS EMPLOYEES,HSHS EMPLOYEES,7.34,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $15.10 in Billed Charges for Rev 637 = $7.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.84,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.10 in Billed Charges for Rev 637 = $12.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,HUMANA,HUMANA CHOICE CARE HMO,9.59,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $15.10 in Billed Charges at 63.5% = $9.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,HUMANA,HUMANA CHOICE CARE PPO,12.84,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.10 in Billed Charges for Rev 637 = $12.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,HUMANA,HUMANA NATIIONAL POS HMO,9.59,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $15.10 in Billed Charges at 63.5% = $9.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.02,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.10 in Billed Charges for Rev 637 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,LIVE360,LIVE360 HSHS HEALTHY PLAN,15.10,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.10 in Billed Charges for Rev 637 = $15.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.10,,,,,,,7.3400,15.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.55,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $15.10 in Billed Charges for Rev 637 = $7.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.68,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.10 in Billed Charges for Rev 637 = $12.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.33,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $15.10 in Billed Charges for Rev 637 = $11.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.89,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $15.10 in Billed Charges for Rev 637 = $13.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9.06,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.10 in Billed Charges for Rev 637 = $9.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9.06,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.10 in Billed Charges for Rev 637 = $9.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,PREVEA HEALTH NETWORK,PREVEA360,9.06,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.10 in Billed Charges for Rev 637 = $9.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9.06,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.10 in Billed Charges for Rev 637 = $9.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.64,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $15.10 in Billed Charges for Rev 637 = $9.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.87,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.10 in Billed Charges for Rev 637 = $10.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.35,,,,,,,7.3400,15.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.10 in Billed Charges for Rev 637 = $8.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,UNITED HEALTHCARE,UHC ONEIDA NATION,8.35,,,,,,,7.3400,15.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.10 in Billed Charges for Rev 637 = $8.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,UNITED HEALTHCARE,UNITED HEALTHCARE,8.35,,,,,,,7.3400,15.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.10 in Billed Charges for Rev 637 = $8.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,UNITY HEALTH PLAN,UNITY HOSPICE,15.10,,,,,,,7.3400,15.1000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.87,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.10 in Billed Charges for Rev 637 = $10.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.36,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $15.10 in Billed Charges for Rev 637 = $9.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.87,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.10 in Billed Charges for Rev 637 = $10.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.87,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.10 in Billed Charges for Rev 637 = $10.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 250 MG TABS,637,RC,43547-688-10,CDM,,,,,,both,1.000000,EA,15.1000,9.9700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.06,,,,,,,7.3400,15.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.10 in Billed Charges for Rev 637 = $9.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,AETNA,AETNA HSHS,6.88,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $10.65 in Billed Charges for Rev 637 = $6.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,AETNA,ALL COMMERCIAL AETNA,10.65,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.65 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,ANTHEM,ANTHEM POS/HMO,7.24,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $10.65 in Billed Charges for Rev 637 = $7.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,ANTHEM,ANTHEM PPO,7.24,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $10.65 in Billed Charges for Rev 637 = $7.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,10.65,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.65 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,CENPATICO,ALL MEDICAID CENPATICO,10.65,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.65 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.05,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.65 in Billed Charges for Rev 637 = $9.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,CIGNA,ALL COMMERCIAL CIGNA,7.46,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $10.65 in Billed Charges for Rev 637 = $7.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,COFINITY,COFINITY,10.65,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.65 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,10.12,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $10.65 in Billed Charges for Rev 637 = $10.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,HEALTH CARE ALLIANCE,THE ALLIANCE,8.95,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.65 in Billed Charges for Rev 637 = $8.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,7.56,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $10.65 in Billed Charges for Rev 637 = $7.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,7.77,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.65 in Billed Charges for Rev 637 = $7.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,HSHS EMPLOYEES,HSHS EMPLOYEES,5.18,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $10.65 in Billed Charges for Rev 637 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.05,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.65 in Billed Charges for Rev 637 = $9.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,HUMANA,HUMANA CHOICE CARE HMO,6.76,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $10.65 in Billed Charges at 63.5% = $6.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,HUMANA,HUMANA CHOICE CARE PPO,9.05,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $10.65 in Billed Charges for Rev 637 = $9.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,HUMANA,HUMANA NATIIONAL POS HMO,6.76,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $10.65 in Billed Charges at 63.5% = $6.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,7.77,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $10.65 in Billed Charges for Rev 637 = $7.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,LIVE360,LIVE360 HSHS HEALTHY PLAN,10.65,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $10.65 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,10.65,,,,,,,5.1800,10.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.33,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $10.65 in Billed Charges for Rev 637 = $5.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,8.95,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $10.65 in Billed Charges for Rev 637 = $8.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,7.99,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $10.65 in Billed Charges for Rev 637 = $7.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,9.80,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $10.65 in Billed Charges for Rev 637 = $9.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,6.39,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.65 in Billed Charges for Rev 637 = $6.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,6.39,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.65 in Billed Charges for Rev 637 = $6.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,PREVEA HEALTH NETWORK,PREVEA360,6.39,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.65 in Billed Charges for Rev 637 = $6.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,6.39,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.65 in Billed Charges for Rev 637 = $6.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,6.80,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $10.65 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,7.67,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.65 in Billed Charges for Rev 637 = $7.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,5.89,,,,,,,5.1800,10.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.65 in Billed Charges for Rev 637 = $5.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,UNITED HEALTHCARE,UHC ONEIDA NATION,5.89,,,,,,,5.1800,10.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.65 in Billed Charges for Rev 637 = $5.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,UNITED HEALTHCARE,UNITED HEALTHCARE,5.89,,,,,,,5.1800,10.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $10.65 in Billed Charges for Rev 637 = $5.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,UNITY HEALTH PLAN,UNITY HOSPICE,10.65,,,,,,,5.1800,10.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,7.67,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.65 in Billed Charges for Rev 637 = $7.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,6.60,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $10.65 in Billed Charges for Rev 637 = $6.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,7.67,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.65 in Billed Charges for Rev 637 = $7.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,7.67,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $10.65 in Billed Charges for Rev 637 = $7.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 10 MG TABS,637,RC,60687-423-11,CDM,,,,,,both,1.000000,EA,10.6500,7.0300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,6.39,,,,,,,5.1800,10.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $10.65 in Billed Charges for Rev 637 = $6.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,AETNA,AETNA HSHS,2281.45,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,531.65 in Billed Charges for Rev 637 = $2,281.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,AETNA,ALL COMMERCIAL AETNA,3531.65,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,531.65 in Billed Charges for Rev 637 = $3,531.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,ANTHEM,ANTHEM POS/HMO,2401.52,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $3,531.65 in Billed Charges for Rev 637 = $2,401.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,ANTHEM,ANTHEM PPO,2401.52,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 68% of $3,531.65 in Billed Charges for Rev 637 = $2,401.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3531.65,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,531.65 in Billed Charges for Rev 637 = $3,531.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,CENPATICO,ALL MEDICAID CENPATICO,3531.65,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,531.65 in Billed Charges for Rev 637 = $3,531.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3001.90,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,531.65 in Billed Charges for Rev 637 = $3,001.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,CIGNA,ALL COMMERCIAL CIGNA,2472.16,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,531.65 in Billed Charges for Rev 637 = $2,472.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,COFINITY,COFINITY,3531.65,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,531.65 in Billed Charges for Rev 637 = $3,531.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3355.07,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,531.65 in Billed Charges for Rev 637 = $3,355.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,HEALTH CARE ALLIANCE,THE ALLIANCE,2966.59,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,531.65 in Billed Charges for Rev 637 = $2,966.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2507.47,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,531.65 in Billed Charges for Rev 637 = $2,507.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2578.10,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,531.65 in Billed Charges for Rev 637 = $2,578.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,HSHS EMPLOYEES,HSHS EMPLOYEES,1716.38,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,531.65 in Billed Charges for Rev 637 = $1,716.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3001.90,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,531.65 in Billed Charges for Rev 637 = $3,001.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,HUMANA,HUMANA CHOICE CARE HMO,2242.60,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $3,531.65 in Billed Charges at 63.5% = $2,242.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,HUMANA,HUMANA CHOICE CARE PPO,3001.90,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,531.65 in Billed Charges for Rev 637 = $3,001.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,HUMANA,HUMANA NATIIONAL POS HMO,2242.60,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 637 $3,531.65 in Billed Charges at 63.5% = $2,242.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2578.10,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,531.65 in Billed Charges for Rev 637 = $2,578.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,LIVE360,LIVE360 HSHS HEALTHY PLAN,3531.65,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,531.65 in Billed Charges for Rev 637 = $3,531.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,3531.65,,,,,,,1716.3800,3531.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1765.83,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,531.65 in Billed Charges for Rev 637 = $1,765.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2966.59,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,531.65 in Billed Charges for Rev 637 = $2,966.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2648.74,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,531.65 in Billed Charges for Rev 637 = $2,648.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3249.12,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,531.65 in Billed Charges for Rev 637 = $3,249.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2118.99,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,531.65 in Billed Charges for Rev 637 = $2,118.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2118.99,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,531.65 in Billed Charges for Rev 637 = $2,118.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,PREVEA HEALTH NETWORK,PREVEA360,2118.99,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,531.65 in Billed Charges for Rev 637 = $2,118.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2118.99,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,531.65 in Billed Charges for Rev 637 = $2,118.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2254.25,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,531.65 in Billed Charges for Rev 637 = $2,254.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2542.79,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,531.65 in Billed Charges for Rev 637 = $2,542.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1953.00,,,,,,,1716.3800,3531.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $3,531.65 in Billed Charges for Rev 637 = $1,953.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,UNITED HEALTHCARE,UHC ONEIDA NATION,1953.00,,,,,,,1716.3800,3531.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $3,531.65 in Billed Charges for Rev 637 = $1,953.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,UNITED HEALTHCARE,UNITED HEALTHCARE,1953.00,,,,,,,1716.3800,3531.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $3,531.65 in Billed Charges for Rev 637 = $1,953.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,UNITY HEALTH PLAN,UNITY HOSPICE,3531.65,,,,,,,1716.3800,3531.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2542.79,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,531.65 in Billed Charges for Rev 637 = $2,542.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2189.62,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,531.65 in Billed Charges for Rev 637 = $2,189.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2542.79,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,531.65 in Billed Charges for Rev 637 = $2,542.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2542.79,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,531.65 in Billed Charges for Rev 637 = $2,542.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBAZAM 2.5 MG/ML SUSP,637,RC,59651-401-12,CDM,,,,,,both,120.000000,ML,3531.6500,2330.8900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2118.99,,,,,,,1716.3800,3531.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $3,531.65 in Billed Charges for Rev 637 = $2,118.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,AETNA,AETNA HSHS,281.66,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $436.00 in Billed Charges for Rev 637 = $281.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,AETNA,ALL COMMERCIAL AETNA,436.00,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 637 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,ANTHEM,ANTHEM POS/HMO,296.48,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $436.00 in Billed Charges for Rev 637 = $296.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,ANTHEM,ANTHEM PPO,296.48,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $436.00 in Billed Charges for Rev 637 = $296.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,436.00,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 637 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,CENPATICO,ALL MEDICAID CENPATICO,436.00,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 637 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,370.60,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 637 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,CIGNA,ALL COMMERCIAL CIGNA,305.20,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $436.00 in Billed Charges for Rev 637 = $305.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,COFINITY,COFINITY,436.00,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 637 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,414.20,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $436.00 in Billed Charges for Rev 637 = $414.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,366.24,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 637 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,309.56,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $436.00 in Billed Charges for Rev 637 = $309.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,318.28,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 637 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,211.90,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $436.00 in Billed Charges for Rev 637 = $211.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,370.60,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 637 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE HMO,276.86,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $436.00 in Billed Charges at 63.5% = $276.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,HUMANA,HUMANA CHOICE CARE PPO,370.60,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $436.00 in Billed Charges for Rev 637 = $370.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,HUMANA,HUMANA NATIIONAL POS HMO,276.86,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $436.00 in Billed Charges at 63.5% = $276.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,318.28,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $436.00 in Billed Charges for Rev 637 = $318.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,436.00,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $436.00 in Billed Charges for Rev 637 = $436.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,436.00,,,,,,,211.9000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,218.00,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $436.00 in Billed Charges for Rev 637 = $218.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,366.24,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $436.00 in Billed Charges for Rev 637 = $366.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,327.00,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $436.00 in Billed Charges for Rev 637 = $327.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,401.12,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $436.00 in Billed Charges for Rev 637 = $401.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,261.60,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,261.60,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360,261.60,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,261.60,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,278.30,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $436.00 in Billed Charges for Rev 637 = $278.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,313.92,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 637 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,241.11,,,,,,,211.9000,436.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $436.00 in Billed Charges for Rev 637 = $241.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,241.11,,,,,,,211.9000,436.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $436.00 in Billed Charges for Rev 637 = $241.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,241.11,,,,,,,211.9000,436.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $436.00 in Billed Charges for Rev 637 = $241.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,UNITY HEALTH PLAN,UNITY HOSPICE,436.00,,,,,,,211.9000,436.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,313.92,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 637 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,270.32,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $436.00 in Billed Charges for Rev 637 = $270.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,313.92,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 637 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,313.92,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $436.00 in Billed Charges for Rev 637 = $313.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOBETASOL 0.05 % CREA 15 G TUBE,637,RC,21922-016-04,CDM,,,,,,both,15.000000,GR,436.0000,287.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,261.60,,,,,,,211.9000,436.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $436.00 in Billed Charges for Rev 637 = $261.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,AETNA,AETNA HSHS,72.84,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $112.75 in Billed Charges for Rev 637 = $72.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,AETNA,ALL COMMERCIAL AETNA,112.75,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.75 in Billed Charges for Rev 637 = $112.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,ANTHEM,ANTHEM POS/HMO,76.67,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $112.75 in Billed Charges for Rev 637 = $76.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,ANTHEM,ANTHEM PPO,76.67,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $112.75 in Billed Charges for Rev 637 = $76.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,112.75,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.75 in Billed Charges for Rev 637 = $112.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,CENPATICO,ALL MEDICAID CENPATICO,112.75,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.75 in Billed Charges for Rev 637 = $112.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,95.84,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.75 in Billed Charges for Rev 637 = $95.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,CIGNA,ALL COMMERCIAL CIGNA,78.93,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $112.75 in Billed Charges for Rev 637 = $78.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,COFINITY,COFINITY,112.75,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.75 in Billed Charges for Rev 637 = $112.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,107.11,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $112.75 in Billed Charges for Rev 637 = $107.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,94.71,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $112.75 in Billed Charges for Rev 637 = $94.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,80.05,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $112.75 in Billed Charges for Rev 637 = $80.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,82.31,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $112.75 in Billed Charges for Rev 637 = $82.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,54.80,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $112.75 in Billed Charges for Rev 637 = $54.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,95.84,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.75 in Billed Charges for Rev 637 = $95.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,HUMANA,HUMANA CHOICE CARE HMO,71.60,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $112.75 in Billed Charges at 63.5% = $71.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,HUMANA,HUMANA CHOICE CARE PPO,95.84,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $112.75 in Billed Charges for Rev 637 = $95.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,HUMANA,HUMANA NATIIONAL POS HMO,71.60,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $112.75 in Billed Charges at 63.5% = $71.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,82.31,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $112.75 in Billed Charges for Rev 637 = $82.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,112.75,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $112.75 in Billed Charges for Rev 637 = $112.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,112.75,,,,,,,54.8000,112.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,56.38,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $112.75 in Billed Charges for Rev 637 = $56.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,94.71,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $112.75 in Billed Charges for Rev 637 = $94.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,84.56,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $112.75 in Billed Charges for Rev 637 = $84.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,103.73,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $112.75 in Billed Charges for Rev 637 = $103.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,67.65,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.75 in Billed Charges for Rev 637 = $67.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,67.65,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.75 in Billed Charges for Rev 637 = $67.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,PREVEA HEALTH NETWORK,PREVEA360,67.65,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.75 in Billed Charges for Rev 637 = $67.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,67.65,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.75 in Billed Charges for Rev 637 = $67.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,71.97,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $112.75 in Billed Charges for Rev 637 = $71.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,81.18,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.75 in Billed Charges for Rev 637 = $81.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,62.35,,,,,,,54.8000,112.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $112.75 in Billed Charges for Rev 637 = $62.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,62.35,,,,,,,54.8000,112.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $112.75 in Billed Charges for Rev 637 = $62.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,62.35,,,,,,,54.8000,112.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $112.75 in Billed Charges for Rev 637 = $62.35 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,UNITY HEALTH PLAN,UNITY HOSPICE,112.75,,,,,,,54.8000,112.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,81.18,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.75 in Billed Charges for Rev 637 = $81.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,69.91,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $112.75 in Billed Charges for Rev 637 = $69.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,81.18,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.75 in Billed Charges for Rev 637 = $81.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,81.18,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $112.75 in Billed Charges for Rev 637 = $81.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.1 MG/24HR PTWK,637,RC,75907-023-11,CDM,,,,,,both,1.000000,EA,112.7500,74.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,67.65,,,,,,,54.8000,112.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $112.75 in Billed Charges for Rev 637 = $67.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,AETNA,AETNA HSHS,169.93,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $263.05 in Billed Charges for Rev 637 = $169.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,AETNA,ALL COMMERCIAL AETNA,263.05,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.05 in Billed Charges for Rev 637 = $263.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,ANTHEM,ANTHEM POS/HMO,178.87,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $263.05 in Billed Charges for Rev 637 = $178.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,ANTHEM,ANTHEM PPO,178.87,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $263.05 in Billed Charges for Rev 637 = $178.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,263.05,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.05 in Billed Charges for Rev 637 = $263.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,CENPATICO,ALL MEDICAID CENPATICO,263.05,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.05 in Billed Charges for Rev 637 = $263.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,223.59,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.05 in Billed Charges for Rev 637 = $223.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,CIGNA,ALL COMMERCIAL CIGNA,184.14,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $263.05 in Billed Charges for Rev 637 = $184.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,COFINITY,COFINITY,263.05,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.05 in Billed Charges for Rev 637 = $263.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,249.90,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $263.05 in Billed Charges for Rev 637 = $249.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,220.96,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $263.05 in Billed Charges for Rev 637 = $220.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,186.77,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $263.05 in Billed Charges for Rev 637 = $186.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,192.03,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $263.05 in Billed Charges for Rev 637 = $192.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,127.84,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $263.05 in Billed Charges for Rev 637 = $127.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,223.59,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.05 in Billed Charges for Rev 637 = $223.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,HUMANA,HUMANA CHOICE CARE HMO,167.04,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $263.05 in Billed Charges at 63.5% = $167.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,HUMANA,HUMANA CHOICE CARE PPO,223.59,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.05 in Billed Charges for Rev 637 = $223.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,HUMANA,HUMANA NATIIONAL POS HMO,167.04,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $263.05 in Billed Charges at 63.5% = $167.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,192.03,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $263.05 in Billed Charges for Rev 637 = $192.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,263.05,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.05 in Billed Charges for Rev 637 = $263.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,263.05,,,,,,,127.8400,263.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,131.53,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $263.05 in Billed Charges for Rev 637 = $131.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,220.96,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $263.05 in Billed Charges for Rev 637 = $220.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,197.29,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $263.05 in Billed Charges for Rev 637 = $197.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,242.01,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $263.05 in Billed Charges for Rev 637 = $242.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,157.83,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.05 in Billed Charges for Rev 637 = $157.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,157.83,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.05 in Billed Charges for Rev 637 = $157.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,PREVEA HEALTH NETWORK,PREVEA360,157.83,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.05 in Billed Charges for Rev 637 = $157.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,157.83,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.05 in Billed Charges for Rev 637 = $157.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,167.90,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $263.05 in Billed Charges for Rev 637 = $167.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,189.40,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.05 in Billed Charges for Rev 637 = $189.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,145.47,,,,,,,127.8400,263.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $263.05 in Billed Charges for Rev 637 = $145.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,145.47,,,,,,,127.8400,263.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $263.05 in Billed Charges for Rev 637 = $145.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,145.47,,,,,,,127.8400,263.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $263.05 in Billed Charges for Rev 637 = $145.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,UNITY HEALTH PLAN,UNITY HOSPICE,263.05,,,,,,,127.8400,263.0500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,189.40,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.05 in Billed Charges for Rev 637 = $189.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,163.09,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $263.05 in Billed Charges for Rev 637 = $163.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,189.40,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.05 in Billed Charges for Rev 637 = $189.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,189.40,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.05 in Billed Charges for Rev 637 = $189.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,0591-3510-54,CDM,,,,,,both,1.000000,EA,263.0500,173.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,157.83,,,,,,,127.8400,263.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.05 in Billed Charges for Rev 637 = $157.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,AETNA,AETNA HSHS,170.12,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $263.35 in Billed Charges for Rev 637 = $170.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,AETNA,ALL COMMERCIAL AETNA,263.35,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.35 in Billed Charges for Rev 637 = $263.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,ANTHEM,ANTHEM POS/HMO,179.08,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $263.35 in Billed Charges for Rev 637 = $179.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,ANTHEM,ANTHEM PPO,179.08,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $263.35 in Billed Charges for Rev 637 = $179.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,263.35,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.35 in Billed Charges for Rev 637 = $263.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,CENPATICO,ALL MEDICAID CENPATICO,263.35,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.35 in Billed Charges for Rev 637 = $263.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,223.85,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.35 in Billed Charges for Rev 637 = $223.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,CIGNA,ALL COMMERCIAL CIGNA,184.35,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $263.35 in Billed Charges for Rev 637 = $184.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,COFINITY,COFINITY,263.35,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.35 in Billed Charges for Rev 637 = $263.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,250.18,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $263.35 in Billed Charges for Rev 637 = $250.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,221.21,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $263.35 in Billed Charges for Rev 637 = $221.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,186.98,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $263.35 in Billed Charges for Rev 637 = $186.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,192.25,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $263.35 in Billed Charges for Rev 637 = $192.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,127.99,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $263.35 in Billed Charges for Rev 637 = $127.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,223.85,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.35 in Billed Charges for Rev 637 = $223.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,HUMANA,HUMANA CHOICE CARE HMO,167.23,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $263.35 in Billed Charges at 63.5% = $167.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,HUMANA,HUMANA CHOICE CARE PPO,223.85,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $263.35 in Billed Charges for Rev 637 = $223.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,HUMANA,HUMANA NATIIONAL POS HMO,167.23,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $263.35 in Billed Charges at 63.5% = $167.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,192.25,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $263.35 in Billed Charges for Rev 637 = $192.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,263.35,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $263.35 in Billed Charges for Rev 637 = $263.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,263.35,,,,,,,127.9900,263.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,131.68,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $263.35 in Billed Charges for Rev 637 = $131.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,221.21,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $263.35 in Billed Charges for Rev 637 = $221.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,197.51,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $263.35 in Billed Charges for Rev 637 = $197.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,242.28,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $263.35 in Billed Charges for Rev 637 = $242.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,158.01,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.35 in Billed Charges for Rev 637 = $158.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,158.01,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.35 in Billed Charges for Rev 637 = $158.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,PREVEA HEALTH NETWORK,PREVEA360,158.01,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.35 in Billed Charges for Rev 637 = $158.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,158.01,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.35 in Billed Charges for Rev 637 = $158.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,168.10,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $263.35 in Billed Charges for Rev 637 = $168.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,189.61,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.35 in Billed Charges for Rev 637 = $189.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,145.63,,,,,,,127.9900,263.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $263.35 in Billed Charges for Rev 637 = $145.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,UNITED HEALTHCARE,UHC ONEIDA NATION,145.63,,,,,,,127.9900,263.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $263.35 in Billed Charges for Rev 637 = $145.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,UNITED HEALTHCARE,UNITED HEALTHCARE,145.63,,,,,,,127.9900,263.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $263.35 in Billed Charges for Rev 637 = $145.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,UNITY HEALTH PLAN,UNITY HOSPICE,263.35,,,,,,,127.9900,263.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,189.61,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.35 in Billed Charges for Rev 637 = $189.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,163.28,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $263.35 in Billed Charges for Rev 637 = $163.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,189.61,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.35 in Billed Charges for Rev 637 = $189.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,189.61,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $263.35 in Billed Charges for Rev 637 = $189.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLONIDINE 0.3 MG/24HR PTWK,637,RC,75907-025-11,CDM,,,,,,both,1.000000,EA,263.3500,173.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,158.01,,,,,,,127.9900,263.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $263.35 in Billed Charges for Rev 637 = $158.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,AETNA,AETNA HSHS,16.80,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $26.00 in Billed Charges for Rev 637 = $16.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,AETNA,ALL COMMERCIAL AETNA,26.00,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 637 = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,ANTHEM,ANTHEM POS/HMO,17.68,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $26.00 in Billed Charges for Rev 637 = $17.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,ANTHEM,ANTHEM PPO,17.68,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $26.00 in Billed Charges for Rev 637 = $17.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,26.00,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 637 = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,CENPATICO,ALL MEDICAID CENPATICO,26.00,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 637 = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,22.10,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.00 in Billed Charges for Rev 637 = $22.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,CIGNA,ALL COMMERCIAL CIGNA,18.20,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $26.00 in Billed Charges for Rev 637 = $18.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,COFINITY,COFINITY,26.00,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 637 = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,24.70,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $26.00 in Billed Charges for Rev 637 = $24.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,21.84,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.00 in Billed Charges for Rev 637 = $21.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,18.46,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $26.00 in Billed Charges for Rev 637 = $18.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.98,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.00 in Billed Charges for Rev 637 = $18.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,12.64,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $26.00 in Billed Charges for Rev 637 = $12.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,22.10,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.00 in Billed Charges for Rev 637 = $22.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,HUMANA,HUMANA CHOICE CARE HMO,16.51,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $26.00 in Billed Charges at 63.5% = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,HUMANA,HUMANA CHOICE CARE PPO,22.10,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $26.00 in Billed Charges for Rev 637 = $22.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,HUMANA,HUMANA NATIIONAL POS HMO,16.51,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $26.00 in Billed Charges at 63.5% = $16.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.98,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $26.00 in Billed Charges for Rev 637 = $18.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,26.00,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $26.00 in Billed Charges for Rev 637 = $26.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,26.00,,,,,,,12.6400,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.00,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $26.00 in Billed Charges for Rev 637 = $13.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,21.84,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $26.00 in Billed Charges for Rev 637 = $21.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,19.50,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $26.00 in Billed Charges for Rev 637 = $19.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,23.92,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $26.00 in Billed Charges for Rev 637 = $23.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.60,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.00 in Billed Charges for Rev 637 = $15.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.60,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.00 in Billed Charges for Rev 637 = $15.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,PREVEA HEALTH NETWORK,PREVEA360,15.60,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.00 in Billed Charges for Rev 637 = $15.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.60,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.00 in Billed Charges for Rev 637 = $15.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,16.60,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $26.00 in Billed Charges for Rev 637 = $16.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,18.72,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.00 in Billed Charges for Rev 637 = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.38,,,,,,,12.6400,26.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $26.00 in Billed Charges for Rev 637 = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,14.38,,,,,,,12.6400,26.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $26.00 in Billed Charges for Rev 637 = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,14.38,,,,,,,12.6400,26.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $26.00 in Billed Charges for Rev 637 = $14.38 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,UNITY HEALTH PLAN,UNITY HOSPICE,26.00,,,,,,,12.6400,26.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,18.72,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.00 in Billed Charges for Rev 637 = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,16.12,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $26.00 in Billed Charges for Rev 637 = $16.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,18.72,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.00 in Billed Charges for Rev 637 = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,18.72,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $26.00 in Billed Charges for Rev 637 = $18.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORPROMAZINE 25 MG TABS,637,RC,69238-1056-1,CDM,,,,,,both,1.000000,EA,26.0000,17.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.60,,,,,,,12.6400,26.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $26.00 in Billed Charges for Rev 637 = $15.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,AETNA,AETNA HSHS,401.52,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $621.55 in Billed Charges for Rev 637 = $401.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,AETNA,ALL COMMERCIAL AETNA,621.55,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.55 in Billed Charges for Rev 637 = $621.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,ANTHEM,ANTHEM POS/HMO,422.65,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $621.55 in Billed Charges for Rev 637 = $422.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,ANTHEM,ANTHEM PPO,422.65,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $621.55 in Billed Charges for Rev 637 = $422.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,621.55,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.55 in Billed Charges for Rev 637 = $621.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,CENPATICO,ALL MEDICAID CENPATICO,621.55,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.55 in Billed Charges for Rev 637 = $621.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,528.32,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $621.55 in Billed Charges for Rev 637 = $528.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,CIGNA,ALL COMMERCIAL CIGNA,435.09,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $621.55 in Billed Charges for Rev 637 = $435.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,COFINITY,COFINITY,621.55,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.55 in Billed Charges for Rev 637 = $621.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,590.47,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $621.55 in Billed Charges for Rev 637 = $590.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,522.10,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $621.55 in Billed Charges for Rev 637 = $522.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,441.30,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $621.55 in Billed Charges for Rev 637 = $441.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,453.73,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $621.55 in Billed Charges for Rev 637 = $453.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,302.07,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $621.55 in Billed Charges for Rev 637 = $302.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,528.32,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $621.55 in Billed Charges for Rev 637 = $528.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,HUMANA,HUMANA CHOICE CARE HMO,394.68,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $621.55 in Billed Charges at 63.5% = $394.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,HUMANA,HUMANA CHOICE CARE PPO,528.32,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $621.55 in Billed Charges for Rev 637 = $528.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,HUMANA,HUMANA NATIIONAL POS HMO,394.68,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $621.55 in Billed Charges at 63.5% = $394.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,453.73,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $621.55 in Billed Charges for Rev 637 = $453.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,621.55,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $621.55 in Billed Charges for Rev 637 = $621.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,621.55,,,,,,,302.0700,621.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,310.78,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $621.55 in Billed Charges for Rev 637 = $310.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,522.10,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $621.55 in Billed Charges for Rev 637 = $522.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,466.16,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $621.55 in Billed Charges for Rev 637 = $466.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,571.83,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $621.55 in Billed Charges for Rev 637 = $571.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,372.93,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $621.55 in Billed Charges for Rev 637 = $372.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,372.93,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $621.55 in Billed Charges for Rev 637 = $372.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,PREVEA HEALTH NETWORK,PREVEA360,372.93,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $621.55 in Billed Charges for Rev 637 = $372.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,372.93,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $621.55 in Billed Charges for Rev 637 = $372.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,396.74,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $621.55 in Billed Charges for Rev 637 = $396.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,447.52,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $621.55 in Billed Charges for Rev 637 = $447.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,343.72,,,,,,,302.0700,621.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $621.55 in Billed Charges for Rev 637 = $343.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,343.72,,,,,,,302.0700,621.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $621.55 in Billed Charges for Rev 637 = $343.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,343.72,,,,,,,302.0700,621.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $621.55 in Billed Charges for Rev 637 = $343.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,UNITY HEALTH PLAN,UNITY HOSPICE,621.55,,,,,,,302.0700,621.5500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,447.52,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $621.55 in Billed Charges for Rev 637 = $447.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,385.36,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $621.55 in Billed Charges for Rev 637 = $385.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,447.52,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $621.55 in Billed Charges for Rev 637 = $447.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,447.52,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $621.55 in Billed Charges for Rev 637 = $447.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,637,RC,50419-773-01,CDM,,,,,,both,100.000000,ML,621.5500,410.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,372.93,,,,,,,302.0700,621.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $621.55 in Billed Charges for Rev 637 = $372.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,AETNA,AETNA HSHS,18.02,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $27.90 in Billed Charges for Rev 637 = $18.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,AETNA,ALL COMMERCIAL AETNA,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,ANTHEM,ANTHEM POS/HMO,18.97,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $27.90 in Billed Charges for Rev 637 = $18.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,ANTHEM,ANTHEM PPO,18.97,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $27.90 in Billed Charges for Rev 637 = $18.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,CENPATICO,ALL MEDICAID CENPATICO,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 637 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,CIGNA,ALL COMMERCIAL CIGNA,19.53,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $27.90 in Billed Charges for Rev 637 = $19.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,COFINITY,COFINITY,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,26.51,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $27.90 in Billed Charges for Rev 637 = $26.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,HEALTH CARE ALLIANCE,THE ALLIANCE,23.44,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.90 in Billed Charges for Rev 637 = $23.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,19.81,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $27.90 in Billed Charges for Rev 637 = $19.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,20.37,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.90 in Billed Charges for Rev 637 = $20.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,HSHS EMPLOYEES,HSHS EMPLOYEES,13.56,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $27.90 in Billed Charges for Rev 637 = $13.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 637 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,HUMANA,HUMANA CHOICE CARE HMO,17.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $27.90 in Billed Charges at 63.5% = $17.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,HUMANA,HUMANA CHOICE CARE PPO,23.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $27.90 in Billed Charges for Rev 637 = $23.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,HUMANA,HUMANA NATIIONAL POS HMO,17.72,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $27.90 in Billed Charges at 63.5% = $17.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,20.37,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $27.90 in Billed Charges for Rev 637 = $20.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,LIVE360,LIVE360 HSHS HEALTHY PLAN,27.90,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $27.90 in Billed Charges for Rev 637 = $27.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,27.90,,,,,,,13.5600,27.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,13.95,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $27.90 in Billed Charges for Rev 637 = $13.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,23.44,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $27.90 in Billed Charges for Rev 637 = $23.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,20.93,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $27.90 in Billed Charges for Rev 637 = $20.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,25.67,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $27.90 in Billed Charges for Rev 637 = $25.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,PREVEA HEALTH NETWORK,PREVEA360,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,17.81,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $27.90 in Billed Charges for Rev 637 = $17.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 637 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.43,,,,,,,13.5600,27.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.90 in Billed Charges for Rev 637 = $15.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,UNITED HEALTHCARE,UHC ONEIDA NATION,15.43,,,,,,,13.5600,27.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.90 in Billed Charges for Rev 637 = $15.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,UNITED HEALTHCARE,UNITED HEALTHCARE,15.43,,,,,,,13.5600,27.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $27.90 in Billed Charges for Rev 637 = $15.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,UNITY HEALTH PLAN,UNITY HOSPICE,27.90,,,,,,,13.5600,27.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 637 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.30,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $27.90 in Billed Charges for Rev 637 = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 637 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,20.09,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $27.90 in Billed Charges for Rev 637 = $20.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLCHICINE 0.6 MG TABS,637,RC,0591-2562-30,CDM,,,,,,both,1.000000,EA,27.9000,18.4100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,16.74,,,,,,,13.5600,27.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $27.90 in Billed Charges for Rev 637 = $16.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,AETNA,AETNA HSHS,253.43,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $392.30 in Billed Charges for Rev 637 = $253.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,AETNA,ALL COMMERCIAL AETNA,392.30,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.30 in Billed Charges for Rev 637 = $392.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,ANTHEM,ANTHEM POS/HMO,266.76,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $392.30 in Billed Charges for Rev 637 = $266.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,ANTHEM,ANTHEM PPO,266.76,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $392.30 in Billed Charges for Rev 637 = $266.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,392.30,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.30 in Billed Charges for Rev 637 = $392.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,CENPATICO,ALL MEDICAID CENPATICO,392.30,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.30 in Billed Charges for Rev 637 = $392.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,333.46,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.30 in Billed Charges for Rev 637 = $333.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,CIGNA,ALL COMMERCIAL CIGNA,274.61,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $392.30 in Billed Charges for Rev 637 = $274.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,COFINITY,COFINITY,392.30,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.30 in Billed Charges for Rev 637 = $392.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,372.69,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $392.30 in Billed Charges for Rev 637 = $372.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,HEALTH CARE ALLIANCE,THE ALLIANCE,329.53,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.30 in Billed Charges for Rev 637 = $329.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,278.53,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $392.30 in Billed Charges for Rev 637 = $278.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,286.38,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.30 in Billed Charges for Rev 637 = $286.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,HSHS EMPLOYEES,HSHS EMPLOYEES,190.66,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $392.30 in Billed Charges for Rev 637 = $190.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,333.46,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.30 in Billed Charges for Rev 637 = $333.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,HUMANA,HUMANA CHOICE CARE HMO,249.11,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $392.30 in Billed Charges at 63.5% = $249.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,HUMANA,HUMANA CHOICE CARE PPO,333.46,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $392.30 in Billed Charges for Rev 637 = $333.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,HUMANA,HUMANA NATIIONAL POS HMO,249.11,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $392.30 in Billed Charges at 63.5% = $249.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,286.38,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $392.30 in Billed Charges for Rev 637 = $286.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,LIVE360,LIVE360 HSHS HEALTHY PLAN,392.30,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $392.30 in Billed Charges for Rev 637 = $392.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,392.30,,,,,,,190.6600,392.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,196.15,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $392.30 in Billed Charges for Rev 637 = $196.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,329.53,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $392.30 in Billed Charges for Rev 637 = $329.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,294.23,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $392.30 in Billed Charges for Rev 637 = $294.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,360.92,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $392.30 in Billed Charges for Rev 637 = $360.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,235.38,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $392.30 in Billed Charges for Rev 637 = $235.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,235.38,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $392.30 in Billed Charges for Rev 637 = $235.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,PREVEA HEALTH NETWORK,PREVEA360,235.38,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $392.30 in Billed Charges for Rev 637 = $235.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,235.38,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $392.30 in Billed Charges for Rev 637 = $235.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,250.41,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $392.30 in Billed Charges for Rev 637 = $250.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,282.46,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.30 in Billed Charges for Rev 637 = $282.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,216.94,,,,,,,190.6600,392.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $392.30 in Billed Charges for Rev 637 = $216.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,UNITED HEALTHCARE,UHC ONEIDA NATION,216.94,,,,,,,190.6600,392.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $392.30 in Billed Charges for Rev 637 = $216.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,UNITED HEALTHCARE,UNITED HEALTHCARE,216.94,,,,,,,190.6600,392.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $392.30 in Billed Charges for Rev 637 = $216.94 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,UNITY HEALTH PLAN,UNITY HOSPICE,392.30,,,,,,,190.6600,392.3000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,282.46,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.30 in Billed Charges for Rev 637 = $282.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,243.23,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $392.30 in Billed Charges for Rev 637 = $243.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,282.46,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.30 in Billed Charges for Rev 637 = $282.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,282.46,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $392.30 in Billed Charges for Rev 637 = $282.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 1 % LOTN 60 ML BOTTLE,637,RC,45802-128-01,CDM,,,,,,both,60.000000,ML,392.3000,258.9200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,235.38,,,,,,,190.6600,392.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $392.30 in Billed Charges for Rev 637 = $235.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,AETNA,AETNA HSHS,15.28,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $23.65 in Billed Charges for Rev 637 = $15.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,AETNA,ALL COMMERCIAL AETNA,23.65,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.65 in Billed Charges for Rev 637 = $23.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,ANTHEM,ANTHEM POS/HMO,16.08,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $23.65 in Billed Charges for Rev 637 = $16.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,ANTHEM,ANTHEM PPO,16.08,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $23.65 in Billed Charges for Rev 637 = $16.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,23.65,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.65 in Billed Charges for Rev 637 = $23.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,CENPATICO,ALL MEDICAID CENPATICO,23.65,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.65 in Billed Charges for Rev 637 = $23.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.10,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.65 in Billed Charges for Rev 637 = $20.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,CIGNA,ALL COMMERCIAL CIGNA,16.56,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $23.65 in Billed Charges for Rev 637 = $16.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,COFINITY,COFINITY,23.65,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.65 in Billed Charges for Rev 637 = $23.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,22.47,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $23.65 in Billed Charges for Rev 637 = $22.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,19.87,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.65 in Billed Charges for Rev 637 = $19.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,16.79,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $23.65 in Billed Charges for Rev 637 = $16.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.26,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.65 in Billed Charges for Rev 637 = $17.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,11.49,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $23.65 in Billed Charges for Rev 637 = $11.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.10,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.65 in Billed Charges for Rev 637 = $20.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,HUMANA,HUMANA CHOICE CARE HMO,15.02,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $23.65 in Billed Charges at 63.5% = $15.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,HUMANA,HUMANA CHOICE CARE PPO,20.10,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.65 in Billed Charges for Rev 637 = $20.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,HUMANA,HUMANA NATIIONAL POS HMO,15.02,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $23.65 in Billed Charges at 63.5% = $15.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.26,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.65 in Billed Charges for Rev 637 = $17.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,23.65,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.65 in Billed Charges for Rev 637 = $23.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,23.65,,,,,,,11.4900,23.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.83,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $23.65 in Billed Charges for Rev 637 = $11.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,19.87,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.65 in Billed Charges for Rev 637 = $19.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,17.74,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $23.65 in Billed Charges for Rev 637 = $17.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,21.76,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $23.65 in Billed Charges for Rev 637 = $21.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.19,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.65 in Billed Charges for Rev 637 = $14.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.19,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.65 in Billed Charges for Rev 637 = $14.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,PREVEA HEALTH NETWORK,PREVEA360,14.19,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.65 in Billed Charges for Rev 637 = $14.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.19,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.65 in Billed Charges for Rev 637 = $14.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.10,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $23.65 in Billed Charges for Rev 637 = $15.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.03,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.65 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,13.08,,,,,,,11.4900,23.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.65 in Billed Charges for Rev 637 = $13.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,13.08,,,,,,,11.4900,23.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.65 in Billed Charges for Rev 637 = $13.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,13.08,,,,,,,11.4900,23.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.65 in Billed Charges for Rev 637 = $13.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,UNITY HEALTH PLAN,UNITY HOSPICE,23.65,,,,,,,11.4900,23.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.03,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.65 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.66,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $23.65 in Billed Charges for Rev 637 = $14.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.03,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.65 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.03,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.65 in Billed Charges for Rev 637 = $17.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,65862-357-05,CDM,,,,,,both,1.000000,EA,23.6500,15.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.19,,,,,,,11.4900,23.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.65 in Billed Charges for Rev 637 = $14.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,AETNA,AETNA HSHS,14.97,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $23.18 in Billed Charges for Rev 637 = $14.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,AETNA,ALL COMMERCIAL AETNA,23.18,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.18 in Billed Charges for Rev 637 = $23.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,ANTHEM,ANTHEM POS/HMO,15.76,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $23.18 in Billed Charges for Rev 637 = $15.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,ANTHEM,ANTHEM PPO,15.76,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $23.18 in Billed Charges for Rev 637 = $15.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,23.18,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.18 in Billed Charges for Rev 637 = $23.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,CENPATICO,ALL MEDICAID CENPATICO,23.18,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.18 in Billed Charges for Rev 637 = $23.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,19.70,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.18 in Billed Charges for Rev 637 = $19.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,CIGNA,ALL COMMERCIAL CIGNA,16.23,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $23.18 in Billed Charges for Rev 637 = $16.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,COFINITY,COFINITY,23.18,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.18 in Billed Charges for Rev 637 = $23.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,22.02,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $23.18 in Billed Charges for Rev 637 = $22.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,19.47,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.18 in Billed Charges for Rev 637 = $19.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,16.46,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $23.18 in Billed Charges for Rev 637 = $16.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,16.92,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.18 in Billed Charges for Rev 637 = $16.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,11.27,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $23.18 in Billed Charges for Rev 637 = $11.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,19.70,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.18 in Billed Charges for Rev 637 = $19.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,HUMANA,HUMANA CHOICE CARE HMO,14.72,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $23.18 in Billed Charges at 63.5% = $14.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,HUMANA,HUMANA CHOICE CARE PPO,19.70,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.18 in Billed Charges for Rev 637 = $19.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,HUMANA,HUMANA NATIIONAL POS HMO,14.72,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $23.18 in Billed Charges at 63.5% = $14.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,16.92,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.18 in Billed Charges for Rev 637 = $16.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,23.18,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.18 in Billed Charges for Rev 637 = $23.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,23.18,,,,,,,11.2700,23.1800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.59,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $23.18 in Billed Charges for Rev 637 = $11.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,19.47,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.18 in Billed Charges for Rev 637 = $19.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,17.39,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $23.18 in Billed Charges for Rev 637 = $17.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,21.33,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $23.18 in Billed Charges for Rev 637 = $21.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,13.91,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.18 in Billed Charges for Rev 637 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,13.91,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.18 in Billed Charges for Rev 637 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,PREVEA HEALTH NETWORK,PREVEA360,13.91,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.18 in Billed Charges for Rev 637 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,13.91,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.18 in Billed Charges for Rev 637 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,14.80,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $23.18 in Billed Charges for Rev 637 = $14.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,16.69,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.18 in Billed Charges for Rev 637 = $16.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,12.82,,,,,,,11.2700,23.1800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.18 in Billed Charges for Rev 637 = $12.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,12.82,,,,,,,11.2700,23.1800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.18 in Billed Charges for Rev 637 = $12.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,12.82,,,,,,,11.2700,23.1800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.18 in Billed Charges for Rev 637 = $12.82 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,UNITY HEALTH PLAN,UNITY HOSPICE,23.18,,,,,,,11.2700,23.1800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,16.69,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.18 in Billed Charges for Rev 637 = $16.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.37,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $23.18 in Billed Charges for Rev 637 = $14.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,16.69,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.18 in Billed Charges for Rev 637 = $16.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,16.69,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.18 in Billed Charges for Rev 637 = $16.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOPIDOGREL 75 MG TABS,637,RC,68084-536-11,CDM,,,,,,both,1.000000,EA,23.1800,15.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,13.91,,,,,,,11.2700,23.1800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.18 in Billed Charges for Rev 637 = $13.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,AETNA,AETNA HSHS,7.56,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $11.70 in Billed Charges for Rev 637 = $7.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,AETNA,ALL COMMERCIAL AETNA,11.70,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.70 in Billed Charges for Rev 637 = $11.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,ANTHEM,ANTHEM POS/HMO,7.96,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.70 in Billed Charges for Rev 637 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,ANTHEM,ANTHEM PPO,7.96,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $11.70 in Billed Charges for Rev 637 = $7.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,11.70,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.70 in Billed Charges for Rev 637 = $11.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,CENPATICO,ALL MEDICAID CENPATICO,11.70,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.70 in Billed Charges for Rev 637 = $11.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,9.95,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.70 in Billed Charges for Rev 637 = $9.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,CIGNA,ALL COMMERCIAL CIGNA,8.19,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $11.70 in Billed Charges for Rev 637 = $8.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,COFINITY,COFINITY,11.70,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.70 in Billed Charges for Rev 637 = $11.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.12,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $11.70 in Billed Charges for Rev 637 = $11.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,9.83,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.70 in Billed Charges for Rev 637 = $9.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.31,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $11.70 in Billed Charges for Rev 637 = $8.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,8.54,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.70 in Billed Charges for Rev 637 = $8.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,5.69,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $11.70 in Billed Charges for Rev 637 = $5.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,9.95,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.70 in Billed Charges for Rev 637 = $9.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,HUMANA,HUMANA CHOICE CARE HMO,7.43,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.70 in Billed Charges at 63.5% = $7.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,HUMANA,HUMANA CHOICE CARE PPO,9.95,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $11.70 in Billed Charges for Rev 637 = $9.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,HUMANA,HUMANA NATIIONAL POS HMO,7.43,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $11.70 in Billed Charges at 63.5% = $7.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,8.54,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $11.70 in Billed Charges for Rev 637 = $8.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,11.70,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $11.70 in Billed Charges for Rev 637 = $11.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,11.70,,,,,,,5.6900,11.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,5.85,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $11.70 in Billed Charges for Rev 637 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,9.83,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $11.70 in Billed Charges for Rev 637 = $9.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,8.78,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $11.70 in Billed Charges for Rev 637 = $8.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,10.76,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $11.70 in Billed Charges for Rev 637 = $10.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.02,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.70 in Billed Charges for Rev 637 = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.02,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.70 in Billed Charges for Rev 637 = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,PREVEA HEALTH NETWORK,PREVEA360,7.02,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.70 in Billed Charges for Rev 637 = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.02,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.70 in Billed Charges for Rev 637 = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.47,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $11.70 in Billed Charges for Rev 637 = $7.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,8.42,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.70 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.47,,,,,,,5.6900,11.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.70 in Billed Charges for Rev 637 = $6.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,6.47,,,,,,,5.6900,11.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.70 in Billed Charges for Rev 637 = $6.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,6.47,,,,,,,5.6900,11.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $11.70 in Billed Charges for Rev 637 = $6.47 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,UNITY HEALTH PLAN,UNITY HOSPICE,11.70,,,,,,,5.6900,11.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,8.42,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.70 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.25,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $11.70 in Billed Charges for Rev 637 = $7.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,8.42,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.70 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,8.42,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $11.70 in Billed Charges for Rev 637 = $8.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE 10 MG TROC,637,RC,0054-8146-22,CDM,,,,,,both,1.000000,EA,11.7000,7.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.02,,,,,,,5.6900,11.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $11.70 in Billed Charges for Rev 637 = $7.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,AETNA,AETNA HSHS,85.11,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $131.75 in Billed Charges for Rev 637 = $85.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,AETNA,ALL COMMERCIAL AETNA,131.75,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.75 in Billed Charges for Rev 637 = $131.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,ANTHEM,ANTHEM POS/HMO,89.59,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $131.75 in Billed Charges for Rev 637 = $89.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,ANTHEM,ANTHEM PPO,89.59,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $131.75 in Billed Charges for Rev 637 = $89.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,131.75,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.75 in Billed Charges for Rev 637 = $131.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,CENPATICO,ALL MEDICAID CENPATICO,131.75,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.75 in Billed Charges for Rev 637 = $131.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,111.99,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.75 in Billed Charges for Rev 637 = $111.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,CIGNA,ALL COMMERCIAL CIGNA,92.23,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $131.75 in Billed Charges for Rev 637 = $92.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,COFINITY,COFINITY,131.75,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.75 in Billed Charges for Rev 637 = $131.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,125.16,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $131.75 in Billed Charges for Rev 637 = $125.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,110.67,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $131.75 in Billed Charges for Rev 637 = $110.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,93.54,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $131.75 in Billed Charges for Rev 637 = $93.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,96.18,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $131.75 in Billed Charges for Rev 637 = $96.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,64.03,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $131.75 in Billed Charges for Rev 637 = $64.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,111.99,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.75 in Billed Charges for Rev 637 = $111.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,HUMANA,HUMANA CHOICE CARE HMO,83.66,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $131.75 in Billed Charges at 63.5% = $83.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,HUMANA,HUMANA CHOICE CARE PPO,111.99,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $131.75 in Billed Charges for Rev 637 = $111.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,HUMANA,HUMANA NATIIONAL POS HMO,83.66,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $131.75 in Billed Charges at 63.5% = $83.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,96.18,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $131.75 in Billed Charges for Rev 637 = $96.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,131.75,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $131.75 in Billed Charges for Rev 637 = $131.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,131.75,,,,,,,64.0300,131.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.88,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $131.75 in Billed Charges for Rev 637 = $65.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,110.67,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $131.75 in Billed Charges for Rev 637 = $110.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,98.81,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $131.75 in Billed Charges for Rev 637 = $98.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,121.21,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $131.75 in Billed Charges for Rev 637 = $121.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,79.05,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $131.75 in Billed Charges for Rev 637 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,79.05,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $131.75 in Billed Charges for Rev 637 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,PREVEA HEALTH NETWORK,PREVEA360,79.05,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $131.75 in Billed Charges for Rev 637 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,79.05,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $131.75 in Billed Charges for Rev 637 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,84.10,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $131.75 in Billed Charges for Rev 637 = $84.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,94.86,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.75 in Billed Charges for Rev 637 = $94.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,72.86,,,,,,,64.0300,131.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $131.75 in Billed Charges for Rev 637 = $72.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,72.86,,,,,,,64.0300,131.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $131.75 in Billed Charges for Rev 637 = $72.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,72.86,,,,,,,64.0300,131.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $131.75 in Billed Charges for Rev 637 = $72.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,UNITY HEALTH PLAN,UNITY HOSPICE,131.75,,,,,,,64.0300,131.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,94.86,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.75 in Billed Charges for Rev 637 = $94.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,81.69,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $131.75 in Billed Charges for Rev 637 = $81.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,94.86,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.75 in Billed Charges for Rev 637 = $94.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,94.86,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $131.75 in Billed Charges for Rev 637 = $94.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,637,RC,0472-0379-15,CDM,,,,,,both,15.000000,GR,131.7500,86.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,79.05,,,,,,,64.0300,131.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $131.75 in Billed Charges for Rev 637 = $79.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,AETNA,AETNA HSHS,8.30,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.85 in Billed Charges for Rev 637 = $8.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,AETNA,ALL COMMERCIAL AETNA,12.85,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.85 in Billed Charges for Rev 637 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,ANTHEM,ANTHEM POS/HMO,8.74,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.85 in Billed Charges for Rev 637 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,ANTHEM,ANTHEM PPO,8.74,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.85 in Billed Charges for Rev 637 = $8.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.85,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.85 in Billed Charges for Rev 637 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,CENPATICO,ALL MEDICAID CENPATICO,12.85,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.85 in Billed Charges for Rev 637 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.92,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.85 in Billed Charges for Rev 637 = $10.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,CIGNA,ALL COMMERCIAL CIGNA,9.00,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.85 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,COFINITY,COFINITY,12.85,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.85 in Billed Charges for Rev 637 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12.21,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.85 in Billed Charges for Rev 637 = $12.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,10.79,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.85 in Billed Charges for Rev 637 = $10.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,9.12,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.85 in Billed Charges for Rev 637 = $9.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.38,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.85 in Billed Charges for Rev 637 = $9.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,6.25,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.85 in Billed Charges for Rev 637 = $6.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.92,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.85 in Billed Charges for Rev 637 = $10.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,HUMANA,HUMANA CHOICE CARE HMO,8.16,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.85 in Billed Charges at 63.5% = $8.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,HUMANA,HUMANA CHOICE CARE PPO,10.92,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.85 in Billed Charges for Rev 637 = $10.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,HUMANA,HUMANA NATIIONAL POS HMO,8.16,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.85 in Billed Charges at 63.5% = $8.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.38,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.85 in Billed Charges for Rev 637 = $9.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.85,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.85 in Billed Charges for Rev 637 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.85,,,,,,,6.2500,12.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.43,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.85 in Billed Charges for Rev 637 = $6.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.79,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.85 in Billed Charges for Rev 637 = $10.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.64,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.85 in Billed Charges for Rev 637 = $9.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.82,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.85 in Billed Charges for Rev 637 = $11.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.71,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.85 in Billed Charges for Rev 637 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.71,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.85 in Billed Charges for Rev 637 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,PREVEA HEALTH NETWORK,PREVEA360,7.71,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.85 in Billed Charges for Rev 637 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.71,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.85 in Billed Charges for Rev 637 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.20,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.85 in Billed Charges for Rev 637 = $8.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.25,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.85 in Billed Charges for Rev 637 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.11,,,,,,,6.2500,12.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.85 in Billed Charges for Rev 637 = $7.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,7.11,,,,,,,6.2500,12.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.85 in Billed Charges for Rev 637 = $7.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,7.11,,,,,,,6.2500,12.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.85 in Billed Charges for Rev 637 = $7.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,UNITY HEALTH PLAN,UNITY HOSPICE,12.85,,,,,,,6.2500,12.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.25,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.85 in Billed Charges for Rev 637 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.97,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.85 in Billed Charges for Rev 637 = $7.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.25,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.85 in Billed Charges for Rev 637 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.25,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.85 in Billed Charges for Rev 637 = $9.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,31722-621-60,CDM,,,,,,both,1.000000,EA,12.8500,8.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.71,,,,,,,6.2500,12.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.85 in Billed Charges for Rev 637 = $7.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,AETNA,AETNA HSHS,31.58,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $48.88 in Billed Charges for Rev 637 = $31.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,AETNA,ALL COMMERCIAL AETNA,48.88,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.88 in Billed Charges for Rev 637 = $48.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,ANTHEM,ANTHEM POS/HMO,33.24,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $48.88 in Billed Charges for Rev 637 = $33.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,ANTHEM,ANTHEM PPO,33.24,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $48.88 in Billed Charges for Rev 637 = $33.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,48.88,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.88 in Billed Charges for Rev 637 = $48.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,CENPATICO,ALL MEDICAID CENPATICO,48.88,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.88 in Billed Charges for Rev 637 = $48.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.55,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.88 in Billed Charges for Rev 637 = $41.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,CIGNA,ALL COMMERCIAL CIGNA,34.22,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $48.88 in Billed Charges for Rev 637 = $34.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,COFINITY,COFINITY,48.88,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.88 in Billed Charges for Rev 637 = $48.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.44,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $48.88 in Billed Charges for Rev 637 = $46.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,HEALTH CARE ALLIANCE,THE ALLIANCE,41.06,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $48.88 in Billed Charges for Rev 637 = $41.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.70,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $48.88 in Billed Charges for Rev 637 = $34.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.68,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $48.88 in Billed Charges for Rev 637 = $35.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,HSHS EMPLOYEES,HSHS EMPLOYEES,23.76,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $48.88 in Billed Charges for Rev 637 = $23.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.55,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.88 in Billed Charges for Rev 637 = $41.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,HUMANA,HUMANA CHOICE CARE HMO,31.04,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $48.88 in Billed Charges at 63.5% = $31.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,HUMANA,HUMANA CHOICE CARE PPO,41.55,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.88 in Billed Charges for Rev 637 = $41.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,HUMANA,HUMANA NATIIONAL POS HMO,31.04,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $48.88 in Billed Charges at 63.5% = $31.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.68,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $48.88 in Billed Charges for Rev 637 = $35.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,LIVE360,LIVE360 HSHS HEALTHY PLAN,48.88,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.88 in Billed Charges for Rev 637 = $48.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,48.88,,,,,,,23.7600,48.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.44,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $48.88 in Billed Charges for Rev 637 = $24.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.06,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $48.88 in Billed Charges for Rev 637 = $41.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.66,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $48.88 in Billed Charges for Rev 637 = $36.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,44.97,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $48.88 in Billed Charges for Rev 637 = $44.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.33,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.88 in Billed Charges for Rev 637 = $29.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.33,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.88 in Billed Charges for Rev 637 = $29.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,PREVEA HEALTH NETWORK,PREVEA360,29.33,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.88 in Billed Charges for Rev 637 = $29.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.33,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.88 in Billed Charges for Rev 637 = $29.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.20,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $48.88 in Billed Charges for Rev 637 = $31.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.19,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.88 in Billed Charges for Rev 637 = $35.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.03,,,,,,,23.7600,48.8800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $48.88 in Billed Charges for Rev 637 = $27.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,UNITED HEALTHCARE,UHC ONEIDA NATION,27.03,,,,,,,23.7600,48.8800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $48.88 in Billed Charges for Rev 637 = $27.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,UNITED HEALTHCARE,UNITED HEALTHCARE,27.03,,,,,,,23.7600,48.8800,other,ST VINCENT HOSPITAL (ACU). 55.3% of $48.88 in Billed Charges for Rev 637 = $27.03 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,UNITY HEALTH PLAN,UNITY HOSPICE,48.88,,,,,,,23.7600,48.8800,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.19,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.88 in Billed Charges for Rev 637 = $35.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.31,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $48.88 in Billed Charges for Rev 637 = $30.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.19,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.88 in Billed Charges for Rev 637 = $35.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.19,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.88 in Billed Charges for Rev 637 = $35.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DABIGATRAN 75 MG CAPS,637,RC,60687-744-11,CDM,,,,,,both,1.000000,EA,48.8800,32.2600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.33,,,,,,,23.7600,48.8800,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.88 in Billed Charges for Rev 637 = $29.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,AETNA,AETNA HSHS,136.18,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $210.80 in Billed Charges for Rev 637 = $136.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,AETNA,ALL COMMERCIAL AETNA,210.80,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.80 in Billed Charges for Rev 637 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,ANTHEM,ANTHEM POS/HMO,143.34,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $210.80 in Billed Charges for Rev 637 = $143.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,ANTHEM,ANTHEM PPO,143.34,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $210.80 in Billed Charges for Rev 637 = $143.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,210.80,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.80 in Billed Charges for Rev 637 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,CENPATICO,ALL MEDICAID CENPATICO,210.80,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.80 in Billed Charges for Rev 637 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,179.18,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.80 in Billed Charges for Rev 637 = $179.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,CIGNA,ALL COMMERCIAL CIGNA,147.56,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $210.80 in Billed Charges for Rev 637 = $147.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,COFINITY,COFINITY,210.80,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.80 in Billed Charges for Rev 637 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,200.26,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $210.80 in Billed Charges for Rev 637 = $200.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,HEALTH CARE ALLIANCE,THE ALLIANCE,177.07,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $210.80 in Billed Charges for Rev 637 = $177.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,149.67,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $210.80 in Billed Charges for Rev 637 = $149.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,153.88,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $210.80 in Billed Charges for Rev 637 = $153.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,HSHS EMPLOYEES,HSHS EMPLOYEES,102.45,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $210.80 in Billed Charges for Rev 637 = $102.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,179.18,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.80 in Billed Charges for Rev 637 = $179.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,HUMANA,HUMANA CHOICE CARE HMO,133.86,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $210.80 in Billed Charges at 63.5% = $133.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,HUMANA,HUMANA CHOICE CARE PPO,179.18,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $210.80 in Billed Charges for Rev 637 = $179.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,HUMANA,HUMANA NATIIONAL POS HMO,133.86,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $210.80 in Billed Charges at 63.5% = $133.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,153.88,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $210.80 in Billed Charges for Rev 637 = $153.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,LIVE360,LIVE360 HSHS HEALTHY PLAN,210.80,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $210.80 in Billed Charges for Rev 637 = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,210.80,,,,,,,102.4500,210.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,105.40,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $210.80 in Billed Charges for Rev 637 = $105.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,177.07,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $210.80 in Billed Charges for Rev 637 = $177.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,158.10,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $210.80 in Billed Charges for Rev 637 = $158.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,193.94,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $210.80 in Billed Charges for Rev 637 = $193.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,126.48,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $210.80 in Billed Charges for Rev 637 = $126.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,126.48,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $210.80 in Billed Charges for Rev 637 = $126.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,PREVEA HEALTH NETWORK,PREVEA360,126.48,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $210.80 in Billed Charges for Rev 637 = $126.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,126.48,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $210.80 in Billed Charges for Rev 637 = $126.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,134.55,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $210.80 in Billed Charges for Rev 637 = $134.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,151.78,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.80 in Billed Charges for Rev 637 = $151.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,116.57,,,,,,,102.4500,210.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $210.80 in Billed Charges for Rev 637 = $116.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,UNITED HEALTHCARE,UHC ONEIDA NATION,116.57,,,,,,,102.4500,210.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $210.80 in Billed Charges for Rev 637 = $116.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,UNITED HEALTHCARE,UNITED HEALTHCARE,116.57,,,,,,,102.4500,210.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $210.80 in Billed Charges for Rev 637 = $116.57 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,UNITY HEALTH PLAN,UNITY HOSPICE,210.80,,,,,,,102.4500,210.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,151.78,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.80 in Billed Charges for Rev 637 = $151.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,130.70,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $210.80 in Billed Charges for Rev 637 = $130.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,151.78,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.80 in Billed Charges for Rev 637 = $151.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,151.78,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $210.80 in Billed Charges for Rev 637 = $151.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CLINDAMYCIN 75 MG/5ML SOLR,637,RC,65862-596-02,CDM,,,,,,both,100.000000,ML,210.8000,139.1300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,126.48,,,,,,,102.4500,210.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $210.80 in Billed Charges for Rev 637 = $126.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,AETNA,AETNA HSHS,9.69,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $15.00 in Billed Charges for Rev 637 = $9.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,AETNA,ALL COMMERCIAL AETNA,15.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.00 in Billed Charges for Rev 637 = $15.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,ANTHEM,ANTHEM POS/HMO,10.20,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $15.00 in Billed Charges for Rev 637 = $10.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,ANTHEM,ANTHEM PPO,10.20,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $15.00 in Billed Charges for Rev 637 = $10.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.00 in Billed Charges for Rev 637 = $15.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,CENPATICO,ALL MEDICAID CENPATICO,15.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.00 in Billed Charges for Rev 637 = $15.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.75,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.00 in Billed Charges for Rev 637 = $12.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,CIGNA,ALL COMMERCIAL CIGNA,10.50,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $15.00 in Billed Charges for Rev 637 = $10.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,COFINITY,COFINITY,15.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.00 in Billed Charges for Rev 637 = $15.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14.25,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $15.00 in Billed Charges for Rev 637 = $14.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,12.60,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.00 in Billed Charges for Rev 637 = $12.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.65,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $15.00 in Billed Charges for Rev 637 = $10.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.95,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.00 in Billed Charges for Rev 637 = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,7.29,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $15.00 in Billed Charges for Rev 637 = $7.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.75,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.00 in Billed Charges for Rev 637 = $12.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,HUMANA,HUMANA CHOICE CARE HMO,9.53,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $15.00 in Billed Charges at 63.5% = $9.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,HUMANA,HUMANA CHOICE CARE PPO,12.75,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.00 in Billed Charges for Rev 637 = $12.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,HUMANA,HUMANA NATIIONAL POS HMO,9.53,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $15.00 in Billed Charges at 63.5% = $9.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.95,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.00 in Billed Charges for Rev 637 = $10.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,15.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.00 in Billed Charges for Rev 637 = $15.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.00,,,,,,,7.2900,15.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.50,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $15.00 in Billed Charges for Rev 637 = $7.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.60,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.00 in Billed Charges for Rev 637 = $12.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.25,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $15.00 in Billed Charges for Rev 637 = $11.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.80,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $15.00 in Billed Charges for Rev 637 = $13.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.00 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.00 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,PREVEA HEALTH NETWORK,PREVEA360,9.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.00 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.00 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.57,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $15.00 in Billed Charges for Rev 637 = $9.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.80,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.00 in Billed Charges for Rev 637 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.30,,,,,,,7.2900,15.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.00 in Billed Charges for Rev 637 = $8.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,8.30,,,,,,,7.2900,15.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.00 in Billed Charges for Rev 637 = $8.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,8.30,,,,,,,7.2900,15.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.00 in Billed Charges for Rev 637 = $8.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,UNITY HEALTH PLAN,UNITY HOSPICE,15.00,,,,,,,7.2900,15.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.80,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.00 in Billed Charges for Rev 637 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.30,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $15.00 in Billed Charges for Rev 637 = $9.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.80,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.00 in Billed Charges for Rev 637 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.80,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.00 in Billed Charges for Rev 637 = $10.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFUROXIME 250 MG TABS,637,RC,65862-699-60,CDM,,,,,,both,1.000000,EA,15.0000,9.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.00,,,,,,,7.2900,15.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.00 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,AETNA,AETNA HSHS,10.17,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $15.75 in Billed Charges for Rev 637 = $10.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,AETNA,ALL COMMERCIAL AETNA,15.75,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.75 in Billed Charges for Rev 637 = $15.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,ANTHEM,ANTHEM POS/HMO,10.71,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $15.75 in Billed Charges for Rev 637 = $10.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,ANTHEM,ANTHEM PPO,10.71,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $15.75 in Billed Charges for Rev 637 = $10.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15.75,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.75 in Billed Charges for Rev 637 = $15.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,CENPATICO,ALL MEDICAID CENPATICO,15.75,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.75 in Billed Charges for Rev 637 = $15.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.39,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.75 in Billed Charges for Rev 637 = $13.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,CIGNA,ALL COMMERCIAL CIGNA,11.03,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $15.75 in Billed Charges for Rev 637 = $11.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,COFINITY,COFINITY,15.75,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.75 in Billed Charges for Rev 637 = $15.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14.96,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $15.75 in Billed Charges for Rev 637 = $14.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,13.23,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.75 in Billed Charges for Rev 637 = $13.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.18,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $15.75 in Billed Charges for Rev 637 = $11.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.50,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.75 in Billed Charges for Rev 637 = $11.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,7.65,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $15.75 in Billed Charges for Rev 637 = $7.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.39,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.75 in Billed Charges for Rev 637 = $13.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,HUMANA,HUMANA CHOICE CARE HMO,10.00,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $15.75 in Billed Charges at 63.5% = $10.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,HUMANA,HUMANA CHOICE CARE PPO,13.39,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.75 in Billed Charges for Rev 637 = $13.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,HUMANA,HUMANA NATIIONAL POS HMO,10.00,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $15.75 in Billed Charges at 63.5% = $10.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.50,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.75 in Billed Charges for Rev 637 = $11.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,15.75,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.75 in Billed Charges for Rev 637 = $15.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,15.75,,,,,,,7.6500,15.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.88,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $15.75 in Billed Charges for Rev 637 = $7.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,13.23,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.75 in Billed Charges for Rev 637 = $13.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.81,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $15.75 in Billed Charges for Rev 637 = $11.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,14.49,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $15.75 in Billed Charges for Rev 637 = $14.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9.45,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.75 in Billed Charges for Rev 637 = $9.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9.45,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.75 in Billed Charges for Rev 637 = $9.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,PREVEA HEALTH NETWORK,PREVEA360,9.45,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.75 in Billed Charges for Rev 637 = $9.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9.45,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.75 in Billed Charges for Rev 637 = $9.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.05,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $15.75 in Billed Charges for Rev 637 = $10.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.34,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.75 in Billed Charges for Rev 637 = $11.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.71,,,,,,,7.6500,15.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.75 in Billed Charges for Rev 637 = $8.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,8.71,,,,,,,7.6500,15.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.75 in Billed Charges for Rev 637 = $8.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,8.71,,,,,,,7.6500,15.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.75 in Billed Charges for Rev 637 = $8.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,UNITY HEALTH PLAN,UNITY HOSPICE,15.75,,,,,,,7.6500,15.7500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.34,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.75 in Billed Charges for Rev 637 = $11.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.77,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $15.75 in Billed Charges for Rev 637 = $9.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.34,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.75 in Billed Charges for Rev 637 = $11.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.34,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.75 in Billed Charges for Rev 637 = $11.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CELECOXIB 100 MG CAPS,637,RC,60687-436-01,CDM,,,,,,both,1.000000,EA,15.7500,10.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.45,,,,,,,7.6500,15.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.75 in Billed Charges for Rev 637 = $9.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,AETNA,AETNA HSHS,346.16,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $535.85 in Billed Charges for Rev 637 = $346.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,AETNA,ALL COMMERCIAL AETNA,535.85,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.85 in Billed Charges for Rev 637 = $535.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,ANTHEM,ANTHEM POS/HMO,364.38,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $535.85 in Billed Charges for Rev 637 = $364.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,ANTHEM,ANTHEM PPO,364.38,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $535.85 in Billed Charges for Rev 637 = $364.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,535.85,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.85 in Billed Charges for Rev 637 = $535.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,CENPATICO,ALL MEDICAID CENPATICO,535.85,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.85 in Billed Charges for Rev 637 = $535.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,455.47,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.85 in Billed Charges for Rev 637 = $455.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,CIGNA,ALL COMMERCIAL CIGNA,375.10,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $535.85 in Billed Charges for Rev 637 = $375.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,COFINITY,COFINITY,535.85,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.85 in Billed Charges for Rev 637 = $535.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,509.06,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $535.85 in Billed Charges for Rev 637 = $509.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,HEALTH CARE ALLIANCE,THE ALLIANCE,450.11,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $535.85 in Billed Charges for Rev 637 = $450.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,380.45,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $535.85 in Billed Charges for Rev 637 = $380.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,391.17,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $535.85 in Billed Charges for Rev 637 = $391.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,HSHS EMPLOYEES,HSHS EMPLOYEES,260.42,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $535.85 in Billed Charges for Rev 637 = $260.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,455.47,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.85 in Billed Charges for Rev 637 = $455.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,HUMANA,HUMANA CHOICE CARE HMO,340.26,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $535.85 in Billed Charges at 63.5% = $340.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,HUMANA,HUMANA CHOICE CARE PPO,455.47,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $535.85 in Billed Charges for Rev 637 = $455.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,HUMANA,HUMANA NATIIONAL POS HMO,340.26,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $535.85 in Billed Charges at 63.5% = $340.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,391.17,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $535.85 in Billed Charges for Rev 637 = $391.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,LIVE360,LIVE360 HSHS HEALTHY PLAN,535.85,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $535.85 in Billed Charges for Rev 637 = $535.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,535.85,,,,,,,260.4200,535.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,267.93,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $535.85 in Billed Charges for Rev 637 = $267.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,450.11,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $535.85 in Billed Charges for Rev 637 = $450.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,401.89,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $535.85 in Billed Charges for Rev 637 = $401.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,492.98,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $535.85 in Billed Charges for Rev 637 = $492.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,321.51,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $535.85 in Billed Charges for Rev 637 = $321.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,321.51,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $535.85 in Billed Charges for Rev 637 = $321.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,PREVEA HEALTH NETWORK,PREVEA360,321.51,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $535.85 in Billed Charges for Rev 637 = $321.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,321.51,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $535.85 in Billed Charges for Rev 637 = $321.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,342.03,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $535.85 in Billed Charges for Rev 637 = $342.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,385.81,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.85 in Billed Charges for Rev 637 = $385.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,296.33,,,,,,,260.4200,535.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $535.85 in Billed Charges for Rev 637 = $296.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,UNITED HEALTHCARE,UHC ONEIDA NATION,296.33,,,,,,,260.4200,535.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $535.85 in Billed Charges for Rev 637 = $296.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,UNITED HEALTHCARE,UNITED HEALTHCARE,296.33,,,,,,,260.4200,535.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $535.85 in Billed Charges for Rev 637 = $296.33 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,UNITY HEALTH PLAN,UNITY HOSPICE,535.85,,,,,,,260.4200,535.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,385.81,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.85 in Billed Charges for Rev 637 = $385.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,332.23,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $535.85 in Billed Charges for Rev 637 = $332.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,385.81,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.85 in Billed Charges for Rev 637 = $385.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,385.81,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $535.85 in Billed Charges for Rev 637 = $385.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CEFDINIR 250 MG/5ML SUSR,637,RC,0093-4137-73,CDM,,,,,,both,100.000000,ML,535.8500,353.6600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,321.51,,,,,,,260.4200,535.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $535.85 in Billed Charges for Rev 637 = $321.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,AETNA,AETNA HSHS,21.90,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $33.90 in Billed Charges for Rev 637 = $21.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,AETNA,ALL COMMERCIAL AETNA,33.90,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.90 in Billed Charges for Rev 637 = $33.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,ANTHEM,ANTHEM POS/HMO,23.05,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $33.90 in Billed Charges for Rev 637 = $23.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,ANTHEM,ANTHEM PPO,23.05,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $33.90 in Billed Charges for Rev 637 = $23.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,33.90,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.90 in Billed Charges for Rev 637 = $33.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,CENPATICO,ALL MEDICAID CENPATICO,33.90,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.90 in Billed Charges for Rev 637 = $33.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,28.82,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.90 in Billed Charges for Rev 637 = $28.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,CIGNA,ALL COMMERCIAL CIGNA,23.73,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $33.90 in Billed Charges for Rev 637 = $23.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,COFINITY,COFINITY,33.90,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.90 in Billed Charges for Rev 637 = $33.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,32.21,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $33.90 in Billed Charges for Rev 637 = $32.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,HEALTH CARE ALLIANCE,THE ALLIANCE,28.48,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.90 in Billed Charges for Rev 637 = $28.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,24.07,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $33.90 in Billed Charges for Rev 637 = $24.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,24.75,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.90 in Billed Charges for Rev 637 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,HSHS EMPLOYEES,HSHS EMPLOYEES,16.48,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $33.90 in Billed Charges for Rev 637 = $16.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,28.82,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.90 in Billed Charges for Rev 637 = $28.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,HUMANA,HUMANA CHOICE CARE HMO,21.53,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $33.90 in Billed Charges at 63.5% = $21.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,HUMANA,HUMANA CHOICE CARE PPO,28.82,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $33.90 in Billed Charges for Rev 637 = $28.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,HUMANA,HUMANA NATIIONAL POS HMO,21.53,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $33.90 in Billed Charges at 63.5% = $21.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,24.75,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $33.90 in Billed Charges for Rev 637 = $24.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,LIVE360,LIVE360 HSHS HEALTHY PLAN,33.90,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $33.90 in Billed Charges for Rev 637 = $33.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,33.90,,,,,,,16.4800,33.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.95,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $33.90 in Billed Charges for Rev 637 = $16.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,28.48,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $33.90 in Billed Charges for Rev 637 = $28.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,25.43,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $33.90 in Billed Charges for Rev 637 = $25.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,31.19,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $33.90 in Billed Charges for Rev 637 = $31.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,20.34,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.90 in Billed Charges for Rev 637 = $20.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,20.34,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.90 in Billed Charges for Rev 637 = $20.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,PREVEA HEALTH NETWORK,PREVEA360,20.34,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.90 in Billed Charges for Rev 637 = $20.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,20.34,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.90 in Billed Charges for Rev 637 = $20.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,21.64,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $33.90 in Billed Charges for Rev 637 = $21.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,24.41,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.90 in Billed Charges for Rev 637 = $24.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,18.75,,,,,,,16.4800,33.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $33.90 in Billed Charges for Rev 637 = $18.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,UNITED HEALTHCARE,UHC ONEIDA NATION,18.75,,,,,,,16.4800,33.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $33.90 in Billed Charges for Rev 637 = $18.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,UNITED HEALTHCARE,UNITED HEALTHCARE,18.75,,,,,,,16.4800,33.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $33.90 in Billed Charges for Rev 637 = $18.75 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,UNITY HEALTH PLAN,UNITY HOSPICE,33.90,,,,,,,16.4800,33.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,24.41,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.90 in Billed Charges for Rev 637 = $24.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,21.02,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $33.90 in Billed Charges for Rev 637 = $21.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,24.41,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.90 in Billed Charges for Rev 637 = $24.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,24.41,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $33.90 in Billed Charges for Rev 637 = $24.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAPSAICIN 0.025 % CREA 60 G TUBE,637,RC,0536-2525-25,CDM,,,,,,both,60.000000,GR,33.9000,22.3700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,20.34,,,,,,,16.4800,33.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $33.90 in Billed Charges for Rev 637 = $20.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,AETNA,AETNA HSHS,27.04,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $41.85 in Billed Charges for Rev 637 = $27.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,AETNA,ALL COMMERCIAL AETNA,41.85,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.85 in Billed Charges for Rev 637 = $41.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,ANTHEM,ANTHEM POS/HMO,28.46,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $41.85 in Billed Charges for Rev 637 = $28.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,ANTHEM,ANTHEM PPO,28.46,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $41.85 in Billed Charges for Rev 637 = $28.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,41.85,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.85 in Billed Charges for Rev 637 = $41.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,CENPATICO,ALL MEDICAID CENPATICO,41.85,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.85 in Billed Charges for Rev 637 = $41.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,35.57,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.85 in Billed Charges for Rev 637 = $35.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,CIGNA,ALL COMMERCIAL CIGNA,29.30,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $41.85 in Billed Charges for Rev 637 = $29.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,COFINITY,COFINITY,41.85,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.85 in Billed Charges for Rev 637 = $41.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,39.76,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $41.85 in Billed Charges for Rev 637 = $39.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,35.15,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.85 in Billed Charges for Rev 637 = $35.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,29.71,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $41.85 in Billed Charges for Rev 637 = $29.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,30.55,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.85 in Billed Charges for Rev 637 = $30.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,20.34,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $41.85 in Billed Charges for Rev 637 = $20.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,35.57,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.85 in Billed Charges for Rev 637 = $35.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,HUMANA,HUMANA CHOICE CARE HMO,26.57,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $41.85 in Billed Charges at 63.5% = $26.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,HUMANA,HUMANA CHOICE CARE PPO,35.57,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $41.85 in Billed Charges for Rev 637 = $35.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,HUMANA,HUMANA NATIIONAL POS HMO,26.57,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $41.85 in Billed Charges at 63.5% = $26.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,30.55,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $41.85 in Billed Charges for Rev 637 = $30.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,41.85,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $41.85 in Billed Charges for Rev 637 = $41.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,41.85,,,,,,,20.3400,41.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,20.93,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $41.85 in Billed Charges for Rev 637 = $20.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,35.15,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $41.85 in Billed Charges for Rev 637 = $35.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,31.39,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $41.85 in Billed Charges for Rev 637 = $31.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,38.50,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $41.85 in Billed Charges for Rev 637 = $38.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,25.11,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.85 in Billed Charges for Rev 637 = $25.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,25.11,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.85 in Billed Charges for Rev 637 = $25.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,PREVEA HEALTH NETWORK,PREVEA360,25.11,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.85 in Billed Charges for Rev 637 = $25.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,25.11,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.85 in Billed Charges for Rev 637 = $25.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,26.71,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $41.85 in Billed Charges for Rev 637 = $26.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,30.13,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.85 in Billed Charges for Rev 637 = $30.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,23.14,,,,,,,20.3400,41.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $41.85 in Billed Charges for Rev 637 = $23.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,UNITED HEALTHCARE,UHC ONEIDA NATION,23.14,,,,,,,20.3400,41.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $41.85 in Billed Charges for Rev 637 = $23.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,UNITED HEALTHCARE,UNITED HEALTHCARE,23.14,,,,,,,20.3400,41.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $41.85 in Billed Charges for Rev 637 = $23.14 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,UNITY HEALTH PLAN,UNITY HOSPICE,41.85,,,,,,,20.3400,41.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,30.13,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.85 in Billed Charges for Rev 637 = $30.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,25.95,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $41.85 in Billed Charges for Rev 637 = $25.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,30.13,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.85 in Billed Charges for Rev 637 = $30.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,30.13,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $41.85 in Billed Charges for Rev 637 = $30.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALCIUM CARBONATE 1250 MG/5ML SUSP,637,RC,0121-0766-16,CDM,,,,,,both,473.000000,ML,41.8500,27.6200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,25.11,,,,,,,20.3400,41.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $41.85 in Billed Charges for Rev 637 = $25.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,AETNA,AETNA HSHS,523.84,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $810.90 in Billed Charges for Rev 637 = $523.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,AETNA,ALL COMMERCIAL AETNA,810.90,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $810.90 in Billed Charges for Rev 637 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,ANTHEM,ANTHEM POS/HMO,551.41,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $810.90 in Billed Charges for Rev 637 = $551.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,ANTHEM,ANTHEM PPO,551.41,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $810.90 in Billed Charges for Rev 637 = $551.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,810.90,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $810.90 in Billed Charges for Rev 637 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,CENPATICO,ALL MEDICAID CENPATICO,810.90,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $810.90 in Billed Charges for Rev 637 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,689.27,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $810.90 in Billed Charges for Rev 637 = $689.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,CIGNA,ALL COMMERCIAL CIGNA,567.63,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $810.90 in Billed Charges for Rev 637 = $567.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,COFINITY,COFINITY,810.90,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $810.90 in Billed Charges for Rev 637 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,770.36,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $810.90 in Billed Charges for Rev 637 = $770.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,681.16,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $810.90 in Billed Charges for Rev 637 = $681.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,575.74,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $810.90 in Billed Charges for Rev 637 = $575.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,591.96,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $810.90 in Billed Charges for Rev 637 = $591.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,394.10,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $810.90 in Billed Charges for Rev 637 = $394.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,689.27,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $810.90 in Billed Charges for Rev 637 = $689.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,HUMANA,HUMANA CHOICE CARE HMO,514.92,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $810.90 in Billed Charges at 63.5% = $514.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,HUMANA,HUMANA CHOICE CARE PPO,689.27,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $810.90 in Billed Charges for Rev 637 = $689.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,HUMANA,HUMANA NATIIONAL POS HMO,514.92,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $810.90 in Billed Charges at 63.5% = $514.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,591.96,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $810.90 in Billed Charges for Rev 637 = $591.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,810.90,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $810.90 in Billed Charges for Rev 637 = $810.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,810.90,,,,,,,394.1000,810.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,405.45,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $810.90 in Billed Charges for Rev 637 = $405.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,681.16,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $810.90 in Billed Charges for Rev 637 = $681.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,608.18,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $810.90 in Billed Charges for Rev 637 = $608.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,746.03,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $810.90 in Billed Charges for Rev 637 = $746.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,486.54,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $810.90 in Billed Charges for Rev 637 = $486.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,486.54,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $810.90 in Billed Charges for Rev 637 = $486.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,PREVEA HEALTH NETWORK,PREVEA360,486.54,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $810.90 in Billed Charges for Rev 637 = $486.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,486.54,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $810.90 in Billed Charges for Rev 637 = $486.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,517.60,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $810.90 in Billed Charges for Rev 637 = $517.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,583.85,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $810.90 in Billed Charges for Rev 637 = $583.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,448.43,,,,,,,394.1000,810.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $810.90 in Billed Charges for Rev 637 = $448.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,UNITED HEALTHCARE,UHC ONEIDA NATION,448.43,,,,,,,394.1000,810.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $810.90 in Billed Charges for Rev 637 = $448.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,UNITED HEALTHCARE,UNITED HEALTHCARE,448.43,,,,,,,394.1000,810.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $810.90 in Billed Charges for Rev 637 = $448.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,UNITY HEALTH PLAN,UNITY HOSPICE,810.90,,,,,,,394.1000,810.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,583.85,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $810.90 in Billed Charges for Rev 637 = $583.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,502.76,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $810.90 in Billed Charges for Rev 637 = $502.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,583.85,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $810.90 in Billed Charges for Rev 637 = $583.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,583.85,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $810.90 in Billed Charges for Rev 637 = $583.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE 100 MG/5ML SUSP,637,RC,0078-0508-83,CDM,,,,,,both,450.000000,ML,810.9000,535.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,486.54,,,,,,,394.1000,810.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $810.90 in Billed Charges for Rev 637 = $486.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,AETNA,AETNA HSHS,8.17,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.65 in Billed Charges for Rev 637 = $8.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,AETNA,ALL COMMERCIAL AETNA,12.65,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.65 in Billed Charges for Rev 637 = $12.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,ANTHEM,ANTHEM POS/HMO,8.60,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.65 in Billed Charges for Rev 637 = $8.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,ANTHEM,ANTHEM PPO,8.60,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.65 in Billed Charges for Rev 637 = $8.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.65,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.65 in Billed Charges for Rev 637 = $12.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,CENPATICO,ALL MEDICAID CENPATICO,12.65,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.65 in Billed Charges for Rev 637 = $12.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.75,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.65 in Billed Charges for Rev 637 = $10.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,CIGNA,ALL COMMERCIAL CIGNA,8.86,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.65 in Billed Charges for Rev 637 = $8.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,COFINITY,COFINITY,12.65,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.65 in Billed Charges for Rev 637 = $12.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,12.02,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.65 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,HEALTH CARE ALLIANCE,THE ALLIANCE,10.63,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.65 in Billed Charges for Rev 637 = $10.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.98,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.65 in Billed Charges for Rev 637 = $8.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.23,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.65 in Billed Charges for Rev 637 = $9.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,HSHS EMPLOYEES,HSHS EMPLOYEES,6.15,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.65 in Billed Charges for Rev 637 = $6.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.75,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.65 in Billed Charges for Rev 637 = $10.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,HUMANA,HUMANA CHOICE CARE HMO,8.03,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.65 in Billed Charges at 63.5% = $8.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,HUMANA,HUMANA CHOICE CARE PPO,10.75,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.65 in Billed Charges for Rev 637 = $10.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,HUMANA,HUMANA NATIIONAL POS HMO,8.03,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.65 in Billed Charges at 63.5% = $8.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.23,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.65 in Billed Charges for Rev 637 = $9.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.65,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.65 in Billed Charges for Rev 637 = $12.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.65,,,,,,,6.1500,12.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.33,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.65 in Billed Charges for Rev 637 = $6.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.63,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.65 in Billed Charges for Rev 637 = $10.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.49,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.65 in Billed Charges for Rev 637 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.64,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.65 in Billed Charges for Rev 637 = $11.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.59,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.65 in Billed Charges for Rev 637 = $7.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.59,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.65 in Billed Charges for Rev 637 = $7.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,PREVEA HEALTH NETWORK,PREVEA360,7.59,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.65 in Billed Charges for Rev 637 = $7.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.59,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.65 in Billed Charges for Rev 637 = $7.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,8.07,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.65 in Billed Charges for Rev 637 = $8.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.11,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.65 in Billed Charges for Rev 637 = $9.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.00,,,,,,,6.1500,12.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.65 in Billed Charges for Rev 637 = $7.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,UNITED HEALTHCARE,UHC ONEIDA NATION,7.00,,,,,,,6.1500,12.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.65 in Billed Charges for Rev 637 = $7.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,UNITED HEALTHCARE,UNITED HEALTHCARE,7.00,,,,,,,6.1500,12.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.65 in Billed Charges for Rev 637 = $7.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,UNITY HEALTH PLAN,UNITY HOSPICE,12.65,,,,,,,6.1500,12.6500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.11,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.65 in Billed Charges for Rev 637 = $9.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.84,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.65 in Billed Charges for Rev 637 = $7.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.11,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.65 in Billed Charges for Rev 637 = $9.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.11,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.65 in Billed Charges for Rev 637 = $9.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBAMAZEPINE ER 100 MG CP12,637,RC,50268-170-11,CDM,,,,,,both,1.000000,EA,12.6500,8.3500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.59,,,,,,,6.1500,12.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.65 in Billed Charges for Rev 637 = $7.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,AETNA,AETNA HSHS,44.70,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $69.20 in Billed Charges for Rev 637 = $44.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,AETNA,ALL COMMERCIAL AETNA,69.20,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.20 in Billed Charges for Rev 637 = $69.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,ANTHEM,ANTHEM POS/HMO,47.06,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $69.20 in Billed Charges for Rev 637 = $47.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,ANTHEM,ANTHEM PPO,47.06,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $69.20 in Billed Charges for Rev 637 = $47.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,69.20,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.20 in Billed Charges for Rev 637 = $69.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,CENPATICO,ALL MEDICAID CENPATICO,69.20,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.20 in Billed Charges for Rev 637 = $69.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.82,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.20 in Billed Charges for Rev 637 = $58.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,CIGNA,ALL COMMERCIAL CIGNA,48.44,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $69.20 in Billed Charges for Rev 637 = $48.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,COFINITY,COFINITY,69.20,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.20 in Billed Charges for Rev 637 = $69.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.74,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $69.20 in Billed Charges for Rev 637 = $65.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,58.13,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $69.20 in Billed Charges for Rev 637 = $58.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,49.13,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $69.20 in Billed Charges for Rev 637 = $49.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.52,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $69.20 in Billed Charges for Rev 637 = $50.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,33.63,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $69.20 in Billed Charges for Rev 637 = $33.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.82,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.20 in Billed Charges for Rev 637 = $58.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,HUMANA,HUMANA CHOICE CARE HMO,43.94,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $69.20 in Billed Charges at 63.5% = $43.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,HUMANA,HUMANA CHOICE CARE PPO,58.82,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $69.20 in Billed Charges for Rev 637 = $58.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,HUMANA,HUMANA NATIIONAL POS HMO,43.94,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $69.20 in Billed Charges at 63.5% = $43.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.52,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $69.20 in Billed Charges for Rev 637 = $50.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,69.20,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $69.20 in Billed Charges for Rev 637 = $69.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,69.20,,,,,,,33.6300,69.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.60,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $69.20 in Billed Charges for Rev 637 = $34.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,58.13,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $69.20 in Billed Charges for Rev 637 = $58.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.90,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $69.20 in Billed Charges for Rev 637 = $51.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.66,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $69.20 in Billed Charges for Rev 637 = $63.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,41.52,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $69.20 in Billed Charges for Rev 637 = $41.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,41.52,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $69.20 in Billed Charges for Rev 637 = $41.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,PREVEA HEALTH NETWORK,PREVEA360,41.52,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $69.20 in Billed Charges for Rev 637 = $41.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,41.52,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $69.20 in Billed Charges for Rev 637 = $41.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44.17,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $69.20 in Billed Charges for Rev 637 = $44.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.82,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.20 in Billed Charges for Rev 637 = $49.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,38.27,,,,,,,33.6300,69.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $69.20 in Billed Charges for Rev 637 = $38.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,UNITED HEALTHCARE,UHC ONEIDA NATION,38.27,,,,,,,33.6300,69.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $69.20 in Billed Charges for Rev 637 = $38.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,UNITED HEALTHCARE,UNITED HEALTHCARE,38.27,,,,,,,33.6300,69.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $69.20 in Billed Charges for Rev 637 = $38.27 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,UNITY HEALTH PLAN,UNITY HOSPICE,69.20,,,,,,,33.6300,69.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.82,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.20 in Billed Charges for Rev 637 = $49.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.90,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $69.20 in Billed Charges for Rev 637 = $42.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.82,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.20 in Billed Charges for Rev 637 = $49.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.82,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $69.20 in Billed Charges for Rev 637 = $49.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BETAMETHASONE VALERATE OINTMENT 0.1 % OINT 15 G TUBE,637,RC,0168-0033-15,CDM,,,,,,both,15.000000,GR,69.2000,45.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.52,,,,,,,33.6300,69.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $69.20 in Billed Charges for Rev 637 = $41.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,AETNA,AETNA HSHS,25.78,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $39.90 in Billed Charges for Rev 637 = $25.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,AETNA,ALL COMMERCIAL AETNA,39.90,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.90 in Billed Charges for Rev 637 = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,ANTHEM,ANTHEM POS/HMO,27.13,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $39.90 in Billed Charges for Rev 637 = $27.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,ANTHEM,ANTHEM PPO,27.13,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $39.90 in Billed Charges for Rev 637 = $27.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,39.90,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.90 in Billed Charges for Rev 637 = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,CENPATICO,ALL MEDICAID CENPATICO,39.90,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.90 in Billed Charges for Rev 637 = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,33.92,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.90 in Billed Charges for Rev 637 = $33.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,CIGNA,ALL COMMERCIAL CIGNA,27.93,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $39.90 in Billed Charges for Rev 637 = $27.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,COFINITY,COFINITY,39.90,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.90 in Billed Charges for Rev 637 = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,37.91,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $39.90 in Billed Charges for Rev 637 = $37.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,33.52,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $39.90 in Billed Charges for Rev 637 = $33.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,28.33,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $39.90 in Billed Charges for Rev 637 = $28.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,29.13,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $39.90 in Billed Charges for Rev 637 = $29.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,19.39,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $39.90 in Billed Charges for Rev 637 = $19.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,33.92,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.90 in Billed Charges for Rev 637 = $33.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,HUMANA,HUMANA CHOICE CARE HMO,25.34,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $39.90 in Billed Charges at 63.5% = $25.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,HUMANA,HUMANA CHOICE CARE PPO,33.92,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $39.90 in Billed Charges for Rev 637 = $33.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,HUMANA,HUMANA NATIIONAL POS HMO,25.34,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $39.90 in Billed Charges at 63.5% = $25.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,29.13,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $39.90 in Billed Charges for Rev 637 = $29.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,39.90,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $39.90 in Billed Charges for Rev 637 = $39.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,39.90,,,,,,,19.3900,39.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.95,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $39.90 in Billed Charges for Rev 637 = $19.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,33.52,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $39.90 in Billed Charges for Rev 637 = $33.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,29.93,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $39.90 in Billed Charges for Rev 637 = $29.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,36.71,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $39.90 in Billed Charges for Rev 637 = $36.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,23.94,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $39.90 in Billed Charges for Rev 637 = $23.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,23.94,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $39.90 in Billed Charges for Rev 637 = $23.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,PREVEA HEALTH NETWORK,PREVEA360,23.94,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $39.90 in Billed Charges for Rev 637 = $23.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,23.94,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $39.90 in Billed Charges for Rev 637 = $23.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,25.47,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $39.90 in Billed Charges for Rev 637 = $25.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,28.73,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.90 in Billed Charges for Rev 637 = $28.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,22.06,,,,,,,19.3900,39.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $39.90 in Billed Charges for Rev 637 = $22.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,22.06,,,,,,,19.3900,39.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $39.90 in Billed Charges for Rev 637 = $22.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,22.06,,,,,,,19.3900,39.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $39.90 in Billed Charges for Rev 637 = $22.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,UNITY HEALTH PLAN,UNITY HOSPICE,39.90,,,,,,,19.3900,39.9000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,28.73,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.90 in Billed Charges for Rev 637 = $28.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,24.74,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $39.90 in Billed Charges for Rev 637 = $24.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,28.73,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.90 in Billed Charges for Rev 637 = $28.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,28.73,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $39.90 in Billed Charges for Rev 637 = $28.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARTIFICIAL TEARS OINT 3.5 G TUBE,637,RC,0023-0312-04,CDM,,,,,,both,3.500000,GR,39.9000,26.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,23.94,,,,,,,19.3900,39.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $39.90 in Billed Charges for Rev 637 = $23.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,AETNA,AETNA HSHS,5.39,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.35 in Billed Charges for Rev 637 = $5.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,AETNA,ALL COMMERCIAL AETNA,8.35,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.35 in Billed Charges for Rev 637 = $8.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,ANTHEM,ANTHEM POS/HMO,5.68,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.35 in Billed Charges for Rev 637 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,ANTHEM,ANTHEM PPO,5.68,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.35 in Billed Charges for Rev 637 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.35,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.35 in Billed Charges for Rev 637 = $8.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,CENPATICO,ALL MEDICAID CENPATICO,8.35,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.35 in Billed Charges for Rev 637 = $8.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.10,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.35 in Billed Charges for Rev 637 = $7.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,CIGNA,ALL COMMERCIAL CIGNA,5.85,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.35 in Billed Charges for Rev 637 = $5.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,COFINITY,COFINITY,8.35,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.35 in Billed Charges for Rev 637 = $8.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.93,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.35 in Billed Charges for Rev 637 = $7.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,HEALTH CARE ALLIANCE,THE ALLIANCE,7.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.35 in Billed Charges for Rev 637 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.93,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.35 in Billed Charges for Rev 637 = $5.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.10,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.35 in Billed Charges for Rev 637 = $6.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,HSHS EMPLOYEES,HSHS EMPLOYEES,4.06,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.35 in Billed Charges for Rev 637 = $4.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.10,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.35 in Billed Charges for Rev 637 = $7.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,HUMANA,HUMANA CHOICE CARE HMO,5.30,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.35 in Billed Charges at 63.5% = $5.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,HUMANA,HUMANA CHOICE CARE PPO,7.10,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.35 in Billed Charges for Rev 637 = $7.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,HUMANA,HUMANA NATIIONAL POS HMO,5.30,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.35 in Billed Charges at 63.5% = $5.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.10,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.35 in Billed Charges for Rev 637 = $6.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.35,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.35 in Billed Charges for Rev 637 = $8.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.35,,,,,,,4.0600,8.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.18,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.35 in Billed Charges for Rev 637 = $4.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.35 in Billed Charges for Rev 637 = $7.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.26,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.35 in Billed Charges for Rev 637 = $6.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.68,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.35 in Billed Charges for Rev 637 = $7.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.35 in Billed Charges for Rev 637 = $5.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.35 in Billed Charges for Rev 637 = $5.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,PREVEA HEALTH NETWORK,PREVEA360,5.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.35 in Billed Charges for Rev 637 = $5.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.35 in Billed Charges for Rev 637 = $5.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.33,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.35 in Billed Charges for Rev 637 = $5.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.35 in Billed Charges for Rev 637 = $6.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.62,,,,,,,4.0600,8.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.35 in Billed Charges for Rev 637 = $4.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,UNITED HEALTHCARE,UHC ONEIDA NATION,4.62,,,,,,,4.0600,8.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.35 in Billed Charges for Rev 637 = $4.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,UNITED HEALTHCARE,UNITED HEALTHCARE,4.62,,,,,,,4.0600,8.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.35 in Billed Charges for Rev 637 = $4.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,UNITY HEALTH PLAN,UNITY HOSPICE,8.35,,,,,,,4.0600,8.3500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.35 in Billed Charges for Rev 637 = $6.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.18,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.35 in Billed Charges for Rev 637 = $5.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.35 in Billed Charges for Rev 637 = $6.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.35 in Billed Charges for Rev 637 = $6.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPRENORPHINE 2 MG SUBL,637,RC,60687-481-11,CDM,,,,,,both,1.000000,EA,8.3500,5.5100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.01,,,,,,,4.0600,8.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.35 in Billed Charges for Rev 637 = $5.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 637 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.00 in Billed Charges for Rev 637 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.00 in Billed Charges for Rev 637 = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 637 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 637 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 637 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 637 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 637 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 637 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 637 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 637 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.00,,,,,,,3.8900,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 637 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 637 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 637 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 637 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 637 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 637 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,UNITY HEALTH PLAN,UNITY HOSPICE,8.00,,,,,,,3.8900,8.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 637 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 637 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CALAMINE WITH ZINC 8-8 % LOTN 177 ML BOTTLE,637,RC,0904-2533-21,CDM,,,,,,both,177.000000,ML,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 637 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,AETNA,AETNA HSHS,1393.42,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,157.00 in Billed Charges for Rev 111 = $1,393.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,AETNA,ALL COMMERCIAL AETNA,2157.00,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,157.00 in Billed Charges for Rev 111 = $2,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2157.00,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,157.00 in Billed Charges for Rev 111 = $2,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1833.45,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,157.00 in Billed Charges for Rev 111 = $1,833.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,CIGNA,ALL COMMERCIAL CIGNA,1509.90,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,157.00 in Billed Charges for Rev 111 = $1,509.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,COFINITY,COFINITY,2157.00,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,157.00 in Billed Charges for Rev 111 = $2,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2049.15,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,157.00 in Billed Charges for Rev 111 = $2,049.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,1811.88,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,157.00 in Billed Charges for Rev 111 = $1,811.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1531.47,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,157.00 in Billed Charges for Rev 111 = $1,531.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1574.61,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,157.00 in Billed Charges for Rev 111 = $1,574.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,1048.30,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,157.00 in Billed Charges for Rev 111 = $1,048.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1833.45,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,157.00 in Billed Charges for Rev 111 = $1,833.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HUMANA,HUMANA CHOICE CARE PPO,1833.45,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,157.00 in Billed Charges for Rev 111 = $1,833.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1574.61,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,157.00 in Billed Charges for Rev 111 = $1,574.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2157.00,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,157.00 in Billed Charges for Rev 111 = $2,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1078.50,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,157.00 in Billed Charges for Rev 111 = $1,078.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1811.88,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,157.00 in Billed Charges for Rev 111 = $1,811.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1617.75,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,157.00 in Billed Charges for Rev 111 = $1,617.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1984.44,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,157.00 in Billed Charges for Rev 111 = $1,984.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1376.81,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,157.00 in Billed Charges for Rev 111 = $1,376.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1553.04,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,157.00 in Billed Charges for Rev 111 = $1,553.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,2157.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 111
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1553.04,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,157.00 in Billed Charges for Rev 111 = $1,553.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1337.34,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,157.00 in Billed Charges for Rev 111 = $1,337.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1553.04,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,157.00 in Billed Charges for Rev 111 = $1,553.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE W/TELEMETRY,111,RC,11100010,CDM,,,,,,inpatient,,,2157.0000,1423.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1553.04,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,157.00 in Billed Charges for Rev 111 = $1,553.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,AETNA,AETNA HSHS,1317.84,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,040.00 in Billed Charges for Rev 128 = $1,317.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,AETNA,ALL COMMERCIAL AETNA,2040.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,040.00 in Billed Charges for Rev 128 = $2,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,ANTHEM,ANTHEM POS/HMO,2040.00,,,,,,,500.0000,2040.0000,per diem,"ST VINCENT HOSPITAL (ACU). $2,976.00 for 1 day = $2,976.00 for Rev 128... Eligible capped at $2,040.00 (Billed Charges)"
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,ANTHEM,ANTHEM PPO,2040.00,,,,,,,500.0000,2040.0000,per diem,"ST VINCENT HOSPITAL (ACU). $2,976.00 for 1 day = $2,976.00 for Rev 128... Eligible capped at $2,040.00 (Billed Charges)"
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2040.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,040.00 in Billed Charges for Rev 128 = $2,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1734.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,040.00 in Billed Charges for Rev 128 = $1,734.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,CIGNA,ALL COMMERCIAL CIGNA,1428.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,040.00 in Billed Charges for Rev 128 = $1,428.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,COFINITY,COFINITY,2040.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,040.00 in Billed Charges for Rev 128 = $2,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1938.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,040.00 in Billed Charges for Rev 128 = $1,938.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,1713.60,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,040.00 in Billed Charges for Rev 128 = $1,713.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1448.40,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,040.00 in Billed Charges for Rev 128 = $1,448.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1489.20,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,040.00 in Billed Charges for Rev 128 = $1,489.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,991.44,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,040.00 in Billed Charges for Rev 128 = $991.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1734.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,040.00 in Billed Charges for Rev 128 = $1,734.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,HUMANA,HUMANA CHOICE CARE PPO,1734.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,040.00 in Billed Charges for Rev 128 = $1,734.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1489.20,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,040.00 in Billed Charges for Rev 128 = $1,489.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2040.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,040.00 in Billed Charges for Rev 128 = $2,040.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1020.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,040.00 in Billed Charges for Rev 128 = $1,020.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1713.60,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,040.00 in Billed Charges for Rev 128 = $1,713.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1530.00,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,040.00 in Billed Charges for Rev 128 = $1,530.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1876.80,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,040.00 in Billed Charges for Rev 128 = $1,876.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1302.13,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,040.00 in Billed Charges for Rev 128 = $1,302.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1468.80,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,040.00 in Billed Charges for Rev 128 = $1,468.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,2040.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 128
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1468.80,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,040.00 in Billed Charges for Rev 128 = $1,468.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1264.80,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,040.00 in Billed Charges for Rev 128 = $1,264.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1468.80,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,040.00 in Billed Charges for Rev 128 = $1,468.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY REHAB SERVICE,128,RC,12800001,CDM,,,,,,inpatient,,,2040.0000,1346.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1468.80,,,,,,,500.0000,2040.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,040.00 in Billed Charges for Rev 128 = $1,468.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,AETNA,AETNA HSHS,904.40,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,400.00 in Billed Charges for Rev 128 = $904.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,AETNA,ALL COMMERCIAL AETNA,1400.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.00 in Billed Charges for Rev 128 = $1,400.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,ANTHEM,ANTHEM POS/HMO,1400.00,,,,,,,500.0000,1400.0000,per diem,"ST VINCENT HOSPITAL (ACU). $2,976.00 for 1 day = $2,976.00 for Rev 128... Eligible capped at $1,400.00 (Billed Charges)"
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,ANTHEM,ANTHEM PPO,1400.00,,,,,,,500.0000,1400.0000,per diem,"ST VINCENT HOSPITAL (ACU). $2,976.00 for 1 day = $2,976.00 for Rev 128... Eligible capped at $1,400.00 (Billed Charges)"
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1400.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.00 in Billed Charges for Rev 128 = $1,400.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1190.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,400.00 in Billed Charges for Rev 128 = $1,190.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,CIGNA,ALL COMMERCIAL CIGNA,980.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,400.00 in Billed Charges for Rev 128 = $980.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,COFINITY,COFINITY,1400.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.00 in Billed Charges for Rev 128 = $1,400.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1330.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,400.00 in Billed Charges for Rev 128 = $1,330.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,1176.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,400.00 in Billed Charges for Rev 128 = $1,176.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,994.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,400.00 in Billed Charges for Rev 128 = $994.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1022.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,400.00 in Billed Charges for Rev 128 = $1,022.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,680.40,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,400.00 in Billed Charges for Rev 128 = $680.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1190.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,400.00 in Billed Charges for Rev 128 = $1,190.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,HUMANA,HUMANA CHOICE CARE PPO,1190.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,400.00 in Billed Charges for Rev 128 = $1,190.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1022.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,400.00 in Billed Charges for Rev 128 = $1,022.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1400.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,400.00 in Billed Charges for Rev 128 = $1,400.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,700.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,400.00 in Billed Charges for Rev 128 = $700.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1176.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,400.00 in Billed Charges for Rev 128 = $1,176.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1050.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,400.00 in Billed Charges for Rev 128 = $1,050.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1288.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,400.00 in Billed Charges for Rev 128 = $1,288.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,893.62,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,400.00 in Billed Charges for Rev 128 = $893.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1008.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,400.00 in Billed Charges for Rev 128 = $1,008.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,1400.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 128
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1008.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,400.00 in Billed Charges for Rev 128 = $1,008.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,868.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,400.00 in Billed Charges for Rev 128 = $868.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1008.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,400.00 in Billed Charges for Rev 128 = $1,008.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MONITORED,128,RC,12800004,CDM,,,,,,inpatient,,,1400.0000,924.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1008.00,,,,,,,500.0000,1400.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,400.00 in Billed Charges for Rev 128 = $1,008.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,AETNA,AETNA HSHS,423.78,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $656.00 in Billed Charges for Rev 169 = $423.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,AETNA,ALL COMMERCIAL AETNA,656.00,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $656.00 in Billed Charges for Rev 169 = $656.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,656.00,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $656.00 in Billed Charges for Rev 169 = $656.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,557.60,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $656.00 in Billed Charges for Rev 169 = $557.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,CIGNA,ALL COMMERCIAL CIGNA,459.20,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $656.00 in Billed Charges for Rev 169 = $459.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,COFINITY,COFINITY,656.00,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $656.00 in Billed Charges for Rev 169 = $656.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,623.20,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $656.00 in Billed Charges for Rev 169 = $623.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,551.04,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $656.00 in Billed Charges for Rev 169 = $551.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,465.76,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $656.00 in Billed Charges for Rev 169 = $465.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,478.88,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $656.00 in Billed Charges for Rev 169 = $478.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,318.82,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $656.00 in Billed Charges for Rev 169 = $318.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,557.60,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $656.00 in Billed Charges for Rev 169 = $557.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,HUMANA,HUMANA CHOICE CARE PPO,557.60,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $656.00 in Billed Charges for Rev 169 = $557.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,478.88,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $656.00 in Billed Charges for Rev 169 = $478.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,656.00,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $656.00 in Billed Charges for Rev 169 = $656.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,328.00,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $656.00 in Billed Charges for Rev 169 = $328.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,551.04,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $656.00 in Billed Charges for Rev 169 = $551.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,492.00,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $656.00 in Billed Charges for Rev 169 = $492.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,603.52,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $656.00 in Billed Charges for Rev 169 = $603.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,418.72,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $656.00 in Billed Charges for Rev 169 = $418.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,472.32,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $656.00 in Billed Charges for Rev 169 = $472.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,318.8200,656.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 169
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,472.32,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $656.00 in Billed Charges for Rev 169 = $472.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,406.72,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $656.00 in Billed Charges for Rev 169 = $406.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,472.32,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $656.00 in Billed Charges for Rev 169 = $472.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE PROLONGED STAY,169,RC,16900000,CDM,,,,,,inpatient,,,656.0000,432.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,472.32,,,,,,,318.8200,656.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $656.00 in Billed Charges for Rev 169 = $472.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,AETNA,AETNA HSHS,3749.38,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,804.00 in Billed Charges for Rev 173 = $3,749.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,AETNA,ALL COMMERCIAL AETNA,5804.00,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,804.00 in Billed Charges for Rev 173 = $5,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5804.00,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,804.00 in Billed Charges for Rev 173 = $5,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4933.40,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,804.00 in Billed Charges for Rev 173 = $4,933.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,CIGNA,ALL COMMERCIAL CIGNA,4062.80,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,804.00 in Billed Charges for Rev 173 = $4,062.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,COFINITY,COFINITY,5804.00,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,804.00 in Billed Charges for Rev 173 = $5,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5513.80,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,804.00 in Billed Charges for Rev 173 = $5,513.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,4875.36,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,804.00 in Billed Charges for Rev 173 = $4,875.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4120.84,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,804.00 in Billed Charges for Rev 173 = $4,120.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4236.92,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,804.00 in Billed Charges for Rev 173 = $4,236.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,2820.74,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,804.00 in Billed Charges for Rev 173 = $2,820.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4933.40,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,804.00 in Billed Charges for Rev 173 = $4,933.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,HUMANA,HUMANA CHOICE CARE PPO,4933.40,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,804.00 in Billed Charges for Rev 173 = $4,933.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4236.92,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,804.00 in Billed Charges for Rev 173 = $4,236.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,5804.00,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,804.00 in Billed Charges for Rev 173 = $5,804.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2902.00,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,804.00 in Billed Charges for Rev 173 = $2,902.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4875.36,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,804.00 in Billed Charges for Rev 173 = $4,875.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4353.00,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,804.00 in Billed Charges for Rev 173 = $4,353.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5339.68,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,804.00 in Billed Charges for Rev 173 = $5,339.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3704.69,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,804.00 in Billed Charges for Rev 173 = $3,704.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4178.88,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,804.00 in Billed Charges for Rev 173 = $4,178.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,5804.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 173
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4178.88,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,804.00 in Billed Charges for Rev 173 = $4,178.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3598.48,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,804.00 in Billed Charges for Rev 173 = $3,598.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4178.88,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,804.00 in Billed Charges for Rev 173 = $4,178.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 3,173,RC,17300001,CDM,,,,,,inpatient,,,5804.0000,3830.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4178.88,,,,,,,500.0000,5804.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,804.00 in Billed Charges for Rev 173 = $4,178.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,AETNA,AETNA HSHS,1518.10,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,350.00 in Billed Charges for Rev 173 = $1,518.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,AETNA,ALL COMMERCIAL AETNA,2350.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 173 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2350.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 173 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1997.50,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,350.00 in Billed Charges for Rev 173 = $1,997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,CIGNA,ALL COMMERCIAL CIGNA,1645.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,350.00 in Billed Charges for Rev 173 = $1,645.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,COFINITY,COFINITY,2350.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 173 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2232.50,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,350.00 in Billed Charges for Rev 173 = $2,232.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,1974.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,350.00 in Billed Charges for Rev 173 = $1,974.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1668.50,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,350.00 in Billed Charges for Rev 173 = $1,668.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1715.50,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,350.00 in Billed Charges for Rev 173 = $1,715.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,1142.10,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,350.00 in Billed Charges for Rev 173 = $1,142.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1997.50,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,350.00 in Billed Charges for Rev 173 = $1,997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,HUMANA,HUMANA CHOICE CARE PPO,1997.50,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,350.00 in Billed Charges for Rev 173 = $1,997.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1715.50,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,350.00 in Billed Charges for Rev 173 = $1,715.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,2350.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,350.00 in Billed Charges for Rev 173 = $2,350.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1175.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,350.00 in Billed Charges for Rev 173 = $1,175.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1974.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,350.00 in Billed Charges for Rev 173 = $1,974.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1762.50,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,350.00 in Billed Charges for Rev 173 = $1,762.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2162.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,350.00 in Billed Charges for Rev 173 = $2,162.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1500.01,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,350.00 in Billed Charges for Rev 173 = $1,500.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1692.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,350.00 in Billed Charges for Rev 173 = $1,692.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,2350.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 173
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1692.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,350.00 in Billed Charges for Rev 173 = $1,692.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1457.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,350.00 in Billed Charges for Rev 173 = $1,457.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1692.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,350.00 in Billed Charges for Rev 173 = $1,692.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 3,173,RC,17300002,CDM,,,,,,inpatient,,,2350.0000,1551.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1692.00,,,,,,,500.0000,2350.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,350.00 in Billed Charges for Rev 173 = $1,692.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,AETNA,AETNA HSHS,5262.96,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $8,147.00 in Billed Charges for Rev 174 = $5,262.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,AETNA,ALL COMMERCIAL AETNA,8147.00,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,147.00 in Billed Charges for Rev 174 = $8,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8147.00,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,147.00 in Billed Charges for Rev 174 = $8,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6924.95,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,147.00 in Billed Charges for Rev 174 = $6,924.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,CIGNA,ALL COMMERCIAL CIGNA,5702.90,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $8,147.00 in Billed Charges for Rev 174 = $5,702.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,COFINITY,COFINITY,8147.00,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,147.00 in Billed Charges for Rev 174 = $8,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7739.65,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $8,147.00 in Billed Charges for Rev 174 = $7,739.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,6843.48,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,147.00 in Billed Charges for Rev 174 = $6,843.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5784.37,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $8,147.00 in Billed Charges for Rev 174 = $5,784.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5947.31,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,147.00 in Billed Charges for Rev 174 = $5,947.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,3959.44,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $8,147.00 in Billed Charges for Rev 174 = $3,959.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6924.95,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,147.00 in Billed Charges for Rev 174 = $6,924.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,HUMANA,HUMANA CHOICE CARE PPO,6924.95,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $8,147.00 in Billed Charges for Rev 174 = $6,924.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5947.31,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $8,147.00 in Billed Charges for Rev 174 = $5,947.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,8147.00,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $8,147.00 in Billed Charges for Rev 174 = $8,147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4073.50,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $8,147.00 in Billed Charges for Rev 174 = $4,073.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6843.48,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $8,147.00 in Billed Charges for Rev 174 = $6,843.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6110.25,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $8,147.00 in Billed Charges for Rev 174 = $6,110.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7495.24,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $8,147.00 in Billed Charges for Rev 174 = $7,495.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5200.23,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $8,147.00 in Billed Charges for Rev 174 = $5,200.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5865.84,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,147.00 in Billed Charges for Rev 174 = $5,865.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,8147.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 174
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5865.84,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,147.00 in Billed Charges for Rev 174 = $5,865.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5051.14,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $8,147.00 in Billed Charges for Rev 174 = $5,051.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5865.84,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,147.00 in Billed Charges for Rev 174 = $5,865.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 4,174,RC,17400001,CDM,,,,,,inpatient,,,8147.0000,5377.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5865.84,,,,,,,500.0000,8147.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $8,147.00 in Billed Charges for Rev 174 = $5,865.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,AETNA,AETNA HSHS,4047.19,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,265.00 in Billed Charges for Rev 200 = $4,047.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,AETNA,ALL COMMERCIAL AETNA,6265.00,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,265.00 in Billed Charges for Rev 200 = $6,265.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6265.00,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,265.00 in Billed Charges for Rev 200 = $6,265.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5325.25,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,265.00 in Billed Charges for Rev 200 = $5,325.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,CIGNA,ALL COMMERCIAL CIGNA,4385.50,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,265.00 in Billed Charges for Rev 200 = $4,385.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,COFINITY,COFINITY,6265.00,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,265.00 in Billed Charges for Rev 200 = $6,265.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5951.75,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,265.00 in Billed Charges for Rev 200 = $5,951.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,5262.60,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,265.00 in Billed Charges for Rev 200 = $5,262.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4448.15,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,265.00 in Billed Charges for Rev 200 = $4,448.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4573.45,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,265.00 in Billed Charges for Rev 200 = $4,573.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,3044.79,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,265.00 in Billed Charges for Rev 200 = $3,044.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5325.25,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,265.00 in Billed Charges for Rev 200 = $5,325.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,HUMANA,HUMANA CHOICE CARE PPO,5325.25,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,265.00 in Billed Charges for Rev 200 = $5,325.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4573.45,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,265.00 in Billed Charges for Rev 200 = $4,573.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,6265.00,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,265.00 in Billed Charges for Rev 200 = $6,265.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3132.50,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,265.00 in Billed Charges for Rev 200 = $3,132.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5262.60,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,265.00 in Billed Charges for Rev 200 = $5,262.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4698.75,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,265.00 in Billed Charges for Rev 200 = $4,698.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5763.80,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,265.00 in Billed Charges for Rev 200 = $5,763.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3998.95,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,265.00 in Billed Charges for Rev 200 = $3,998.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4510.80,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,265.00 in Billed Charges for Rev 200 = $4,510.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,6265.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 200
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4510.80,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,265.00 in Billed Charges for Rev 200 = $4,510.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3884.30,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,265.00 in Billed Charges for Rev 200 = $3,884.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4510.80,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,265.00 in Billed Charges for Rev 200 = $4,510.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVICU,200,RC,20000002,CDM,,,,,,inpatient,,,6265.0000,4134.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4510.80,,,,,,,500.0000,6265.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,265.00 in Billed Charges for Rev 200 = $4,510.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,AETNA,AETNA HSHS,107.24,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $166.00 in Billed Charges for Rev 231 = $107.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,AETNA,ALL COMMERCIAL AETNA,166.00,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $166.00 in Billed Charges for Rev 231 = $166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,166.00,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $166.00 in Billed Charges for Rev 231 = $166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,141.10,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $166.00 in Billed Charges for Rev 231 = $141.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,CIGNA,ALL COMMERCIAL CIGNA,116.20,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $166.00 in Billed Charges for Rev 231 = $116.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,COFINITY,COFINITY,166.00,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $166.00 in Billed Charges for Rev 231 = $166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,157.70,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $166.00 in Billed Charges for Rev 231 = $157.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,139.44,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $166.00 in Billed Charges for Rev 231 = $139.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,117.86,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $166.00 in Billed Charges for Rev 231 = $117.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,121.18,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $166.00 in Billed Charges for Rev 231 = $121.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,80.68,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $166.00 in Billed Charges for Rev 231 = $80.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,141.10,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $166.00 in Billed Charges for Rev 231 = $141.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,HUMANA,HUMANA CHOICE CARE PPO,141.10,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $166.00 in Billed Charges for Rev 231 = $141.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,121.18,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $166.00 in Billed Charges for Rev 231 = $121.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,166.00,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $166.00 in Billed Charges for Rev 231 = $166.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,83.00,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $166.00 in Billed Charges for Rev 231 = $83.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,139.44,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $166.00 in Billed Charges for Rev 231 = $139.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,124.50,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $166.00 in Billed Charges for Rev 231 = $124.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,152.72,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $166.00 in Billed Charges for Rev 231 = $152.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,105.96,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $166.00 in Billed Charges for Rev 231 = $105.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,119.52,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $166.00 in Billed Charges for Rev 231 = $119.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,119.52,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $166.00 in Billed Charges for Rev 231 = $119.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,102.92,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $166.00 in Billed Charges for Rev 231 = $102.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,119.52,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $166.00 in Billed Charges for Rev 231 = $119.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE BOARDER,231,RC,23100001,CDM,,,,,,inpatient,,,166.0000,109.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,119.52,,,,,,,80.6800,166.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $166.00 in Billed Charges for Rev 231 = $119.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,AETNA,AETNA HSHS,94.96,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $147.00 in Billed Charges for Rev 233 = $94.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,AETNA,ALL COMMERCIAL AETNA,147.00,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.00 in Billed Charges for Rev 233 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,ANTHEM,ANTHEM POS/HMO,99.96,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $147.00 in Billed Charges for Rev 233 = $99.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,ANTHEM,ANTHEM PPO,99.96,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $147.00 in Billed Charges for Rev 233 = $99.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,147.00,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.00 in Billed Charges for Rev 233 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,CENPATICO,ALL MEDICAID CENPATICO,147.00,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.00 in Billed Charges for Rev 233 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.95,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $147.00 in Billed Charges for Rev 233 = $124.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,CIGNA,ALL COMMERCIAL CIGNA,102.90,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $147.00 in Billed Charges for Rev 233 = $102.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,COFINITY,COFINITY,147.00,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.00 in Billed Charges for Rev 233 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,139.65,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $147.00 in Billed Charges for Rev 233 = $139.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,123.48,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $147.00 in Billed Charges for Rev 233 = $123.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,104.37,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $147.00 in Billed Charges for Rev 233 = $104.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,107.31,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $147.00 in Billed Charges for Rev 233 = $107.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,71.44,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $147.00 in Billed Charges for Rev 233 = $71.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.95,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $147.00 in Billed Charges for Rev 233 = $124.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,HUMANA,HUMANA CHOICE CARE HMO,93.35,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $147.00 in Billed Charges for Rev 233 = $93.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,HUMANA,HUMANA CHOICE CARE PPO,124.95,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $147.00 in Billed Charges for Rev 233 = $124.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,HUMANA,HUMANA NATIIONAL POS HMO,93.35,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $147.00 in Billed Charges for Rev 233 = $93.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,107.31,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $147.00 in Billed Charges for Rev 233 = $107.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,147.00,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.00 in Billed Charges for Rev 233 = $147.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.50,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $147.00 in Billed Charges for Rev 233 = $73.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,123.48,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $147.00 in Billed Charges for Rev 233 = $123.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,110.25,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $147.00 in Billed Charges for Rev 233 = $110.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,135.24,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $147.00 in Billed Charges for Rev 233 = $135.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,88.20,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.00 in Billed Charges for Rev 233 = $88.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,88.20,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.00 in Billed Charges for Rev 233 = $88.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,PREVEA HEALTH NETWORK,PREVEA360,88.20,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.00 in Billed Charges for Rev 233 = $88.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,88.20,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.00 in Billed Charges for Rev 233 = $88.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.83,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $147.00 in Billed Charges for Rev 233 = $93.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.84,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $147.00 in Billed Charges for Rev 233 = $105.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,81.29,,,,,,,71.4400,147.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $147.00 in Billed Charges for Rev 233 = $81.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,81.29,,,,,,,71.4400,147.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $147.00 in Billed Charges for Rev 233 = $81.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,81.29,,,,,,,71.4400,147.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $147.00 in Billed Charges for Rev 233 = $81.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.84,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $147.00 in Billed Charges for Rev 233 = $105.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,91.14,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $147.00 in Billed Charges for Rev 233 = $91.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.84,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $147.00 in Billed Charges for Rev 233 = $105.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.84,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $147.00 in Billed Charges for Rev 233 = $105.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE ICU/HR,233,RC,23300001,CDM,,,,,,both,,,147.0000,97.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,88.20,,,,,,,71.4400,147.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.00 in Billed Charges for Rev 233 = $88.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,AETNA,AETNA HSHS,56.20,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $87.00 in Billed Charges for Rev 233 = $56.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,AETNA,ALL COMMERCIAL AETNA,87.00,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.00 in Billed Charges for Rev 233 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,ANTHEM,ANTHEM POS/HMO,59.16,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $87.00 in Billed Charges for Rev 233 = $59.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,ANTHEM,ANTHEM PPO,59.16,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $87.00 in Billed Charges for Rev 233 = $59.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,87.00,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.00 in Billed Charges for Rev 233 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,CENPATICO,ALL MEDICAID CENPATICO,87.00,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.00 in Billed Charges for Rev 233 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,73.95,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $87.00 in Billed Charges for Rev 233 = $73.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,CIGNA,ALL COMMERCIAL CIGNA,60.90,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $87.00 in Billed Charges for Rev 233 = $60.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,COFINITY,COFINITY,87.00,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.00 in Billed Charges for Rev 233 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,82.65,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $87.00 in Billed Charges for Rev 233 = $82.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,73.08,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $87.00 in Billed Charges for Rev 233 = $73.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,61.77,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $87.00 in Billed Charges for Rev 233 = $61.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,63.51,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $87.00 in Billed Charges for Rev 233 = $63.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,42.28,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $87.00 in Billed Charges for Rev 233 = $42.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,73.95,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $87.00 in Billed Charges for Rev 233 = $73.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,HUMANA,HUMANA CHOICE CARE HMO,55.25,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $87.00 in Billed Charges for Rev 233 = $55.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,HUMANA,HUMANA CHOICE CARE PPO,73.95,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $87.00 in Billed Charges for Rev 233 = $73.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,HUMANA,HUMANA NATIIONAL POS HMO,55.25,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $87.00 in Billed Charges for Rev 233 = $55.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,63.51,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $87.00 in Billed Charges for Rev 233 = $63.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,87.00,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $87.00 in Billed Charges for Rev 233 = $87.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,43.50,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $87.00 in Billed Charges for Rev 233 = $43.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,73.08,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $87.00 in Billed Charges for Rev 233 = $73.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,65.25,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $87.00 in Billed Charges for Rev 233 = $65.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,80.04,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $87.00 in Billed Charges for Rev 233 = $80.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,52.20,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.00 in Billed Charges for Rev 233 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,52.20,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.00 in Billed Charges for Rev 233 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,PREVEA HEALTH NETWORK,PREVEA360,52.20,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.00 in Billed Charges for Rev 233 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,52.20,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.00 in Billed Charges for Rev 233 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,55.53,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $87.00 in Billed Charges for Rev 233 = $55.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,62.64,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $87.00 in Billed Charges for Rev 233 = $62.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,48.11,,,,,,,42.2800,87.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $87.00 in Billed Charges for Rev 233 = $48.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,48.11,,,,,,,42.2800,87.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $87.00 in Billed Charges for Rev 233 = $48.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,48.11,,,,,,,42.2800,87.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $87.00 in Billed Charges for Rev 233 = $48.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,62.64,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $87.00 in Billed Charges for Rev 233 = $62.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,53.94,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $87.00 in Billed Charges for Rev 233 = $53.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,62.64,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $87.00 in Billed Charges for Rev 233 = $62.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,62.64,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $87.00 in Billed Charges for Rev 233 = $62.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC SURCHARGE IMCU/HR,233,RC,23300002,CDM,,,,,,both,,,87.0000,57.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,52.20,,,,,,,42.2800,87.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $87.00 in Billed Charges for Rev 233 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 250 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,72.08,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $106.00 in Billed Charges at 68% = $72.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM PPO,72.08,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $106.00 in Billed Charges at 68% = $72.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 250 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 250 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 250 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 250 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 250 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 250 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 250 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 250 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,67.31,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $106.00 in Billed Charges at 63.5% = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 250 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,67.31,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $106.00 in Billed Charges at 63.5% = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 250 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 250 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 250 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 250 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 250 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 250 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 250 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,58.62,,,,,,,51.5200,106.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $106.00 in Billed Charges for Rev 250 = $58.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,58.62,,,,,,,51.5200,106.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $106.00 in Billed Charges for Rev 250 = $58.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,58.62,,,,,,,51.5200,106.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $106.00 in Billed Charges for Rev 250 = $58.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 250 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 250 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 250 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 250 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 0.25 % SOLN 500 ML PLAS CONT,250,RC,0264-2304-10,CDM,,,,,,both,500.000000,ML,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,AETNA,AETNA HSHS,278.10,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $430.50 in Billed Charges for Rev 250 = $278.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,AETNA,ALL COMMERCIAL AETNA,430.50,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.50 in Billed Charges for Rev 250 = $430.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,ANTHEM,ANTHEM POS/HMO,292.74,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $430.50 in Billed Charges at 68% = $292.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,ANTHEM,ANTHEM PPO,292.74,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $430.50 in Billed Charges at 68% = $292.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,430.50,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.50 in Billed Charges for Rev 250 = $430.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,CENPATICO,ALL MEDICAID CENPATICO,430.50,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.50 in Billed Charges for Rev 250 = $430.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,365.93,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $430.50 in Billed Charges for Rev 250 = $365.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,CIGNA,ALL COMMERCIAL CIGNA,301.35,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $430.50 in Billed Charges for Rev 250 = $301.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,COFINITY,COFINITY,430.50,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.50 in Billed Charges for Rev 250 = $430.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,408.98,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $430.50 in Billed Charges for Rev 250 = $408.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,HEALTH CARE ALLIANCE,THE ALLIANCE,361.62,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $430.50 in Billed Charges for Rev 250 = $361.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,305.66,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $430.50 in Billed Charges for Rev 250 = $305.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,314.27,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $430.50 in Billed Charges for Rev 250 = $314.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,HSHS EMPLOYEES,HSHS EMPLOYEES,209.22,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $430.50 in Billed Charges for Rev 250 = $209.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,365.93,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $430.50 in Billed Charges for Rev 250 = $365.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,HUMANA,HUMANA CHOICE CARE HMO,273.37,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $430.50 in Billed Charges at 63.5% = $273.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,HUMANA,HUMANA CHOICE CARE PPO,365.93,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $430.50 in Billed Charges for Rev 250 = $365.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,HUMANA,HUMANA NATIIONAL POS HMO,273.37,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $430.50 in Billed Charges at 63.5% = $273.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,314.27,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $430.50 in Billed Charges for Rev 250 = $314.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,LIVE360,LIVE360 HSHS HEALTHY PLAN,430.50,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $430.50 in Billed Charges for Rev 250 = $430.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,215.25,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $430.50 in Billed Charges for Rev 250 = $215.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,361.62,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $430.50 in Billed Charges for Rev 250 = $361.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,322.88,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $430.50 in Billed Charges for Rev 250 = $322.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,396.06,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $430.50 in Billed Charges for Rev 250 = $396.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,258.30,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $430.50 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,258.30,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $430.50 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,PREVEA HEALTH NETWORK,PREVEA360,258.30,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $430.50 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,258.30,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $430.50 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,274.79,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $430.50 in Billed Charges for Rev 250 = $274.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,309.96,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $430.50 in Billed Charges for Rev 250 = $309.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,238.07,,,,,,,209.2200,430.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $430.50 in Billed Charges for Rev 250 = $238.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,UNITED HEALTHCARE,UHC ONEIDA NATION,238.07,,,,,,,209.2200,430.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $430.50 in Billed Charges for Rev 250 = $238.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,UNITED HEALTHCARE,UNITED HEALTHCARE,238.07,,,,,,,209.2200,430.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $430.50 in Billed Charges for Rev 250 = $238.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,309.96,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $430.50 in Billed Charges for Rev 250 = $309.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,266.91,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $430.50 in Billed Charges for Rev 250 = $266.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,309.96,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $430.50 in Billed Charges for Rev 250 = $309.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,309.96,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $430.50 in Billed Charges for Rev 250 = $309.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETIC ACID 5 % SOLN,250,RC,51552-055-06,CDM,,,,,,both,500.000000,ML,430.5000,284.1300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,258.30,,,,,,,209.2200,430.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $430.50 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,AETNA,AETNA HSHS,38.40,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $59.45 in Billed Charges for Rev 250 = $38.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,AETNA,ALL COMMERCIAL AETNA,59.45,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.45 in Billed Charges for Rev 250 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,ANTHEM,ANTHEM POS/HMO,40.43,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $59.45 in Billed Charges at 68% = $40.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,ANTHEM,ANTHEM PPO,40.43,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $59.45 in Billed Charges at 68% = $40.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,59.45,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.45 in Billed Charges for Rev 250 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,CENPATICO,ALL MEDICAID CENPATICO,59.45,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.45 in Billed Charges for Rev 250 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,50.53,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.45 in Billed Charges for Rev 250 = $50.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,CIGNA,ALL COMMERCIAL CIGNA,41.62,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $59.45 in Billed Charges for Rev 250 = $41.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,COFINITY,COFINITY,59.45,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.45 in Billed Charges for Rev 250 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,56.48,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $59.45 in Billed Charges for Rev 250 = $56.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,49.94,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $59.45 in Billed Charges for Rev 250 = $49.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,42.21,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $59.45 in Billed Charges for Rev 250 = $42.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,43.40,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $59.45 in Billed Charges for Rev 250 = $43.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,28.89,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $59.45 in Billed Charges for Rev 250 = $28.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,50.53,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.45 in Billed Charges for Rev 250 = $50.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,HUMANA,HUMANA CHOICE CARE HMO,37.75,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $59.45 in Billed Charges at 63.5% = $37.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,HUMANA,HUMANA CHOICE CARE PPO,50.53,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $59.45 in Billed Charges for Rev 250 = $50.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,HUMANA,HUMANA NATIIONAL POS HMO,37.75,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $59.45 in Billed Charges at 63.5% = $37.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,43.40,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $59.45 in Billed Charges for Rev 250 = $43.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,59.45,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $59.45 in Billed Charges for Rev 250 = $59.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,29.73,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $59.45 in Billed Charges for Rev 250 = $29.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,49.94,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $59.45 in Billed Charges for Rev 250 = $49.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,44.59,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $59.45 in Billed Charges for Rev 250 = $44.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,54.69,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $59.45 in Billed Charges for Rev 250 = $54.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,35.67,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.45 in Billed Charges for Rev 250 = $35.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,35.67,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.45 in Billed Charges for Rev 250 = $35.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,PREVEA HEALTH NETWORK,PREVEA360,35.67,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.45 in Billed Charges for Rev 250 = $35.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,35.67,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.45 in Billed Charges for Rev 250 = $35.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,37.95,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $59.45 in Billed Charges for Rev 250 = $37.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,42.80,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.45 in Billed Charges for Rev 250 = $42.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32.88,,,,,,,28.8900,59.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $59.45 in Billed Charges for Rev 250 = $32.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,32.88,,,,,,,28.8900,59.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $59.45 in Billed Charges for Rev 250 = $32.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,32.88,,,,,,,28.8900,59.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $59.45 in Billed Charges for Rev 250 = $32.88 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,42.80,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.45 in Billed Charges for Rev 250 = $42.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,36.86,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $59.45 in Billed Charges for Rev 250 = $36.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,42.80,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.45 in Billed Charges for Rev 250 = $42.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,42.80,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $59.45 in Billed Charges for Rev 250 = $42.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,63323-695-04,CDM,,,,,,both,4.000000,ML,59.4500,39.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,35.67,,,,,,,28.8900,59.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $59.45 in Billed Charges for Rev 250 = $35.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 250 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 250 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 250 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 250 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 250 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 250 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 250 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 250 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 250 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 250 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,250,RC,60687-395-79,CDM,,,,,,both,3.000000,ML,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,AETNA,AETNA HSHS,47.45,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $73.45 in Billed Charges for Rev 250 = $47.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,AETNA,ALL COMMERCIAL AETNA,73.45,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.45 in Billed Charges for Rev 250 = $73.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,ANTHEM,ANTHEM POS/HMO,49.95,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $73.45 in Billed Charges at 68% = $49.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,ANTHEM,ANTHEM PPO,49.95,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $73.45 in Billed Charges at 68% = $49.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,73.45,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.45 in Billed Charges for Rev 250 = $73.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,CENPATICO,ALL MEDICAID CENPATICO,73.45,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.45 in Billed Charges for Rev 250 = $73.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,62.43,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.45 in Billed Charges for Rev 250 = $62.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,CIGNA,ALL COMMERCIAL CIGNA,51.42,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $73.45 in Billed Charges for Rev 250 = $51.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,COFINITY,COFINITY,73.45,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.45 in Billed Charges for Rev 250 = $73.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,69.78,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $73.45 in Billed Charges for Rev 250 = $69.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,61.70,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.45 in Billed Charges for Rev 250 = $61.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.15,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $73.45 in Billed Charges for Rev 250 = $52.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,53.62,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.45 in Billed Charges for Rev 250 = $53.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,35.70,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $73.45 in Billed Charges for Rev 250 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,62.43,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.45 in Billed Charges for Rev 250 = $62.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,HUMANA,HUMANA CHOICE CARE HMO,46.64,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $73.45 in Billed Charges at 63.5% = $46.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,HUMANA,HUMANA CHOICE CARE PPO,62.43,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.45 in Billed Charges for Rev 250 = $62.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,HUMANA,HUMANA NATIIONAL POS HMO,46.64,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $73.45 in Billed Charges at 63.5% = $46.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,53.62,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.45 in Billed Charges for Rev 250 = $53.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,73.45,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.45 in Billed Charges for Rev 250 = $73.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,36.73,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $73.45 in Billed Charges for Rev 250 = $36.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,61.70,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.45 in Billed Charges for Rev 250 = $61.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.09,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $73.45 in Billed Charges for Rev 250 = $55.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,67.57,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $73.45 in Billed Charges for Rev 250 = $67.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,44.07,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.45 in Billed Charges for Rev 250 = $44.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,44.07,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.45 in Billed Charges for Rev 250 = $44.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,PREVEA HEALTH NETWORK,PREVEA360,44.07,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.45 in Billed Charges for Rev 250 = $44.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,44.07,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.45 in Billed Charges for Rev 250 = $44.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,46.88,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $73.45 in Billed Charges for Rev 250 = $46.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,52.88,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.45 in Billed Charges for Rev 250 = $52.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,40.62,,,,,,,35.7000,73.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.45 in Billed Charges for Rev 250 = $40.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,40.62,,,,,,,35.7000,73.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.45 in Billed Charges for Rev 250 = $40.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,40.62,,,,,,,35.7000,73.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.45 in Billed Charges for Rev 250 = $40.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,52.88,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.45 in Billed Charges for Rev 250 = $52.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.54,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $73.45 in Billed Charges for Rev 250 = $45.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,52.88,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.45 in Billed Charges for Rev 250 = $52.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,52.88,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.45 in Billed Charges for Rev 250 = $52.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU,250,RC,69374-309-20,CDM,,,,,,both,20.000000,ML,73.4500,48.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.07,,,,,,,35.7000,73.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.45 in Billed Charges for Rev 250 = $44.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,AETNA,AETNA HSHS,44.51,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $68.90 in Billed Charges for Rev 250 = $44.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,AETNA,ALL COMMERCIAL AETNA,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 250 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,ANTHEM,ANTHEM POS/HMO,46.85,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.90 in Billed Charges at 68% = $46.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,ANTHEM,ANTHEM PPO,46.85,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.90 in Billed Charges at 68% = $46.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 250 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,CENPATICO,ALL MEDICAID CENPATICO,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 250 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.57,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.90 in Billed Charges for Rev 250 = $58.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,CIGNA,ALL COMMERCIAL CIGNA,48.23,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $68.90 in Billed Charges for Rev 250 = $48.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,COFINITY,COFINITY,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 250 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,65.46,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $68.90 in Billed Charges for Rev 250 = $65.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,57.88,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.90 in Billed Charges for Rev 250 = $57.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.92,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $68.90 in Billed Charges for Rev 250 = $48.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,50.30,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.90 in Billed Charges for Rev 250 = $50.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,33.49,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $68.90 in Billed Charges for Rev 250 = $33.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.57,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.90 in Billed Charges for Rev 250 = $58.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,HUMANA,HUMANA CHOICE CARE HMO,43.75,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.90 in Billed Charges at 63.5% = $43.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,HUMANA,HUMANA CHOICE CARE PPO,58.57,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.90 in Billed Charges for Rev 250 = $58.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,HUMANA,HUMANA NATIIONAL POS HMO,43.75,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.90 in Billed Charges at 63.5% = $43.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,50.30,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.90 in Billed Charges for Rev 250 = $50.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,68.90,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.90 in Billed Charges for Rev 250 = $68.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.45,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $68.90 in Billed Charges for Rev 250 = $34.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.88,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.90 in Billed Charges for Rev 250 = $57.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.68,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $68.90 in Billed Charges for Rev 250 = $51.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,63.39,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $68.90 in Billed Charges for Rev 250 = $63.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,41.34,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.90 in Billed Charges for Rev 250 = $41.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,41.34,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.90 in Billed Charges for Rev 250 = $41.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,PREVEA HEALTH NETWORK,PREVEA360,41.34,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.90 in Billed Charges for Rev 250 = $41.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,41.34,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.90 in Billed Charges for Rev 250 = $41.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.98,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $68.90 in Billed Charges for Rev 250 = $43.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.61,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.90 in Billed Charges for Rev 250 = $49.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,38.10,,,,,,,33.4900,68.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.90 in Billed Charges for Rev 250 = $38.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,38.10,,,,,,,33.4900,68.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.90 in Billed Charges for Rev 250 = $38.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,38.10,,,,,,,33.4900,68.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.90 in Billed Charges for Rev 250 = $38.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.61,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.90 in Billed Charges for Rev 250 = $49.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.72,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $68.90 in Billed Charges for Rev 250 = $42.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.61,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.90 in Billed Charges for Rev 250 = $49.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.61,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.90 in Billed Charges for Rev 250 = $49.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARFORMOTEROL 15 MCG/2ML NEBU,250,RC,69097-168-87,CDM,,,,,,both,2.000000,ML,68.9000,45.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,41.34,,,,,,,33.4900,68.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.90 in Billed Charges for Rev 250 = $41.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,AETNA,AETNA HSHS,109.92,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $170.15 in Billed Charges for Rev 250 = $109.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,AETNA,ALL COMMERCIAL AETNA,170.15,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.15 in Billed Charges for Rev 250 = $170.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,ANTHEM,ANTHEM POS/HMO,115.70,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $170.15 in Billed Charges at 68% = $115.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,ANTHEM,ANTHEM PPO,115.70,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $170.15 in Billed Charges at 68% = $115.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,170.15,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.15 in Billed Charges for Rev 250 = $170.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,CENPATICO,ALL MEDICAID CENPATICO,170.15,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.15 in Billed Charges for Rev 250 = $170.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,144.63,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $170.15 in Billed Charges for Rev 250 = $144.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,CIGNA,ALL COMMERCIAL CIGNA,119.11,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $170.15 in Billed Charges for Rev 250 = $119.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,COFINITY,COFINITY,170.15,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.15 in Billed Charges for Rev 250 = $170.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,161.64,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $170.15 in Billed Charges for Rev 250 = $161.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,HEALTH CARE ALLIANCE,THE ALLIANCE,142.93,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $170.15 in Billed Charges for Rev 250 = $142.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,120.81,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $170.15 in Billed Charges for Rev 250 = $120.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,124.21,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $170.15 in Billed Charges for Rev 250 = $124.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,HSHS EMPLOYEES,HSHS EMPLOYEES,82.69,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $170.15 in Billed Charges for Rev 250 = $82.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,144.63,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $170.15 in Billed Charges for Rev 250 = $144.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,HUMANA,HUMANA CHOICE CARE HMO,108.05,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $170.15 in Billed Charges at 63.5% = $108.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,HUMANA,HUMANA CHOICE CARE PPO,144.63,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $170.15 in Billed Charges for Rev 250 = $144.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,HUMANA,HUMANA NATIIONAL POS HMO,108.05,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $170.15 in Billed Charges at 63.5% = $108.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,124.21,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $170.15 in Billed Charges for Rev 250 = $124.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,LIVE360,LIVE360 HSHS HEALTHY PLAN,170.15,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $170.15 in Billed Charges for Rev 250 = $170.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,85.08,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $170.15 in Billed Charges for Rev 250 = $85.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,142.93,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $170.15 in Billed Charges for Rev 250 = $142.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,127.61,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $170.15 in Billed Charges for Rev 250 = $127.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,156.54,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $170.15 in Billed Charges for Rev 250 = $156.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,102.09,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $170.15 in Billed Charges for Rev 250 = $102.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,102.09,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $170.15 in Billed Charges for Rev 250 = $102.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,PREVEA HEALTH NETWORK,PREVEA360,102.09,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $170.15 in Billed Charges for Rev 250 = $102.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,102.09,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $170.15 in Billed Charges for Rev 250 = $102.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,108.61,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $170.15 in Billed Charges for Rev 250 = $108.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,122.51,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $170.15 in Billed Charges for Rev 250 = $122.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,94.09,,,,,,,82.6900,170.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $170.15 in Billed Charges for Rev 250 = $94.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,UNITED HEALTHCARE,UHC ONEIDA NATION,94.09,,,,,,,82.6900,170.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $170.15 in Billed Charges for Rev 250 = $94.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,UNITED HEALTHCARE,UNITED HEALTHCARE,94.09,,,,,,,82.6900,170.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $170.15 in Billed Charges for Rev 250 = $94.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,122.51,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $170.15 in Billed Charges for Rev 250 = $122.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,105.49,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $170.15 in Billed Charges for Rev 250 = $105.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,122.51,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $170.15 in Billed Charges for Rev 250 = $122.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,122.51,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $170.15 in Billed Charges for Rev 250 = $122.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,0065-0817-02,CDM,,,,,,both,2.000000,ML,170.1500,112.3000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,102.09,,,,,,,82.6900,170.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $170.15 in Billed Charges for Rev 250 = $102.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,AETNA,AETNA HSHS,99.87,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $154.60 in Billed Charges for Rev 250 = $99.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,AETNA,ALL COMMERCIAL AETNA,154.60,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.60 in Billed Charges for Rev 250 = $154.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,ANTHEM,ANTHEM POS/HMO,105.13,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $154.60 in Billed Charges at 68% = $105.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,ANTHEM,ANTHEM PPO,105.13,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $154.60 in Billed Charges at 68% = $105.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,154.60,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.60 in Billed Charges for Rev 250 = $154.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,CENPATICO,ALL MEDICAID CENPATICO,154.60,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.60 in Billed Charges for Rev 250 = $154.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,131.41,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $154.60 in Billed Charges for Rev 250 = $131.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,CIGNA,ALL COMMERCIAL CIGNA,108.22,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $154.60 in Billed Charges for Rev 250 = $108.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,COFINITY,COFINITY,154.60,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.60 in Billed Charges for Rev 250 = $154.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,146.87,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $154.60 in Billed Charges for Rev 250 = $146.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,129.86,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $154.60 in Billed Charges for Rev 250 = $129.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,109.77,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $154.60 in Billed Charges for Rev 250 = $109.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,112.86,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $154.60 in Billed Charges for Rev 250 = $112.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,75.14,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $154.60 in Billed Charges for Rev 250 = $75.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,131.41,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $154.60 in Billed Charges for Rev 250 = $131.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,HUMANA,HUMANA CHOICE CARE HMO,98.17,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $154.60 in Billed Charges at 63.5% = $98.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,HUMANA,HUMANA CHOICE CARE PPO,131.41,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $154.60 in Billed Charges for Rev 250 = $131.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,HUMANA,HUMANA NATIIONAL POS HMO,98.17,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $154.60 in Billed Charges at 63.5% = $98.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,112.86,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $154.60 in Billed Charges for Rev 250 = $112.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,154.60,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $154.60 in Billed Charges for Rev 250 = $154.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,77.30,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $154.60 in Billed Charges for Rev 250 = $77.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,129.86,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $154.60 in Billed Charges for Rev 250 = $129.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,115.95,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $154.60 in Billed Charges for Rev 250 = $115.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,142.23,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $154.60 in Billed Charges for Rev 250 = $142.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,92.76,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $154.60 in Billed Charges for Rev 250 = $92.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,92.76,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $154.60 in Billed Charges for Rev 250 = $92.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,PREVEA HEALTH NETWORK,PREVEA360,92.76,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $154.60 in Billed Charges for Rev 250 = $92.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,92.76,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $154.60 in Billed Charges for Rev 250 = $92.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,98.68,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $154.60 in Billed Charges for Rev 250 = $98.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,111.31,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $154.60 in Billed Charges for Rev 250 = $111.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,85.49,,,,,,,75.1400,154.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $154.60 in Billed Charges for Rev 250 = $85.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,85.49,,,,,,,75.1400,154.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $154.60 in Billed Charges for Rev 250 = $85.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,85.49,,,,,,,75.1400,154.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $154.60 in Billed Charges for Rev 250 = $85.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,111.31,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $154.60 in Billed Charges for Rev 250 = $111.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,95.85,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $154.60 in Billed Charges for Rev 250 = $95.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,111.31,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $154.60 in Billed Charges for Rev 250 = $111.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,111.31,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $154.60 in Billed Charges for Rev 250 = $111.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 2 ML BOTTLE,250,RC,60505-6226-0,CDM,,,,,,both,2.000000,ML,154.6000,102.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,92.76,,,,,,,75.1400,154.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $154.60 in Billed Charges for Rev 250 = $92.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,AETNA,AETNA HSHS,121.84,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $188.60 in Billed Charges for Rev 250 = $121.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,AETNA,ALL COMMERCIAL AETNA,188.60,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.60 in Billed Charges for Rev 250 = $188.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,ANTHEM,ANTHEM POS/HMO,128.25,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $188.60 in Billed Charges at 68% = $128.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,ANTHEM,ANTHEM PPO,128.25,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $188.60 in Billed Charges at 68% = $128.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,188.60,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.60 in Billed Charges for Rev 250 = $188.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,CENPATICO,ALL MEDICAID CENPATICO,188.60,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.60 in Billed Charges for Rev 250 = $188.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,160.31,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.60 in Billed Charges for Rev 250 = $160.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,CIGNA,ALL COMMERCIAL CIGNA,132.02,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $188.60 in Billed Charges for Rev 250 = $132.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,COFINITY,COFINITY,188.60,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.60 in Billed Charges for Rev 250 = $188.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,179.17,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $188.60 in Billed Charges for Rev 250 = $179.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,158.42,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $188.60 in Billed Charges for Rev 250 = $158.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,133.91,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $188.60 in Billed Charges for Rev 250 = $133.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,137.68,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $188.60 in Billed Charges for Rev 250 = $137.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,91.66,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $188.60 in Billed Charges for Rev 250 = $91.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,160.31,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.60 in Billed Charges for Rev 250 = $160.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,HUMANA,HUMANA CHOICE CARE HMO,119.76,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $188.60 in Billed Charges at 63.5% = $119.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,HUMANA,HUMANA CHOICE CARE PPO,160.31,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.60 in Billed Charges for Rev 250 = $160.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,HUMANA,HUMANA NATIIONAL POS HMO,119.76,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $188.60 in Billed Charges at 63.5% = $119.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,137.68,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $188.60 in Billed Charges for Rev 250 = $137.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,188.60,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.60 in Billed Charges for Rev 250 = $188.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,94.30,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $188.60 in Billed Charges for Rev 250 = $94.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,158.42,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $188.60 in Billed Charges for Rev 250 = $158.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,141.45,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $188.60 in Billed Charges for Rev 250 = $141.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,173.51,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $188.60 in Billed Charges for Rev 250 = $173.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,113.16,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.60 in Billed Charges for Rev 250 = $113.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,113.16,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.60 in Billed Charges for Rev 250 = $113.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,PREVEA HEALTH NETWORK,PREVEA360,113.16,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.60 in Billed Charges for Rev 250 = $113.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,113.16,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.60 in Billed Charges for Rev 250 = $113.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,120.38,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $188.60 in Billed Charges for Rev 250 = $120.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,135.79,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.60 in Billed Charges for Rev 250 = $135.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,104.30,,,,,,,91.6600,188.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $188.60 in Billed Charges for Rev 250 = $104.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,104.30,,,,,,,91.6600,188.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $188.60 in Billed Charges for Rev 250 = $104.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,104.30,,,,,,,91.6600,188.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $188.60 in Billed Charges for Rev 250 = $104.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,135.79,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.60 in Billed Charges for Rev 250 = $135.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,116.93,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $188.60 in Billed Charges for Rev 250 = $116.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,135.79,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.60 in Billed Charges for Rev 250 = $135.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,135.79,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.60 in Billed Charges for Rev 250 = $135.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60505-6226-1,CDM,,,,,,both,5.000000,ML,188.6000,124.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,113.16,,,,,,,91.6600,188.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.60 in Billed Charges for Rev 250 = $113.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACTERIOSTATIC WATER SOLN,250,RC,0409-3977-01,CDM,,,,,,both,30.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,AETNA,AETNA HSHS,96.64,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $149.60 in Billed Charges for Rev 250 = $96.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,AETNA,ALL COMMERCIAL AETNA,149.60,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.60 in Billed Charges for Rev 250 = $149.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,ANTHEM,ANTHEM POS/HMO,101.73,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $149.60 in Billed Charges at 68% = $101.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,ANTHEM,ANTHEM PPO,101.73,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $149.60 in Billed Charges at 68% = $101.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,149.60,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.60 in Billed Charges for Rev 250 = $149.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,CENPATICO,ALL MEDICAID CENPATICO,149.60,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.60 in Billed Charges for Rev 250 = $149.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.16,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $149.60 in Billed Charges for Rev 250 = $127.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,CIGNA,ALL COMMERCIAL CIGNA,104.72,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $149.60 in Billed Charges for Rev 250 = $104.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,COFINITY,COFINITY,149.60,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.60 in Billed Charges for Rev 250 = $149.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,142.12,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $149.60 in Billed Charges for Rev 250 = $142.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,125.66,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $149.60 in Billed Charges for Rev 250 = $125.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.22,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $149.60 in Billed Charges for Rev 250 = $106.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.21,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $149.60 in Billed Charges for Rev 250 = $109.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,72.71,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $149.60 in Billed Charges for Rev 250 = $72.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.16,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $149.60 in Billed Charges for Rev 250 = $127.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,HUMANA,HUMANA CHOICE CARE HMO,95.00,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $149.60 in Billed Charges at 63.5% = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,HUMANA,HUMANA CHOICE CARE PPO,127.16,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $149.60 in Billed Charges for Rev 250 = $127.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,HUMANA,HUMANA NATIIONAL POS HMO,95.00,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $149.60 in Billed Charges at 63.5% = $95.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.21,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $149.60 in Billed Charges for Rev 250 = $109.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,149.60,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.60 in Billed Charges for Rev 250 = $149.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,74.80,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $149.60 in Billed Charges for Rev 250 = $74.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,125.66,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $149.60 in Billed Charges for Rev 250 = $125.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.20,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $149.60 in Billed Charges for Rev 250 = $112.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,137.63,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $149.60 in Billed Charges for Rev 250 = $137.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,89.76,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.60 in Billed Charges for Rev 250 = $89.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,89.76,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.60 in Billed Charges for Rev 250 = $89.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,PREVEA HEALTH NETWORK,PREVEA360,89.76,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.60 in Billed Charges for Rev 250 = $89.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,89.76,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.60 in Billed Charges for Rev 250 = $89.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.49,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $149.60 in Billed Charges for Rev 250 = $95.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,107.71,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $149.60 in Billed Charges for Rev 250 = $107.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,82.73,,,,,,,72.7100,149.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $149.60 in Billed Charges for Rev 250 = $82.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,82.73,,,,,,,72.7100,149.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $149.60 in Billed Charges for Rev 250 = $82.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,82.73,,,,,,,72.7100,149.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $149.60 in Billed Charges for Rev 250 = $82.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,107.71,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $149.60 in Billed Charges for Rev 250 = $107.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,92.75,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $149.60 in Billed Charges for Rev 250 = $92.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,107.71,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $149.60 in Billed Charges for Rev 250 = $107.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,107.71,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $149.60 in Billed Charges for Rev 250 = $107.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 500 ML GLASS CONT,250,RC,0065-0795-50,CDM,,,,,,both,500.000000,ML,149.6000,98.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,89.76,,,,,,,72.7100,149.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.60 in Billed Charges for Rev 250 = $89.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,AETNA,AETNA HSHS,23.39,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $36.20 in Billed Charges for Rev 250 = $23.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,AETNA,ALL COMMERCIAL AETNA,36.20,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.20 in Billed Charges for Rev 250 = $36.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,ANTHEM,ANTHEM POS/HMO,24.62,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $36.20 in Billed Charges at 68% = $24.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,ANTHEM,ANTHEM PPO,24.62,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $36.20 in Billed Charges at 68% = $24.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,36.20,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.20 in Billed Charges for Rev 250 = $36.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,CENPATICO,ALL MEDICAID CENPATICO,36.20,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.20 in Billed Charges for Rev 250 = $36.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,30.77,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.20 in Billed Charges for Rev 250 = $30.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,CIGNA,ALL COMMERCIAL CIGNA,25.34,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $36.20 in Billed Charges for Rev 250 = $25.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,COFINITY,COFINITY,36.20,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.20 in Billed Charges for Rev 250 = $36.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,34.39,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $36.20 in Billed Charges for Rev 250 = $34.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,HEALTH CARE ALLIANCE,THE ALLIANCE,30.41,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $36.20 in Billed Charges for Rev 250 = $30.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,25.70,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $36.20 in Billed Charges for Rev 250 = $25.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,26.43,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $36.20 in Billed Charges for Rev 250 = $26.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,HSHS EMPLOYEES,HSHS EMPLOYEES,17.59,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $36.20 in Billed Charges for Rev 250 = $17.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,30.77,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.20 in Billed Charges for Rev 250 = $30.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,HUMANA,HUMANA CHOICE CARE HMO,22.99,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $36.20 in Billed Charges at 63.5% = $22.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,HUMANA,HUMANA CHOICE CARE PPO,30.77,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $36.20 in Billed Charges for Rev 250 = $30.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,HUMANA,HUMANA NATIIONAL POS HMO,22.99,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $36.20 in Billed Charges at 63.5% = $22.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,26.43,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $36.20 in Billed Charges for Rev 250 = $26.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,LIVE360,LIVE360 HSHS HEALTHY PLAN,36.20,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $36.20 in Billed Charges for Rev 250 = $36.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,18.10,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $36.20 in Billed Charges for Rev 250 = $18.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,30.41,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $36.20 in Billed Charges for Rev 250 = $30.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,27.15,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $36.20 in Billed Charges for Rev 250 = $27.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,33.30,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $36.20 in Billed Charges for Rev 250 = $33.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.72,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $36.20 in Billed Charges for Rev 250 = $21.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.72,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $36.20 in Billed Charges for Rev 250 = $21.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,PREVEA HEALTH NETWORK,PREVEA360,21.72,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $36.20 in Billed Charges for Rev 250 = $21.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.72,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $36.20 in Billed Charges for Rev 250 = $21.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,23.11,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $36.20 in Billed Charges for Rev 250 = $23.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,26.06,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.20 in Billed Charges for Rev 250 = $26.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,20.02,,,,,,,17.5900,36.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $36.20 in Billed Charges for Rev 250 = $20.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,UNITED HEALTHCARE,UHC ONEIDA NATION,20.02,,,,,,,17.5900,36.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $36.20 in Billed Charges for Rev 250 = $20.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,UNITED HEALTHCARE,UNITED HEALTHCARE,20.02,,,,,,,17.5900,36.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $36.20 in Billed Charges for Rev 250 = $20.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,26.06,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.20 in Billed Charges for Rev 250 = $26.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,22.44,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $36.20 in Billed Charges for Rev 250 = $22.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,26.06,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.20 in Billed Charges for Rev 250 = $26.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,26.06,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $36.20 in Billed Charges for Rev 250 = $26.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE 20 % 20 % SOLN,250,RC,0283-0610-43,CDM,,,,,,both,1.000000,EA,36.2000,23.8900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,21.72,,,,,,,17.5900,36.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $36.20 in Billed Charges for Rev 250 = $21.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,AETNA,AETNA HSHS,496.68,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $768.85 in Billed Charges for Rev 250 = $496.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,AETNA,ALL COMMERCIAL AETNA,768.85,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $768.85 in Billed Charges for Rev 250 = $768.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,ANTHEM,ANTHEM POS/HMO,522.82,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $768.85 in Billed Charges at 68% = $522.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,ANTHEM,ANTHEM PPO,522.82,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $768.85 in Billed Charges at 68% = $522.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,768.85,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $768.85 in Billed Charges for Rev 250 = $768.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,CENPATICO,ALL MEDICAID CENPATICO,768.85,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $768.85 in Billed Charges for Rev 250 = $768.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,653.52,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $768.85 in Billed Charges for Rev 250 = $653.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,CIGNA,ALL COMMERCIAL CIGNA,538.20,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $768.85 in Billed Charges for Rev 250 = $538.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,COFINITY,COFINITY,768.85,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $768.85 in Billed Charges for Rev 250 = $768.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,730.41,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $768.85 in Billed Charges for Rev 250 = $730.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,645.83,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $768.85 in Billed Charges for Rev 250 = $645.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,545.88,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $768.85 in Billed Charges for Rev 250 = $545.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,561.26,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $768.85 in Billed Charges for Rev 250 = $561.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,373.66,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $768.85 in Billed Charges for Rev 250 = $373.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,653.52,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $768.85 in Billed Charges for Rev 250 = $653.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,HUMANA,HUMANA CHOICE CARE HMO,488.22,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $768.85 in Billed Charges at 63.5% = $488.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,HUMANA,HUMANA CHOICE CARE PPO,653.52,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $768.85 in Billed Charges for Rev 250 = $653.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,HUMANA,HUMANA NATIIONAL POS HMO,488.22,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $768.85 in Billed Charges at 63.5% = $488.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,561.26,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $768.85 in Billed Charges for Rev 250 = $561.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,768.85,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $768.85 in Billed Charges for Rev 250 = $768.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,384.43,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $768.85 in Billed Charges for Rev 250 = $384.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,645.83,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $768.85 in Billed Charges for Rev 250 = $645.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,576.64,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $768.85 in Billed Charges for Rev 250 = $576.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,707.34,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $768.85 in Billed Charges for Rev 250 = $707.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,461.31,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $768.85 in Billed Charges for Rev 250 = $461.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,461.31,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $768.85 in Billed Charges for Rev 250 = $461.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,PREVEA HEALTH NETWORK,PREVEA360,461.31,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $768.85 in Billed Charges for Rev 250 = $461.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,461.31,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $768.85 in Billed Charges for Rev 250 = $461.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,490.76,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $768.85 in Billed Charges for Rev 250 = $490.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,553.57,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $768.85 in Billed Charges for Rev 250 = $553.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,425.17,,,,,,,373.6600,768.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $768.85 in Billed Charges for Rev 250 = $425.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,425.17,,,,,,,373.6600,768.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $768.85 in Billed Charges for Rev 250 = $425.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,425.17,,,,,,,373.6600,768.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $768.85 in Billed Charges for Rev 250 = $425.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,553.57,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $768.85 in Billed Charges for Rev 250 = $553.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,476.69,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $768.85 in Billed Charges for Rev 250 = $476.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,553.57,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $768.85 in Billed Charges for Rev 250 = $553.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,553.57,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $768.85 in Billed Charges for Rev 250 = $553.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRILLIANT BLUE G 0.025 % SOSY,250,RC,68803-722-05,CDM,,,,,,both,0.500000,ML,768.8500,507.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,461.31,,,,,,,373.6600,768.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $768.85 in Billed Charges for Rev 250 = $461.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,AETNA,AETNA HSHS,18.41,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $28.50 in Billed Charges for Rev 250 = $18.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,AETNA,ALL COMMERCIAL AETNA,28.50,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.50 in Billed Charges for Rev 250 = $28.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,ANTHEM,ANTHEM POS/HMO,19.38,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $28.50 in Billed Charges at 68% = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,ANTHEM,ANTHEM PPO,19.38,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $28.50 in Billed Charges at 68% = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,28.50,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.50 in Billed Charges for Rev 250 = $28.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,CENPATICO,ALL MEDICAID CENPATICO,28.50,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.50 in Billed Charges for Rev 250 = $28.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,24.23,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.50 in Billed Charges for Rev 250 = $24.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,CIGNA,ALL COMMERCIAL CIGNA,19.95,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $28.50 in Billed Charges for Rev 250 = $19.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,COFINITY,COFINITY,28.50,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.50 in Billed Charges for Rev 250 = $28.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,27.08,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $28.50 in Billed Charges for Rev 250 = $27.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,23.94,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $28.50 in Billed Charges for Rev 250 = $23.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,20.24,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $28.50 in Billed Charges for Rev 250 = $20.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,20.81,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $28.50 in Billed Charges for Rev 250 = $20.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,13.85,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $28.50 in Billed Charges for Rev 250 = $13.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,24.23,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.50 in Billed Charges for Rev 250 = $24.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,HUMANA,HUMANA CHOICE CARE HMO,18.10,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $28.50 in Billed Charges at 63.5% = $18.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,HUMANA,HUMANA CHOICE CARE PPO,24.23,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $28.50 in Billed Charges for Rev 250 = $24.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,HUMANA,HUMANA NATIIONAL POS HMO,18.10,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $28.50 in Billed Charges at 63.5% = $18.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,20.81,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $28.50 in Billed Charges for Rev 250 = $20.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,28.50,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $28.50 in Billed Charges for Rev 250 = $28.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,14.25,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $28.50 in Billed Charges for Rev 250 = $14.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,23.94,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $28.50 in Billed Charges for Rev 250 = $23.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,21.38,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $28.50 in Billed Charges for Rev 250 = $21.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,26.22,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $28.50 in Billed Charges for Rev 250 = $26.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,17.10,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $28.50 in Billed Charges for Rev 250 = $17.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,17.10,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $28.50 in Billed Charges for Rev 250 = $17.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,PREVEA HEALTH NETWORK,PREVEA360,17.10,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $28.50 in Billed Charges for Rev 250 = $17.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,17.10,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $28.50 in Billed Charges for Rev 250 = $17.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,18.19,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $28.50 in Billed Charges for Rev 250 = $18.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,20.52,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.50 in Billed Charges for Rev 250 = $20.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,15.76,,,,,,,13.8500,28.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $28.50 in Billed Charges for Rev 250 = $15.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,UNITED HEALTHCARE,UHC ONEIDA NATION,15.76,,,,,,,13.8500,28.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $28.50 in Billed Charges for Rev 250 = $15.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,UNITED HEALTHCARE,UNITED HEALTHCARE,15.76,,,,,,,13.8500,28.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $28.50 in Billed Charges for Rev 250 = $15.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,20.52,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.50 in Billed Charges for Rev 250 = $20.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,17.67,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $28.50 in Billed Charges for Rev 250 = $17.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,20.52,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.50 in Billed Charges for Rev 250 = $20.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,20.52,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $28.50 in Billed Charges for Rev 250 = $20.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 10 ML BOTTLE,250,RC,70069-232-01,CDM,,,,,,both,10.000000,ML,28.5000,18.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,17.10,,,,,,,13.8500,28.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $28.50 in Billed Charges for Rev 250 = $17.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,AETNA,AETNA HSHS,27.46,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $42.50 in Billed Charges for Rev 250 = $27.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,AETNA,ALL COMMERCIAL AETNA,42.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.50 in Billed Charges for Rev 250 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,ANTHEM,ANTHEM POS/HMO,28.90,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $42.50 in Billed Charges at 68% = $28.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,ANTHEM,ANTHEM PPO,28.90,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $42.50 in Billed Charges at 68% = $28.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,42.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.50 in Billed Charges for Rev 250 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,CENPATICO,ALL MEDICAID CENPATICO,42.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.50 in Billed Charges for Rev 250 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,36.13,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $42.50 in Billed Charges for Rev 250 = $36.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,CIGNA,ALL COMMERCIAL CIGNA,29.75,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $42.50 in Billed Charges for Rev 250 = $29.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,COFINITY,COFINITY,42.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.50 in Billed Charges for Rev 250 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,40.38,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $42.50 in Billed Charges for Rev 250 = $40.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,35.70,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $42.50 in Billed Charges for Rev 250 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,30.18,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $42.50 in Billed Charges for Rev 250 = $30.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,31.03,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $42.50 in Billed Charges for Rev 250 = $31.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,20.66,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $42.50 in Billed Charges for Rev 250 = $20.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,36.13,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $42.50 in Billed Charges for Rev 250 = $36.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,HUMANA,HUMANA CHOICE CARE HMO,26.99,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $42.50 in Billed Charges at 63.5% = $26.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,HUMANA,HUMANA CHOICE CARE PPO,36.13,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $42.50 in Billed Charges for Rev 250 = $36.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,HUMANA,HUMANA NATIIONAL POS HMO,26.99,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $42.50 in Billed Charges at 63.5% = $26.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,31.03,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $42.50 in Billed Charges for Rev 250 = $31.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,42.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $42.50 in Billed Charges for Rev 250 = $42.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,21.25,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $42.50 in Billed Charges for Rev 250 = $21.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,35.70,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $42.50 in Billed Charges for Rev 250 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,31.88,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $42.50 in Billed Charges for Rev 250 = $31.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,39.10,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $42.50 in Billed Charges for Rev 250 = $39.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,25.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $42.50 in Billed Charges for Rev 250 = $25.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,25.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $42.50 in Billed Charges for Rev 250 = $25.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,PREVEA HEALTH NETWORK,PREVEA360,25.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $42.50 in Billed Charges for Rev 250 = $25.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,25.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $42.50 in Billed Charges for Rev 250 = $25.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,27.13,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $42.50 in Billed Charges for Rev 250 = $27.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,30.60,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $42.50 in Billed Charges for Rev 250 = $30.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,23.50,,,,,,,20.6600,42.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $42.50 in Billed Charges for Rev 250 = $23.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,UNITED HEALTHCARE,UHC ONEIDA NATION,23.50,,,,,,,20.6600,42.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $42.50 in Billed Charges for Rev 250 = $23.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,UNITED HEALTHCARE,UNITED HEALTHCARE,23.50,,,,,,,20.6600,42.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $42.50 in Billed Charges for Rev 250 = $23.50 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,30.60,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $42.50 in Billed Charges for Rev 250 = $30.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,26.35,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $42.50 in Billed Charges for Rev 250 = $26.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,30.60,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $42.50 in Billed Charges for Rev 250 = $30.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,30.60,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $42.50 in Billed Charges for Rev 250 = $30.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BRIMONIDINE 0.2 % SOLN 5 ML BOTTLE,250,RC,70069-231-01,CDM,,,,,,both,5.000000,ML,42.5000,28.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,25.50,,,,,,,20.6600,42.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $42.50 in Billed Charges for Rev 250 = $25.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,AETNA,AETNA HSHS,23.00,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $35.60 in Billed Charges for Rev 250 = $23.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,AETNA,ALL COMMERCIAL AETNA,35.60,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.60 in Billed Charges for Rev 250 = $35.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,ANTHEM,ANTHEM POS/HMO,24.21,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $35.60 in Billed Charges at 68% = $24.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,ANTHEM,ANTHEM PPO,24.21,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $35.60 in Billed Charges at 68% = $24.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,35.60,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.60 in Billed Charges for Rev 250 = $35.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,CENPATICO,ALL MEDICAID CENPATICO,35.60,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.60 in Billed Charges for Rev 250 = $35.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,30.26,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.60 in Billed Charges for Rev 250 = $30.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,CIGNA,ALL COMMERCIAL CIGNA,24.92,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $35.60 in Billed Charges for Rev 250 = $24.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,COFINITY,COFINITY,35.60,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.60 in Billed Charges for Rev 250 = $35.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,33.82,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $35.60 in Billed Charges for Rev 250 = $33.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,HEALTH CARE ALLIANCE,THE ALLIANCE,29.90,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.60 in Billed Charges for Rev 250 = $29.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,25.28,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $35.60 in Billed Charges for Rev 250 = $25.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,25.99,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.60 in Billed Charges for Rev 250 = $25.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,HSHS EMPLOYEES,HSHS EMPLOYEES,17.30,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $35.60 in Billed Charges for Rev 250 = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,30.26,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.60 in Billed Charges for Rev 250 = $30.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,HUMANA,HUMANA CHOICE CARE HMO,22.61,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $35.60 in Billed Charges at 63.5% = $22.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,HUMANA,HUMANA CHOICE CARE PPO,30.26,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $35.60 in Billed Charges for Rev 250 = $30.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,HUMANA,HUMANA NATIIONAL POS HMO,22.61,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $35.60 in Billed Charges at 63.5% = $22.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,25.99,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $35.60 in Billed Charges for Rev 250 = $25.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,LIVE360,LIVE360 HSHS HEALTHY PLAN,35.60,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $35.60 in Billed Charges for Rev 250 = $35.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,17.80,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $35.60 in Billed Charges for Rev 250 = $17.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,29.90,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $35.60 in Billed Charges for Rev 250 = $29.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,26.70,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $35.60 in Billed Charges for Rev 250 = $26.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,32.75,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $35.60 in Billed Charges for Rev 250 = $32.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,21.36,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.60 in Billed Charges for Rev 250 = $21.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,21.36,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.60 in Billed Charges for Rev 250 = $21.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,PREVEA HEALTH NETWORK,PREVEA360,21.36,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.60 in Billed Charges for Rev 250 = $21.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,21.36,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.60 in Billed Charges for Rev 250 = $21.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,22.72,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $35.60 in Billed Charges for Rev 250 = $22.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,25.63,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.60 in Billed Charges for Rev 250 = $25.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,19.69,,,,,,,17.3000,35.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.60 in Billed Charges for Rev 250 = $19.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,UNITED HEALTHCARE,UHC ONEIDA NATION,19.69,,,,,,,17.3000,35.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.60 in Billed Charges for Rev 250 = $19.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,UNITED HEALTHCARE,UNITED HEALTHCARE,19.69,,,,,,,17.3000,35.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $35.60 in Billed Charges for Rev 250 = $19.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,25.63,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.60 in Billed Charges for Rev 250 = $25.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,22.07,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $35.60 in Billed Charges for Rev 250 = $22.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,25.63,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.60 in Billed Charges for Rev 250 = $25.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,25.63,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $35.60 in Billed Charges for Rev 250 = $25.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0186-1988-04,CDM,,,,,,both,2.000000,ML,35.6000,23.5000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,21.36,,,,,,,17.3000,35.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $35.60 in Billed Charges for Rev 250 = $21.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,AETNA,AETNA HSHS,24.61,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $38.10 in Billed Charges for Rev 250 = $24.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,AETNA,ALL COMMERCIAL AETNA,38.10,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.10 in Billed Charges for Rev 250 = $38.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,ANTHEM,ANTHEM POS/HMO,25.91,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $38.10 in Billed Charges at 68% = $25.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,ANTHEM,ANTHEM PPO,25.91,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $38.10 in Billed Charges at 68% = $25.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,38.10,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.10 in Billed Charges for Rev 250 = $38.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,CENPATICO,ALL MEDICAID CENPATICO,38.10,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.10 in Billed Charges for Rev 250 = $38.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,32.39,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.10 in Billed Charges for Rev 250 = $32.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,CIGNA,ALL COMMERCIAL CIGNA,26.67,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $38.10 in Billed Charges for Rev 250 = $26.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,COFINITY,COFINITY,38.10,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.10 in Billed Charges for Rev 250 = $38.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,36.20,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $38.10 in Billed Charges for Rev 250 = $36.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,32.00,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.10 in Billed Charges for Rev 250 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,27.05,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $38.10 in Billed Charges for Rev 250 = $27.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,27.81,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.10 in Billed Charges for Rev 250 = $27.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,18.52,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $38.10 in Billed Charges for Rev 250 = $18.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,32.39,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.10 in Billed Charges for Rev 250 = $32.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,HUMANA,HUMANA CHOICE CARE HMO,24.19,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $38.10 in Billed Charges at 63.5% = $24.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,HUMANA,HUMANA CHOICE CARE PPO,32.39,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.10 in Billed Charges for Rev 250 = $32.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,HUMANA,HUMANA NATIIONAL POS HMO,24.19,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $38.10 in Billed Charges at 63.5% = $24.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,27.81,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.10 in Billed Charges for Rev 250 = $27.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,38.10,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.10 in Billed Charges for Rev 250 = $38.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.05,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $38.10 in Billed Charges for Rev 250 = $19.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,32.00,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.10 in Billed Charges for Rev 250 = $32.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,28.58,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $38.10 in Billed Charges for Rev 250 = $28.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,35.05,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $38.10 in Billed Charges for Rev 250 = $35.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,22.86,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.10 in Billed Charges for Rev 250 = $22.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,22.86,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.10 in Billed Charges for Rev 250 = $22.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,PREVEA HEALTH NETWORK,PREVEA360,22.86,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.10 in Billed Charges for Rev 250 = $22.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,22.86,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.10 in Billed Charges for Rev 250 = $22.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,24.32,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $38.10 in Billed Charges for Rev 250 = $24.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,27.43,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.10 in Billed Charges for Rev 250 = $27.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,21.07,,,,,,,18.5200,38.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.10 in Billed Charges for Rev 250 = $21.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,UNITED HEALTHCARE,UHC ONEIDA NATION,21.07,,,,,,,18.5200,38.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.10 in Billed Charges for Rev 250 = $21.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,UNITED HEALTHCARE,UNITED HEALTHCARE,21.07,,,,,,,18.5200,38.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.10 in Billed Charges for Rev 250 = $21.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,27.43,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.10 in Billed Charges for Rev 250 = $27.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,23.62,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $38.10 in Billed Charges for Rev 250 = $23.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,27.43,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.10 in Billed Charges for Rev 250 = $27.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,27.43,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.10 in Billed Charges for Rev 250 = $27.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,60687-524-79,CDM,,,,,,both,2.000000,ML,38.1000,25.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,22.86,,,,,,,18.5200,38.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.10 in Billed Charges for Rev 250 = $22.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,AETNA,AETNA HSHS,32.07,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.65 in Billed Charges for Rev 250 = $32.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,AETNA,ALL COMMERCIAL AETNA,49.65,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.65 in Billed Charges for Rev 250 = $49.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,ANTHEM,ANTHEM POS/HMO,33.76,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.65 in Billed Charges at 68% = $33.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,ANTHEM,ANTHEM PPO,33.76,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.65 in Billed Charges at 68% = $33.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.65,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.65 in Billed Charges for Rev 250 = $49.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,CENPATICO,ALL MEDICAID CENPATICO,49.65,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.65 in Billed Charges for Rev 250 = $49.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,42.20,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.65 in Billed Charges for Rev 250 = $42.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,CIGNA,ALL COMMERCIAL CIGNA,34.76,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.65 in Billed Charges for Rev 250 = $34.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,COFINITY,COFINITY,49.65,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.65 in Billed Charges for Rev 250 = $49.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,47.17,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.65 in Billed Charges for Rev 250 = $47.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,HEALTH CARE ALLIANCE,THE ALLIANCE,41.71,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.65 in Billed Charges for Rev 250 = $41.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,35.25,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.65 in Billed Charges for Rev 250 = $35.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,36.24,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.65 in Billed Charges for Rev 250 = $36.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,HSHS EMPLOYEES,HSHS EMPLOYEES,24.13,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.65 in Billed Charges for Rev 250 = $24.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,42.20,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.65 in Billed Charges for Rev 250 = $42.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,HUMANA,HUMANA CHOICE CARE HMO,31.53,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.65 in Billed Charges at 63.5% = $31.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,HUMANA,HUMANA CHOICE CARE PPO,42.20,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.65 in Billed Charges for Rev 250 = $42.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,HUMANA,HUMANA NATIIONAL POS HMO,31.53,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.65 in Billed Charges at 63.5% = $31.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,36.24,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.65 in Billed Charges for Rev 250 = $36.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.65,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.65 in Billed Charges for Rev 250 = $49.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.83,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.65 in Billed Charges for Rev 250 = $24.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.71,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.65 in Billed Charges for Rev 250 = $41.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,37.24,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.65 in Billed Charges for Rev 250 = $37.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.68,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.65 in Billed Charges for Rev 250 = $45.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.79,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.65 in Billed Charges for Rev 250 = $29.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.79,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.65 in Billed Charges for Rev 250 = $29.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,PREVEA HEALTH NETWORK,PREVEA360,29.79,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.65 in Billed Charges for Rev 250 = $29.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.79,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.65 in Billed Charges for Rev 250 = $29.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.69,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.65 in Billed Charges for Rev 250 = $31.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.75,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.65 in Billed Charges for Rev 250 = $35.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.46,,,,,,,24.1300,49.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.65 in Billed Charges for Rev 250 = $27.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,UNITED HEALTHCARE,UHC ONEIDA NATION,27.46,,,,,,,24.1300,49.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.65 in Billed Charges for Rev 250 = $27.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,UNITED HEALTHCARE,UNITED HEALTHCARE,27.46,,,,,,,24.1300,49.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.65 in Billed Charges for Rev 250 = $27.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.75,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.65 in Billed Charges for Rev 250 = $35.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.78,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.65 in Billed Charges for Rev 250 = $30.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.75,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.65 in Billed Charges for Rev 250 = $35.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.75,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.65 in Billed Charges for Rev 250 = $35.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-10,CDM,,,,,,both,10.000000,ML,49.6500,32.7700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.79,,,,,,,24.1300,49.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.65 in Billed Charges for Rev 250 = $29.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,AETNA,AETNA HSHS,55.33,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $85.65 in Billed Charges for Rev 250 = $55.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,AETNA,ALL COMMERCIAL AETNA,85.65,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.65 in Billed Charges for Rev 250 = $85.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,ANTHEM,ANTHEM POS/HMO,58.24,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $85.65 in Billed Charges at 68% = $58.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,ANTHEM,ANTHEM PPO,58.24,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $85.65 in Billed Charges at 68% = $58.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,85.65,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.65 in Billed Charges for Rev 250 = $85.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,CENPATICO,ALL MEDICAID CENPATICO,85.65,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.65 in Billed Charges for Rev 250 = $85.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,72.80,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.65 in Billed Charges for Rev 250 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,CIGNA,ALL COMMERCIAL CIGNA,59.96,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $85.65 in Billed Charges for Rev 250 = $59.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,COFINITY,COFINITY,85.65,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.65 in Billed Charges for Rev 250 = $85.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,81.37,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $85.65 in Billed Charges for Rev 250 = $81.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,HEALTH CARE ALLIANCE,THE ALLIANCE,71.95,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.65 in Billed Charges for Rev 250 = $71.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,60.81,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $85.65 in Billed Charges for Rev 250 = $60.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,62.52,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.65 in Billed Charges for Rev 250 = $62.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,HSHS EMPLOYEES,HSHS EMPLOYEES,41.63,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $85.65 in Billed Charges for Rev 250 = $41.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,72.80,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.65 in Billed Charges for Rev 250 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,HUMANA,HUMANA CHOICE CARE HMO,54.39,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $85.65 in Billed Charges at 63.5% = $54.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,HUMANA,HUMANA CHOICE CARE PPO,72.80,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $85.65 in Billed Charges for Rev 250 = $72.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,HUMANA,HUMANA NATIIONAL POS HMO,54.39,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $85.65 in Billed Charges at 63.5% = $54.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,62.52,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $85.65 in Billed Charges for Rev 250 = $62.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,LIVE360,LIVE360 HSHS HEALTHY PLAN,85.65,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $85.65 in Billed Charges for Rev 250 = $85.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,42.83,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $85.65 in Billed Charges for Rev 250 = $42.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,71.95,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $85.65 in Billed Charges for Rev 250 = $71.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,64.24,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $85.65 in Billed Charges for Rev 250 = $64.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,78.80,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $85.65 in Billed Charges for Rev 250 = $78.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,51.39,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.65 in Billed Charges for Rev 250 = $51.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,51.39,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.65 in Billed Charges for Rev 250 = $51.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,PREVEA HEALTH NETWORK,PREVEA360,51.39,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.65 in Billed Charges for Rev 250 = $51.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,51.39,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.65 in Billed Charges for Rev 250 = $51.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,54.67,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $85.65 in Billed Charges for Rev 250 = $54.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,61.67,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.65 in Billed Charges for Rev 250 = $61.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,47.36,,,,,,,41.6300,85.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $85.65 in Billed Charges for Rev 250 = $47.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,UNITED HEALTHCARE,UHC ONEIDA NATION,47.36,,,,,,,41.6300,85.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $85.65 in Billed Charges for Rev 250 = $47.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,UNITED HEALTHCARE,UNITED HEALTHCARE,47.36,,,,,,,41.6300,85.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $85.65 in Billed Charges for Rev 250 = $47.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,61.67,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.65 in Billed Charges for Rev 250 = $61.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,53.10,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $85.65 in Billed Charges for Rev 250 = $53.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,61.67,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.65 in Billed Charges for Rev 250 = $61.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,61.67,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $85.65 in Billed Charges for Rev 250 = $61.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-30,CDM,,,,,,both,30.000000,ML,85.6500,56.5300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,51.39,,,,,,,41.6300,85.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $85.65 in Billed Charges for Rev 250 = $51.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,AETNA,AETNA HSHS,32.04,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.60 in Billed Charges for Rev 250 = $32.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,AETNA,ALL COMMERCIAL AETNA,49.60,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.60 in Billed Charges for Rev 250 = $49.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,ANTHEM,ANTHEM POS/HMO,33.73,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.60 in Billed Charges at 68% = $33.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,ANTHEM,ANTHEM PPO,33.73,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.60 in Billed Charges at 68% = $33.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.60,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.60 in Billed Charges for Rev 250 = $49.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,CENPATICO,ALL MEDICAID CENPATICO,49.60,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.60 in Billed Charges for Rev 250 = $49.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,42.16,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.60 in Billed Charges for Rev 250 = $42.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,CIGNA,ALL COMMERCIAL CIGNA,34.72,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.60 in Billed Charges for Rev 250 = $34.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,COFINITY,COFINITY,49.60,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.60 in Billed Charges for Rev 250 = $49.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,47.12,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.60 in Billed Charges for Rev 250 = $47.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.66,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.60 in Billed Charges for Rev 250 = $41.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,35.22,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.60 in Billed Charges for Rev 250 = $35.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,36.21,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.60 in Billed Charges for Rev 250 = $36.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,24.11,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.60 in Billed Charges for Rev 250 = $24.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,42.16,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.60 in Billed Charges for Rev 250 = $42.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,HUMANA,HUMANA CHOICE CARE HMO,31.50,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.60 in Billed Charges at 63.5% = $31.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,HUMANA,HUMANA CHOICE CARE PPO,42.16,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.60 in Billed Charges for Rev 250 = $42.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,HUMANA,HUMANA NATIIONAL POS HMO,31.50,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.60 in Billed Charges at 63.5% = $31.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,36.21,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.60 in Billed Charges for Rev 250 = $36.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.60,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.60 in Billed Charges for Rev 250 = $49.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.80,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.60 in Billed Charges for Rev 250 = $24.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.66,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.60 in Billed Charges for Rev 250 = $41.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,37.20,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.60 in Billed Charges for Rev 250 = $37.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.63,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.60 in Billed Charges for Rev 250 = $45.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.76,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.60 in Billed Charges for Rev 250 = $29.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.76,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.60 in Billed Charges for Rev 250 = $29.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,PREVEA HEALTH NETWORK,PREVEA360,29.76,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.60 in Billed Charges for Rev 250 = $29.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.76,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.60 in Billed Charges for Rev 250 = $29.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.66,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.60 in Billed Charges for Rev 250 = $31.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.71,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.60 in Billed Charges for Rev 250 = $35.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.43,,,,,,,24.1100,49.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.60 in Billed Charges for Rev 250 = $27.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.43,,,,,,,24.1100,49.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.60 in Billed Charges for Rev 250 = $27.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.43,,,,,,,24.1100,49.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.60 in Billed Charges for Rev 250 = $27.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.71,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.60 in Billed Charges for Rev 250 = $35.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.75,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.60 in Billed Charges for Rev 250 = $30.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.71,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.60 in Billed Charges for Rev 250 = $35.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.71,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.60 in Billed Charges for Rev 250 = $35.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 SOLN,250,RC,0409-1746-70,CDM,,,,,,both,10.000000,ML,49.6000,32.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.76,,,,,,,24.1100,49.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.60 in Billed Charges for Rev 250 = $29.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,AETNA,AETNA HSHS,92.57,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $143.30 in Billed Charges for Rev 250 = $92.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,AETNA,ALL COMMERCIAL AETNA,143.30,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.30 in Billed Charges for Rev 250 = $143.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,ANTHEM,ANTHEM POS/HMO,97.44,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $143.30 in Billed Charges at 68% = $97.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,ANTHEM,ANTHEM PPO,97.44,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $143.30 in Billed Charges at 68% = $97.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,143.30,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.30 in Billed Charges for Rev 250 = $143.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,CENPATICO,ALL MEDICAID CENPATICO,143.30,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.30 in Billed Charges for Rev 250 = $143.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,121.81,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $143.30 in Billed Charges for Rev 250 = $121.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,CIGNA,ALL COMMERCIAL CIGNA,100.31,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $143.30 in Billed Charges for Rev 250 = $100.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,COFINITY,COFINITY,143.30,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.30 in Billed Charges for Rev 250 = $143.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,136.14,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $143.30 in Billed Charges for Rev 250 = $136.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,120.37,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $143.30 in Billed Charges for Rev 250 = $120.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,101.74,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $143.30 in Billed Charges for Rev 250 = $101.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,104.61,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $143.30 in Billed Charges for Rev 250 = $104.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,69.64,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $143.30 in Billed Charges for Rev 250 = $69.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,121.81,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $143.30 in Billed Charges for Rev 250 = $121.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,HUMANA,HUMANA CHOICE CARE HMO,91.00,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $143.30 in Billed Charges at 63.5% = $91.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,HUMANA,HUMANA CHOICE CARE PPO,121.81,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $143.30 in Billed Charges for Rev 250 = $121.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,HUMANA,HUMANA NATIIONAL POS HMO,91.00,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $143.30 in Billed Charges at 63.5% = $91.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,104.61,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $143.30 in Billed Charges for Rev 250 = $104.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,143.30,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $143.30 in Billed Charges for Rev 250 = $143.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,71.65,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $143.30 in Billed Charges for Rev 250 = $71.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,120.37,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $143.30 in Billed Charges for Rev 250 = $120.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,107.48,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $143.30 in Billed Charges for Rev 250 = $107.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,131.84,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $143.30 in Billed Charges for Rev 250 = $131.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,85.98,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $143.30 in Billed Charges for Rev 250 = $85.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,85.98,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $143.30 in Billed Charges for Rev 250 = $85.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,PREVEA HEALTH NETWORK,PREVEA360,85.98,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $143.30 in Billed Charges for Rev 250 = $85.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,85.98,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $143.30 in Billed Charges for Rev 250 = $85.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,91.47,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $143.30 in Billed Charges for Rev 250 = $91.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,103.18,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $143.30 in Billed Charges for Rev 250 = $103.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,79.24,,,,,,,69.6400,143.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $143.30 in Billed Charges for Rev 250 = $79.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,79.24,,,,,,,69.6400,143.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $143.30 in Billed Charges for Rev 250 = $79.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,79.24,,,,,,,69.6400,143.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $143.30 in Billed Charges for Rev 250 = $79.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,103.18,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $143.30 in Billed Charges for Rev 250 = $103.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,88.85,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $143.30 in Billed Charges for Rev 250 = $88.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,103.18,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $143.30 in Billed Charges for Rev 250 = $103.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,103.18,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $143.30 in Billed Charges for Rev 250 = $103.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 SOLN,250,RC,63323-461-57,CDM,,,,,,both,50.000000,ML,143.3000,94.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,85.98,,,,,,,69.6400,143.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $143.30 in Billed Charges for Rev 250 = $85.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,AETNA,AETNA HSHS,98.93,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $153.15 in Billed Charges for Rev 250 = $98.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,AETNA,ALL COMMERCIAL AETNA,153.15,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.15 in Billed Charges for Rev 250 = $153.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,ANTHEM,ANTHEM POS/HMO,104.14,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $153.15 in Billed Charges at 68% = $104.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,ANTHEM,ANTHEM PPO,104.14,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $153.15 in Billed Charges at 68% = $104.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,153.15,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.15 in Billed Charges for Rev 250 = $153.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,CENPATICO,ALL MEDICAID CENPATICO,153.15,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.15 in Billed Charges for Rev 250 = $153.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,130.18,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $153.15 in Billed Charges for Rev 250 = $130.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,CIGNA,ALL COMMERCIAL CIGNA,107.21,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $153.15 in Billed Charges for Rev 250 = $107.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,COFINITY,COFINITY,153.15,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.15 in Billed Charges for Rev 250 = $153.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,145.49,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $153.15 in Billed Charges for Rev 250 = $145.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,128.65,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $153.15 in Billed Charges for Rev 250 = $128.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,108.74,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $153.15 in Billed Charges for Rev 250 = $108.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,111.80,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $153.15 in Billed Charges for Rev 250 = $111.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,74.43,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $153.15 in Billed Charges for Rev 250 = $74.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,130.18,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $153.15 in Billed Charges for Rev 250 = $130.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,HUMANA,HUMANA CHOICE CARE HMO,97.25,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $153.15 in Billed Charges at 63.5% = $97.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,HUMANA,HUMANA CHOICE CARE PPO,130.18,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $153.15 in Billed Charges for Rev 250 = $130.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,HUMANA,HUMANA NATIIONAL POS HMO,97.25,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $153.15 in Billed Charges at 63.5% = $97.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,111.80,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $153.15 in Billed Charges for Rev 250 = $111.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,153.15,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $153.15 in Billed Charges for Rev 250 = $153.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,76.58,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $153.15 in Billed Charges for Rev 250 = $76.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,128.65,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $153.15 in Billed Charges for Rev 250 = $128.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,114.86,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $153.15 in Billed Charges for Rev 250 = $114.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,140.90,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $153.15 in Billed Charges for Rev 250 = $140.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,91.89,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $153.15 in Billed Charges for Rev 250 = $91.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,91.89,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $153.15 in Billed Charges for Rev 250 = $91.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,PREVEA HEALTH NETWORK,PREVEA360,91.89,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $153.15 in Billed Charges for Rev 250 = $91.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,91.89,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $153.15 in Billed Charges for Rev 250 = $91.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,97.76,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $153.15 in Billed Charges for Rev 250 = $97.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,110.27,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $153.15 in Billed Charges for Rev 250 = $110.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,84.69,,,,,,,74.4300,153.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $153.15 in Billed Charges for Rev 250 = $84.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,84.69,,,,,,,74.4300,153.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $153.15 in Billed Charges for Rev 250 = $84.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,84.69,,,,,,,74.4300,153.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $153.15 in Billed Charges for Rev 250 = $84.69 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,110.27,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $153.15 in Billed Charges for Rev 250 = $110.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,94.95,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $153.15 in Billed Charges for Rev 250 = $94.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,110.27,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $153.15 in Billed Charges for Rev 250 = $110.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,110.27,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $153.15 in Billed Charges for Rev 250 = $110.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 SOLN,250,RC,63323-463-01,CDM,,,,,,both,50.000000,ML,153.1500,101.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,91.89,,,,,,,74.4300,153.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $153.15 in Billed Charges for Rev 250 = $91.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,AETNA,AETNA HSHS,37.40,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $57.90 in Billed Charges for Rev 250 = $37.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,AETNA,ALL COMMERCIAL AETNA,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 250 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,ANTHEM,ANTHEM POS/HMO,39.37,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $57.90 in Billed Charges at 68% = $39.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,ANTHEM,ANTHEM PPO,39.37,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $57.90 in Billed Charges at 68% = $39.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 250 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,CENPATICO,ALL MEDICAID CENPATICO,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 250 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,49.22,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.90 in Billed Charges for Rev 250 = $49.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,CIGNA,ALL COMMERCIAL CIGNA,40.53,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $57.90 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,COFINITY,COFINITY,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 250 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,55.01,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $57.90 in Billed Charges for Rev 250 = $55.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,48.64,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.90 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,41.11,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $57.90 in Billed Charges for Rev 250 = $41.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,42.27,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.90 in Billed Charges for Rev 250 = $42.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,28.14,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $57.90 in Billed Charges for Rev 250 = $28.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,49.22,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.90 in Billed Charges for Rev 250 = $49.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,HUMANA,HUMANA CHOICE CARE HMO,36.77,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $57.90 in Billed Charges at 63.5% = $36.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,HUMANA,HUMANA CHOICE CARE PPO,49.22,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.90 in Billed Charges for Rev 250 = $49.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,HUMANA,HUMANA NATIIONAL POS HMO,36.77,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $57.90 in Billed Charges at 63.5% = $36.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,42.27,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.90 in Billed Charges for Rev 250 = $42.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,57.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.90 in Billed Charges for Rev 250 = $57.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,28.95,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $57.90 in Billed Charges for Rev 250 = $28.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,48.64,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.90 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,43.43,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $57.90 in Billed Charges for Rev 250 = $43.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,53.27,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $57.90 in Billed Charges for Rev 250 = $53.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 250 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 250 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,PREVEA HEALTH NETWORK,PREVEA360,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 250 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 250 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,36.96,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $57.90 in Billed Charges for Rev 250 = $36.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,41.69,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.90 in Billed Charges for Rev 250 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,32.02,,,,,,,28.1400,57.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.90 in Billed Charges for Rev 250 = $32.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,UNITED HEALTHCARE,UHC ONEIDA NATION,32.02,,,,,,,28.1400,57.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.90 in Billed Charges for Rev 250 = $32.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,UNITED HEALTHCARE,UNITED HEALTHCARE,32.02,,,,,,,28.1400,57.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.90 in Billed Charges for Rev 250 = $32.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,41.69,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.90 in Billed Charges for Rev 250 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,35.90,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $57.90 in Billed Charges for Rev 250 = $35.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,41.69,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.90 in Billed Charges for Rev 250 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,41.69,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.90 in Billed Charges for Rev 250 = $41.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-04,CDM,,,,,,both,10.000000,ML,57.9000,38.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,34.74,,,,,,,28.1400,57.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.90 in Billed Charges for Rev 250 = $34.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,AETNA,AETNA HSHS,46.96,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $72.70 in Billed Charges for Rev 250 = $46.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,AETNA,ALL COMMERCIAL AETNA,72.70,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.70 in Billed Charges for Rev 250 = $72.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,ANTHEM,ANTHEM POS/HMO,49.44,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $72.70 in Billed Charges at 68% = $49.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,ANTHEM,ANTHEM PPO,49.44,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $72.70 in Billed Charges at 68% = $49.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,72.70,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.70 in Billed Charges for Rev 250 = $72.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,CENPATICO,ALL MEDICAID CENPATICO,72.70,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.70 in Billed Charges for Rev 250 = $72.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,61.80,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.70 in Billed Charges for Rev 250 = $61.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,CIGNA,ALL COMMERCIAL CIGNA,50.89,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $72.70 in Billed Charges for Rev 250 = $50.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,COFINITY,COFINITY,72.70,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.70 in Billed Charges for Rev 250 = $72.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,69.07,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $72.70 in Billed Charges for Rev 250 = $69.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,HEALTH CARE ALLIANCE,THE ALLIANCE,61.07,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $72.70 in Billed Charges for Rev 250 = $61.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,51.62,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $72.70 in Billed Charges for Rev 250 = $51.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,53.07,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $72.70 in Billed Charges for Rev 250 = $53.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,HSHS EMPLOYEES,HSHS EMPLOYEES,35.33,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $72.70 in Billed Charges for Rev 250 = $35.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,61.80,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.70 in Billed Charges for Rev 250 = $61.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,HUMANA,HUMANA CHOICE CARE HMO,46.16,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $72.70 in Billed Charges at 63.5% = $46.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,HUMANA,HUMANA CHOICE CARE PPO,61.80,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $72.70 in Billed Charges for Rev 250 = $61.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,HUMANA,HUMANA NATIIONAL POS HMO,46.16,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $72.70 in Billed Charges at 63.5% = $46.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,53.07,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $72.70 in Billed Charges for Rev 250 = $53.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,LIVE360,LIVE360 HSHS HEALTHY PLAN,72.70,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $72.70 in Billed Charges for Rev 250 = $72.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,36.35,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $72.70 in Billed Charges for Rev 250 = $36.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,61.07,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $72.70 in Billed Charges for Rev 250 = $61.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,54.53,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $72.70 in Billed Charges for Rev 250 = $54.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,66.88,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $72.70 in Billed Charges for Rev 250 = $66.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,43.62,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $72.70 in Billed Charges for Rev 250 = $43.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,43.62,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $72.70 in Billed Charges for Rev 250 = $43.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,PREVEA HEALTH NETWORK,PREVEA360,43.62,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $72.70 in Billed Charges for Rev 250 = $43.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,43.62,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $72.70 in Billed Charges for Rev 250 = $43.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,46.40,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $72.70 in Billed Charges for Rev 250 = $46.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,52.34,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.70 in Billed Charges for Rev 250 = $52.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,40.20,,,,,,,35.3300,72.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $72.70 in Billed Charges for Rev 250 = $40.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,UNITED HEALTHCARE,UHC ONEIDA NATION,40.20,,,,,,,35.3300,72.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $72.70 in Billed Charges for Rev 250 = $40.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,UNITED HEALTHCARE,UNITED HEALTHCARE,40.20,,,,,,,35.3300,72.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $72.70 in Billed Charges for Rev 250 = $40.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,52.34,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.70 in Billed Charges for Rev 250 = $52.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.07,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $72.70 in Billed Charges for Rev 250 = $45.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,52.34,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.70 in Billed Charges for Rev 250 = $52.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,52.34,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $72.70 in Billed Charges for Rev 250 = $52.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 10 G TUBE,250,RC,40565-12255,CDM,,,,,,both,10.000000,GR,72.7000,47.9800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,43.62,,,,,,,35.3300,72.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $72.70 in Billed Charges for Rev 250 = $43.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,AETNA,AETNA HSHS,187.86,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $290.80 in Billed Charges for Rev 250 = $187.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,AETNA,ALL COMMERCIAL AETNA,290.80,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $290.80 in Billed Charges for Rev 250 = $290.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,ANTHEM,ANTHEM POS/HMO,197.74,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $290.80 in Billed Charges at 68% = $197.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,ANTHEM,ANTHEM PPO,197.74,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $290.80 in Billed Charges at 68% = $197.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,290.80,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $290.80 in Billed Charges for Rev 250 = $290.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,CENPATICO,ALL MEDICAID CENPATICO,290.80,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $290.80 in Billed Charges for Rev 250 = $290.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,247.18,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $290.80 in Billed Charges for Rev 250 = $247.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,CIGNA,ALL COMMERCIAL CIGNA,203.56,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $290.80 in Billed Charges for Rev 250 = $203.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,COFINITY,COFINITY,290.80,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $290.80 in Billed Charges for Rev 250 = $290.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,276.26,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $290.80 in Billed Charges for Rev 250 = $276.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,HEALTH CARE ALLIANCE,THE ALLIANCE,244.27,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $290.80 in Billed Charges for Rev 250 = $244.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,206.47,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $290.80 in Billed Charges for Rev 250 = $206.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,212.28,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $290.80 in Billed Charges for Rev 250 = $212.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,HSHS EMPLOYEES,HSHS EMPLOYEES,141.33,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $290.80 in Billed Charges for Rev 250 = $141.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,247.18,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $290.80 in Billed Charges for Rev 250 = $247.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,HUMANA,HUMANA CHOICE CARE HMO,184.66,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $290.80 in Billed Charges at 63.5% = $184.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,HUMANA,HUMANA CHOICE CARE PPO,247.18,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $290.80 in Billed Charges for Rev 250 = $247.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,HUMANA,HUMANA NATIIONAL POS HMO,184.66,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $290.80 in Billed Charges at 63.5% = $184.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,212.28,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $290.80 in Billed Charges for Rev 250 = $212.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,LIVE360,LIVE360 HSHS HEALTHY PLAN,290.80,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $290.80 in Billed Charges for Rev 250 = $290.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,145.40,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $290.80 in Billed Charges for Rev 250 = $145.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,244.27,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $290.80 in Billed Charges for Rev 250 = $244.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,218.10,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $290.80 in Billed Charges for Rev 250 = $218.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,267.54,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $290.80 in Billed Charges for Rev 250 = $267.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,174.48,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $290.80 in Billed Charges for Rev 250 = $174.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,174.48,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $290.80 in Billed Charges for Rev 250 = $174.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,PREVEA HEALTH NETWORK,PREVEA360,174.48,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $290.80 in Billed Charges for Rev 250 = $174.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,174.48,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $290.80 in Billed Charges for Rev 250 = $174.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,185.62,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $290.80 in Billed Charges for Rev 250 = $185.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,209.38,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $290.80 in Billed Charges for Rev 250 = $209.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,160.81,,,,,,,141.3300,290.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $290.80 in Billed Charges for Rev 250 = $160.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,UNITED HEALTHCARE,UHC ONEIDA NATION,160.81,,,,,,,141.3300,290.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $290.80 in Billed Charges for Rev 250 = $160.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,UNITED HEALTHCARE,UNITED HEALTHCARE,160.81,,,,,,,141.3300,290.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $290.80 in Billed Charges for Rev 250 = $160.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,209.38,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $290.80 in Billed Charges for Rev 250 = $209.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,180.30,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $290.80 in Billed Charges for Rev 250 = $180.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,209.38,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $290.80 in Billed Charges for Rev 250 = $209.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,209.38,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $290.80 in Billed Charges for Rev 250 = $209.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,250,RC,40565-12249,CDM,,,,,,both,40.000000,GR,290.8000,191.9300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,174.48,,,,,,,141.3300,290.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $290.80 in Billed Charges for Rev 250 = $174.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE CITRATE SOLN,250,RC,51754-0501-3,CDM,,,,,,both,3.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,AETNA,AETNA HSHS,89.12,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $137.95 in Billed Charges for Rev 250 = $89.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,AETNA,ALL COMMERCIAL AETNA,137.95,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.95 in Billed Charges for Rev 250 = $137.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,ANTHEM,ANTHEM POS/HMO,93.81,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $137.95 in Billed Charges at 68% = $93.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,ANTHEM,ANTHEM PPO,93.81,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $137.95 in Billed Charges at 68% = $93.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,137.95,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.95 in Billed Charges for Rev 250 = $137.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,CENPATICO,ALL MEDICAID CENPATICO,137.95,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.95 in Billed Charges for Rev 250 = $137.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,117.26,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.95 in Billed Charges for Rev 250 = $117.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,CIGNA,ALL COMMERCIAL CIGNA,96.57,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $137.95 in Billed Charges for Rev 250 = $96.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,COFINITY,COFINITY,137.95,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.95 in Billed Charges for Rev 250 = $137.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,131.05,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $137.95 in Billed Charges for Rev 250 = $131.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,115.88,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $137.95 in Billed Charges for Rev 250 = $115.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,97.94,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $137.95 in Billed Charges for Rev 250 = $97.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,100.70,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $137.95 in Billed Charges for Rev 250 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,67.04,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $137.95 in Billed Charges for Rev 250 = $67.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,117.26,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.95 in Billed Charges for Rev 250 = $117.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,HUMANA,HUMANA CHOICE CARE HMO,87.60,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $137.95 in Billed Charges at 63.5% = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,HUMANA,HUMANA CHOICE CARE PPO,117.26,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.95 in Billed Charges for Rev 250 = $117.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,HUMANA,HUMANA NATIIONAL POS HMO,87.60,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $137.95 in Billed Charges at 63.5% = $87.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,100.70,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $137.95 in Billed Charges for Rev 250 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,137.95,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.95 in Billed Charges for Rev 250 = $137.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,68.98,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $137.95 in Billed Charges for Rev 250 = $68.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,115.88,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $137.95 in Billed Charges for Rev 250 = $115.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,103.46,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $137.95 in Billed Charges for Rev 250 = $103.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,126.91,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $137.95 in Billed Charges for Rev 250 = $126.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,82.77,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.95 in Billed Charges for Rev 250 = $82.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,82.77,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.95 in Billed Charges for Rev 250 = $82.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,PREVEA HEALTH NETWORK,PREVEA360,82.77,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.95 in Billed Charges for Rev 250 = $82.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,82.77,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.95 in Billed Charges for Rev 250 = $82.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,88.05,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $137.95 in Billed Charges for Rev 250 = $88.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,99.32,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.95 in Billed Charges for Rev 250 = $99.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,76.29,,,,,,,67.0400,137.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $137.95 in Billed Charges for Rev 250 = $76.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,UNITED HEALTHCARE,UHC ONEIDA NATION,76.29,,,,,,,67.0400,137.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $137.95 in Billed Charges for Rev 250 = $76.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,UNITED HEALTHCARE,UNITED HEALTHCARE,76.29,,,,,,,67.0400,137.9500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $137.95 in Billed Charges for Rev 250 = $76.29 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,99.32,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.95 in Billed Charges for Rev 250 = $99.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,85.53,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $137.95 in Billed Charges for Rev 250 = $85.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,99.32,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.95 in Billed Charges for Rev 250 = $99.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,99.32,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.95 in Billed Charges for Rev 250 = $99.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML BOTTLE,250,RC,66689-201-08,CDM,,,,,,both,240.000000,ML,137.9500,91.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,82.77,,,,,,,67.0400,137.9500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.95 in Billed Charges for Rev 250 = $82.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,AETNA,AETNA HSHS,337.89,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $523.05 in Billed Charges for Rev 250 = $337.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,AETNA,ALL COMMERCIAL AETNA,523.05,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $523.05 in Billed Charges for Rev 250 = $523.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,ANTHEM,ANTHEM POS/HMO,355.67,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $523.05 in Billed Charges at 68% = $355.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,ANTHEM,ANTHEM PPO,355.67,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $523.05 in Billed Charges at 68% = $355.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,523.05,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $523.05 in Billed Charges for Rev 250 = $523.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,CENPATICO,ALL MEDICAID CENPATICO,523.05,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $523.05 in Billed Charges for Rev 250 = $523.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,444.59,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $523.05 in Billed Charges for Rev 250 = $444.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,CIGNA,ALL COMMERCIAL CIGNA,366.14,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $523.05 in Billed Charges for Rev 250 = $366.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,COFINITY,COFINITY,523.05,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $523.05 in Billed Charges for Rev 250 = $523.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,496.90,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $523.05 in Billed Charges for Rev 250 = $496.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,HEALTH CARE ALLIANCE,THE ALLIANCE,439.36,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $523.05 in Billed Charges for Rev 250 = $439.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,371.37,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $523.05 in Billed Charges for Rev 250 = $371.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,381.83,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $523.05 in Billed Charges for Rev 250 = $381.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,HSHS EMPLOYEES,HSHS EMPLOYEES,254.20,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $523.05 in Billed Charges for Rev 250 = $254.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,444.59,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $523.05 in Billed Charges for Rev 250 = $444.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,HUMANA,HUMANA CHOICE CARE HMO,332.14,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $523.05 in Billed Charges at 63.5% = $332.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,HUMANA,HUMANA CHOICE CARE PPO,444.59,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $523.05 in Billed Charges for Rev 250 = $444.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,HUMANA,HUMANA NATIIONAL POS HMO,332.14,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $523.05 in Billed Charges at 63.5% = $332.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,381.83,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $523.05 in Billed Charges for Rev 250 = $381.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,LIVE360,LIVE360 HSHS HEALTHY PLAN,523.05,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $523.05 in Billed Charges for Rev 250 = $523.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,261.53,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $523.05 in Billed Charges for Rev 250 = $261.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,439.36,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $523.05 in Billed Charges for Rev 250 = $439.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,392.29,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $523.05 in Billed Charges for Rev 250 = $392.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,481.21,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $523.05 in Billed Charges for Rev 250 = $481.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,313.83,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $523.05 in Billed Charges for Rev 250 = $313.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,313.83,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $523.05 in Billed Charges for Rev 250 = $313.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,PREVEA HEALTH NETWORK,PREVEA360,313.83,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $523.05 in Billed Charges for Rev 250 = $313.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,313.83,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $523.05 in Billed Charges for Rev 250 = $313.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,333.86,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $523.05 in Billed Charges for Rev 250 = $333.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,376.60,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $523.05 in Billed Charges for Rev 250 = $376.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,289.25,,,,,,,254.2000,523.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $523.05 in Billed Charges for Rev 250 = $289.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,UNITED HEALTHCARE,UHC ONEIDA NATION,289.25,,,,,,,254.2000,523.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $523.05 in Billed Charges for Rev 250 = $289.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,UNITED HEALTHCARE,UNITED HEALTHCARE,289.25,,,,,,,254.2000,523.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $523.05 in Billed Charges for Rev 250 = $289.25 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,376.60,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $523.05 in Billed Charges for Rev 250 = $376.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,324.29,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $523.05 in Billed Charges for Rev 250 = $324.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,376.60,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $523.05 in Billed Charges for Rev 250 = $376.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,376.60,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $523.05 in Billed Charges for Rev 250 = $376.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,250,RC,72485-625-13,CDM,,,,,,both,7.500000,ML,523.0500,345.2100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,313.83,,,,,,,254.2000,523.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $523.05 in Billed Charges for Rev 250 = $313.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,AETNA,AETNA HSHS,33.40,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $51.70 in Billed Charges for Rev 250 = $33.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,AETNA,ALL COMMERCIAL AETNA,51.70,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.70 in Billed Charges for Rev 250 = $51.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,ANTHEM,ANTHEM POS/HMO,35.16,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $51.70 in Billed Charges at 68% = $35.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,ANTHEM,ANTHEM PPO,35.16,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $51.70 in Billed Charges at 68% = $35.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,51.70,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.70 in Billed Charges for Rev 250 = $51.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,CENPATICO,ALL MEDICAID CENPATICO,51.70,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.70 in Billed Charges for Rev 250 = $51.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,43.95,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.70 in Billed Charges for Rev 250 = $43.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,CIGNA,ALL COMMERCIAL CIGNA,36.19,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $51.70 in Billed Charges for Rev 250 = $36.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,COFINITY,COFINITY,51.70,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.70 in Billed Charges for Rev 250 = $51.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,49.12,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $51.70 in Billed Charges for Rev 250 = $49.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,43.43,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $51.70 in Billed Charges for Rev 250 = $43.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,36.71,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $51.70 in Billed Charges for Rev 250 = $36.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,37.74,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $51.70 in Billed Charges for Rev 250 = $37.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,25.13,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $51.70 in Billed Charges for Rev 250 = $25.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,43.95,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.70 in Billed Charges for Rev 250 = $43.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,HUMANA,HUMANA CHOICE CARE HMO,32.83,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $51.70 in Billed Charges at 63.5% = $32.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,HUMANA,HUMANA CHOICE CARE PPO,43.95,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.70 in Billed Charges for Rev 250 = $43.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,HUMANA,HUMANA NATIIONAL POS HMO,32.83,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $51.70 in Billed Charges at 63.5% = $32.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,37.74,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $51.70 in Billed Charges for Rev 250 = $37.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,51.70,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.70 in Billed Charges for Rev 250 = $51.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,25.85,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $51.70 in Billed Charges for Rev 250 = $25.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,43.43,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $51.70 in Billed Charges for Rev 250 = $43.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,38.78,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $51.70 in Billed Charges for Rev 250 = $38.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,47.56,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $51.70 in Billed Charges for Rev 250 = $47.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,31.02,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.70 in Billed Charges for Rev 250 = $31.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,31.02,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.70 in Billed Charges for Rev 250 = $31.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,PREVEA HEALTH NETWORK,PREVEA360,31.02,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.70 in Billed Charges for Rev 250 = $31.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,31.02,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.70 in Billed Charges for Rev 250 = $31.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,33.00,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $51.70 in Billed Charges for Rev 250 = $33.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,37.22,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.70 in Billed Charges for Rev 250 = $37.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,28.59,,,,,,,25.1300,51.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $51.70 in Billed Charges for Rev 250 = $28.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,28.59,,,,,,,25.1300,51.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $51.70 in Billed Charges for Rev 250 = $28.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,28.59,,,,,,,25.1300,51.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $51.70 in Billed Charges for Rev 250 = $28.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,37.22,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.70 in Billed Charges for Rev 250 = $37.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.05,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $51.70 in Billed Charges for Rev 250 = $32.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,37.22,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.70 in Billed Charges for Rev 250 = $37.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,37.22,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.70 in Billed Charges for Rev 250 = $37.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 10 MG/5ML SOLN,250,RC,71288-712-05,CDM,,,,,,both,5.000000,ML,51.7000,34.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.02,,,,,,,25.1300,51.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.70 in Billed Charges for Rev 250 = $31.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,AETNA,AETNA HSHS,110.79,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $171.50 in Billed Charges for Rev 250 = $110.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,AETNA,ALL COMMERCIAL AETNA,171.50,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $171.50 in Billed Charges for Rev 250 = $171.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,ANTHEM,ANTHEM POS/HMO,116.62,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $171.50 in Billed Charges at 68% = $116.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,ANTHEM,ANTHEM PPO,116.62,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $171.50 in Billed Charges at 68% = $116.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,171.50,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $171.50 in Billed Charges for Rev 250 = $171.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,CENPATICO,ALL MEDICAID CENPATICO,171.50,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $171.50 in Billed Charges for Rev 250 = $171.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,145.78,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $171.50 in Billed Charges for Rev 250 = $145.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,CIGNA,ALL COMMERCIAL CIGNA,120.05,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $171.50 in Billed Charges for Rev 250 = $120.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,COFINITY,COFINITY,171.50,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $171.50 in Billed Charges for Rev 250 = $171.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,162.93,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $171.50 in Billed Charges for Rev 250 = $162.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,144.06,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $171.50 in Billed Charges for Rev 250 = $144.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,121.77,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $171.50 in Billed Charges for Rev 250 = $121.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,125.20,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $171.50 in Billed Charges for Rev 250 = $125.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,83.35,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $171.50 in Billed Charges for Rev 250 = $83.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,145.78,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $171.50 in Billed Charges for Rev 250 = $145.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,HUMANA,HUMANA CHOICE CARE HMO,108.90,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $171.50 in Billed Charges at 63.5% = $108.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,HUMANA,HUMANA CHOICE CARE PPO,145.78,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $171.50 in Billed Charges for Rev 250 = $145.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,HUMANA,HUMANA NATIIONAL POS HMO,108.90,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $171.50 in Billed Charges at 63.5% = $108.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,125.20,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $171.50 in Billed Charges for Rev 250 = $125.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,171.50,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $171.50 in Billed Charges for Rev 250 = $171.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,85.75,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $171.50 in Billed Charges for Rev 250 = $85.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,144.06,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $171.50 in Billed Charges for Rev 250 = $144.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,128.63,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $171.50 in Billed Charges for Rev 250 = $128.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,157.78,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $171.50 in Billed Charges for Rev 250 = $157.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,102.90,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $171.50 in Billed Charges for Rev 250 = $102.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,102.90,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $171.50 in Billed Charges for Rev 250 = $102.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,PREVEA HEALTH NETWORK,PREVEA360,102.90,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $171.50 in Billed Charges for Rev 250 = $102.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,102.90,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $171.50 in Billed Charges for Rev 250 = $102.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,109.47,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $171.50 in Billed Charges for Rev 250 = $109.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,123.48,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $171.50 in Billed Charges for Rev 250 = $123.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,94.84,,,,,,,83.3500,171.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $171.50 in Billed Charges for Rev 250 = $94.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,UNITED HEALTHCARE,UHC ONEIDA NATION,94.84,,,,,,,83.3500,171.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $171.50 in Billed Charges for Rev 250 = $94.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,UNITED HEALTHCARE,UNITED HEALTHCARE,94.84,,,,,,,83.3500,171.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $171.50 in Billed Charges for Rev 250 = $94.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,123.48,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $171.50 in Billed Charges for Rev 250 = $123.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,106.33,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $171.50 in Billed Charges for Rev 250 = $106.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,123.48,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $171.50 in Billed Charges for Rev 250 = $123.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,123.48,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $171.50 in Billed Charges for Rev 250 = $123.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN,250,RC,0409-1208-01,CDM,,,,,,both,10.000000,ML,171.5000,113.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,102.90,,,,,,,83.3500,171.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $171.50 in Billed Charges for Rev 250 = $102.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,AETNA,AETNA HSHS,43.48,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $67.30 in Billed Charges for Rev 250 = $43.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,AETNA,ALL COMMERCIAL AETNA,67.30,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.30 in Billed Charges for Rev 250 = $67.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,ANTHEM,ANTHEM POS/HMO,45.76,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.30 in Billed Charges at 68% = $45.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,ANTHEM,ANTHEM PPO,45.76,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.30 in Billed Charges at 68% = $45.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,67.30,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.30 in Billed Charges for Rev 250 = $67.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,CENPATICO,ALL MEDICAID CENPATICO,67.30,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.30 in Billed Charges for Rev 250 = $67.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,57.21,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.30 in Billed Charges for Rev 250 = $57.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,CIGNA,ALL COMMERCIAL CIGNA,47.11,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $67.30 in Billed Charges for Rev 250 = $47.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,COFINITY,COFINITY,67.30,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.30 in Billed Charges for Rev 250 = $67.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,63.94,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $67.30 in Billed Charges for Rev 250 = $63.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,56.53,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $67.30 in Billed Charges for Rev 250 = $56.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,47.78,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $67.30 in Billed Charges for Rev 250 = $47.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,49.13,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $67.30 in Billed Charges for Rev 250 = $49.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,32.71,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $67.30 in Billed Charges for Rev 250 = $32.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,57.21,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.30 in Billed Charges for Rev 250 = $57.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,HUMANA,HUMANA CHOICE CARE HMO,42.74,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.30 in Billed Charges at 63.5% = $42.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,HUMANA,HUMANA CHOICE CARE PPO,57.21,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.30 in Billed Charges for Rev 250 = $57.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,HUMANA,HUMANA NATIIONAL POS HMO,42.74,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.30 in Billed Charges at 63.5% = $42.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,49.13,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $67.30 in Billed Charges for Rev 250 = $49.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,67.30,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.30 in Billed Charges for Rev 250 = $67.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,33.65,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $67.30 in Billed Charges for Rev 250 = $33.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,56.53,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $67.30 in Billed Charges for Rev 250 = $56.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,50.48,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $67.30 in Billed Charges for Rev 250 = $50.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,61.92,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $67.30 in Billed Charges for Rev 250 = $61.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,40.38,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.30 in Billed Charges for Rev 250 = $40.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,40.38,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.30 in Billed Charges for Rev 250 = $40.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,PREVEA HEALTH NETWORK,PREVEA360,40.38,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.30 in Billed Charges for Rev 250 = $40.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,40.38,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.30 in Billed Charges for Rev 250 = $40.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,42.96,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $67.30 in Billed Charges for Rev 250 = $42.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,48.46,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.30 in Billed Charges for Rev 250 = $48.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,37.22,,,,,,,32.7100,67.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.30 in Billed Charges for Rev 250 = $37.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,37.22,,,,,,,32.7100,67.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.30 in Billed Charges for Rev 250 = $37.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,37.22,,,,,,,32.7100,67.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.30 in Billed Charges for Rev 250 = $37.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,48.46,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.30 in Billed Charges for Rev 250 = $48.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,41.73,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $67.30 in Billed Charges for Rev 250 = $41.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,48.46,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.30 in Billed Charges for Rev 250 = $48.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,48.46,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.30 in Billed Charges for Rev 250 = $48.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,25021-670-10,CDM,,,,,,both,10.000000,ML,67.3000,44.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,40.38,,,,,,,32.7100,67.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.30 in Billed Charges for Rev 250 = $40.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,AETNA,AETNA HSHS,47.67,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $73.80 in Billed Charges for Rev 250 = $47.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,AETNA,ALL COMMERCIAL AETNA,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 250 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,ANTHEM,ANTHEM POS/HMO,50.18,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $73.80 in Billed Charges at 68% = $50.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,ANTHEM,ANTHEM PPO,50.18,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $73.80 in Billed Charges at 68% = $50.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 250 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,CENPATICO,ALL MEDICAID CENPATICO,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 250 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,62.73,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.80 in Billed Charges for Rev 250 = $62.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,CIGNA,ALL COMMERCIAL CIGNA,51.66,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $73.80 in Billed Charges for Rev 250 = $51.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,COFINITY,COFINITY,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 250 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,70.11,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $73.80 in Billed Charges for Rev 250 = $70.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,HEALTH CARE ALLIANCE,THE ALLIANCE,61.99,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.80 in Billed Charges for Rev 250 = $61.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.40,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $73.80 in Billed Charges for Rev 250 = $52.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,53.87,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.80 in Billed Charges for Rev 250 = $53.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,HSHS EMPLOYEES,HSHS EMPLOYEES,35.87,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $73.80 in Billed Charges for Rev 250 = $35.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,62.73,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.80 in Billed Charges for Rev 250 = $62.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,HUMANA,HUMANA CHOICE CARE HMO,46.86,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $73.80 in Billed Charges at 63.5% = $46.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,HUMANA,HUMANA CHOICE CARE PPO,62.73,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $73.80 in Billed Charges for Rev 250 = $62.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,HUMANA,HUMANA NATIIONAL POS HMO,46.86,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $73.80 in Billed Charges at 63.5% = $46.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,53.87,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $73.80 in Billed Charges for Rev 250 = $53.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,LIVE360,LIVE360 HSHS HEALTHY PLAN,73.80,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $73.80 in Billed Charges for Rev 250 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,36.90,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $73.80 in Billed Charges for Rev 250 = $36.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,61.99,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $73.80 in Billed Charges for Rev 250 = $61.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.35,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $73.80 in Billed Charges for Rev 250 = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,67.90,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $73.80 in Billed Charges for Rev 250 = $67.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 250 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 250 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,PREVEA HEALTH NETWORK,PREVEA360,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 250 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 250 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.11,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $73.80 in Billed Charges for Rev 250 = $47.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.14,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.80 in Billed Charges for Rev 250 = $53.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,40.81,,,,,,,35.8700,73.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.80 in Billed Charges for Rev 250 = $40.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,UNITED HEALTHCARE,UHC ONEIDA NATION,40.81,,,,,,,35.8700,73.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.80 in Billed Charges for Rev 250 = $40.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,UNITED HEALTHCARE,UNITED HEALTHCARE,40.81,,,,,,,35.8700,73.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $73.80 in Billed Charges for Rev 250 = $40.81 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.14,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.80 in Billed Charges for Rev 250 = $53.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.76,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $73.80 in Billed Charges for Rev 250 = $45.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.14,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.80 in Billed Charges for Rev 250 = $53.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.14,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $73.80 in Billed Charges for Rev 250 = $53.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CISATRACURIUM 20 MG/10ML SOLN 10 ML VIAL,250,RC,71288-714-10,CDM,,,,,,both,10.000000,ML,73.8000,48.7100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.28,,,,,,,35.8700,73.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $73.80 in Billed Charges for Rev 250 = $44.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,AETNA,AETNA HSHS,36.92,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $57.15 in Billed Charges for Rev 250 = $36.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,AETNA,ALL COMMERCIAL AETNA,57.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.15 in Billed Charges for Rev 250 = $57.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,ANTHEM,ANTHEM POS/HMO,38.86,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $57.15 in Billed Charges at 68% = $38.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,ANTHEM,ANTHEM PPO,38.86,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $57.15 in Billed Charges at 68% = $38.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,57.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.15 in Billed Charges for Rev 250 = $57.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,CENPATICO,ALL MEDICAID CENPATICO,57.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.15 in Billed Charges for Rev 250 = $57.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,48.58,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.15 in Billed Charges for Rev 250 = $48.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,CIGNA,ALL COMMERCIAL CIGNA,40.01,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $57.15 in Billed Charges for Rev 250 = $40.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,COFINITY,COFINITY,57.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.15 in Billed Charges for Rev 250 = $57.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,54.29,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $57.15 in Billed Charges for Rev 250 = $54.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,48.01,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.15 in Billed Charges for Rev 250 = $48.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,40.58,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $57.15 in Billed Charges for Rev 250 = $40.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,41.72,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.15 in Billed Charges for Rev 250 = $41.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,27.77,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $57.15 in Billed Charges for Rev 250 = $27.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,48.58,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.15 in Billed Charges for Rev 250 = $48.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,HUMANA,HUMANA CHOICE CARE HMO,36.29,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $57.15 in Billed Charges at 63.5% = $36.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,HUMANA,HUMANA CHOICE CARE PPO,48.58,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $57.15 in Billed Charges for Rev 250 = $48.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,HUMANA,HUMANA NATIIONAL POS HMO,36.29,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $57.15 in Billed Charges at 63.5% = $36.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,41.72,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $57.15 in Billed Charges for Rev 250 = $41.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,57.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $57.15 in Billed Charges for Rev 250 = $57.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,28.58,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $57.15 in Billed Charges for Rev 250 = $28.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,48.01,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $57.15 in Billed Charges for Rev 250 = $48.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,42.86,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $57.15 in Billed Charges for Rev 250 = $42.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,52.58,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $57.15 in Billed Charges for Rev 250 = $52.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,34.29,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.15 in Billed Charges for Rev 250 = $34.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,34.29,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.15 in Billed Charges for Rev 250 = $34.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,PREVEA HEALTH NETWORK,PREVEA360,34.29,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.15 in Billed Charges for Rev 250 = $34.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,34.29,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.15 in Billed Charges for Rev 250 = $34.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,36.48,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $57.15 in Billed Charges for Rev 250 = $36.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,41.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.15 in Billed Charges for Rev 250 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,31.60,,,,,,,27.7700,57.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.15 in Billed Charges for Rev 250 = $31.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,31.60,,,,,,,27.7700,57.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.15 in Billed Charges for Rev 250 = $31.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,31.60,,,,,,,27.7700,57.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $57.15 in Billed Charges for Rev 250 = $31.60 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,41.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.15 in Billed Charges for Rev 250 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,35.43,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $57.15 in Billed Charges for Rev 250 = $35.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,41.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.15 in Billed Charges for Rev 250 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,41.15,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $57.15 in Billed Charges for Rev 250 = $41.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,250,RC,61314-396-01,CDM,,,,,,both,2.000000,ML,57.1500,37.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,34.29,,,,,,,27.7700,57.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $57.15 in Billed Charges for Rev 250 = $34.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,AETNA,AETNA HSHS,97.58,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $151.05 in Billed Charges for Rev 250 = $97.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,AETNA,ALL COMMERCIAL AETNA,151.05,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.05 in Billed Charges for Rev 250 = $151.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,ANTHEM,ANTHEM POS/HMO,102.71,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $151.05 in Billed Charges at 68% = $102.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,ANTHEM,ANTHEM PPO,102.71,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $151.05 in Billed Charges at 68% = $102.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,151.05,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.05 in Billed Charges for Rev 250 = $151.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,CENPATICO,ALL MEDICAID CENPATICO,151.05,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.05 in Billed Charges for Rev 250 = $151.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,128.39,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.05 in Billed Charges for Rev 250 = $128.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,CIGNA,ALL COMMERCIAL CIGNA,105.74,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $151.05 in Billed Charges for Rev 250 = $105.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,COFINITY,COFINITY,151.05,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.05 in Billed Charges for Rev 250 = $151.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,143.50,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $151.05 in Billed Charges for Rev 250 = $143.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,HEALTH CARE ALLIANCE,THE ALLIANCE,126.88,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $151.05 in Billed Charges for Rev 250 = $126.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,107.25,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $151.05 in Billed Charges for Rev 250 = $107.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,110.27,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $151.05 in Billed Charges for Rev 250 = $110.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,HSHS EMPLOYEES,HSHS EMPLOYEES,73.41,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $151.05 in Billed Charges for Rev 250 = $73.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,128.39,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.05 in Billed Charges for Rev 250 = $128.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,HUMANA,HUMANA CHOICE CARE HMO,95.92,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $151.05 in Billed Charges at 63.5% = $95.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,HUMANA,HUMANA CHOICE CARE PPO,128.39,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $151.05 in Billed Charges for Rev 250 = $128.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,HUMANA,HUMANA NATIIONAL POS HMO,95.92,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $151.05 in Billed Charges at 63.5% = $95.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,110.27,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $151.05 in Billed Charges for Rev 250 = $110.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,LIVE360,LIVE360 HSHS HEALTHY PLAN,151.05,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $151.05 in Billed Charges for Rev 250 = $151.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,75.53,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $151.05 in Billed Charges for Rev 250 = $75.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,126.88,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $151.05 in Billed Charges for Rev 250 = $126.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,113.29,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $151.05 in Billed Charges for Rev 250 = $113.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,138.97,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $151.05 in Billed Charges for Rev 250 = $138.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,90.63,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $151.05 in Billed Charges for Rev 250 = $90.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,90.63,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $151.05 in Billed Charges for Rev 250 = $90.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,PREVEA HEALTH NETWORK,PREVEA360,90.63,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $151.05 in Billed Charges for Rev 250 = $90.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,90.63,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $151.05 in Billed Charges for Rev 250 = $90.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,96.42,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $151.05 in Billed Charges for Rev 250 = $96.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,108.76,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.05 in Billed Charges for Rev 250 = $108.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,83.53,,,,,,,73.4100,151.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $151.05 in Billed Charges for Rev 250 = $83.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,UNITED HEALTHCARE,UHC ONEIDA NATION,83.53,,,,,,,73.4100,151.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $151.05 in Billed Charges for Rev 250 = $83.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,UNITED HEALTHCARE,UNITED HEALTHCARE,83.53,,,,,,,73.4100,151.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $151.05 in Billed Charges for Rev 250 = $83.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,108.76,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.05 in Billed Charges for Rev 250 = $108.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,93.65,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $151.05 in Billed Charges for Rev 250 = $93.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,108.76,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.05 in Billed Charges for Rev 250 = $108.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,108.76,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $151.05 in Billed Charges for Rev 250 = $108.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % SOLN 2 ML BOTTLE,250,RC,0065-0359-02,CDM,,,,,,both,2.000000,ML,151.0500,99.6900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,90.63,,,,,,,73.4100,151.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $151.05 in Billed Charges for Rev 250 = $90.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,AETNA,AETNA HSHS,836.76,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,295.30 in Billed Charges for Rev 250 = $836.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,AETNA,ALL COMMERCIAL AETNA,1295.30,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,295.30 in Billed Charges for Rev 250 = $1,295.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,ANTHEM,ANTHEM POS/HMO,880.80,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,295.30 in Billed Charges at 68% = $880.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,ANTHEM,ANTHEM PPO,880.80,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,295.30 in Billed Charges at 68% = $880.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1295.30,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,295.30 in Billed Charges for Rev 250 = $1,295.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,CENPATICO,ALL MEDICAID CENPATICO,1295.30,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,295.30 in Billed Charges for Rev 250 = $1,295.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1101.01,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,295.30 in Billed Charges for Rev 250 = $1,101.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,CIGNA,ALL COMMERCIAL CIGNA,906.71,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,295.30 in Billed Charges for Rev 250 = $906.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,COFINITY,COFINITY,1295.30,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,295.30 in Billed Charges for Rev 250 = $1,295.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1230.54,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,295.30 in Billed Charges for Rev 250 = $1,230.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,1088.05,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,295.30 in Billed Charges for Rev 250 = $1,088.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,919.66,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,295.30 in Billed Charges for Rev 250 = $919.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,945.57,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,295.30 in Billed Charges for Rev 250 = $945.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,629.52,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,295.30 in Billed Charges for Rev 250 = $629.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1101.01,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,295.30 in Billed Charges for Rev 250 = $1,101.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,HUMANA,HUMANA CHOICE CARE HMO,822.52,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,295.30 in Billed Charges at 63.5% = $822.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,HUMANA,HUMANA CHOICE CARE PPO,1101.01,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,295.30 in Billed Charges for Rev 250 = $1,101.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,HUMANA,HUMANA NATIIONAL POS HMO,822.52,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,295.30 in Billed Charges at 63.5% = $822.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,945.57,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,295.30 in Billed Charges for Rev 250 = $945.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1295.30,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,295.30 in Billed Charges for Rev 250 = $1,295.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,647.65,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,295.30 in Billed Charges for Rev 250 = $647.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1088.05,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,295.30 in Billed Charges for Rev 250 = $1,088.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,971.48,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,295.30 in Billed Charges for Rev 250 = $971.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1191.68,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,295.30 in Billed Charges for Rev 250 = $1,191.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,777.18,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,295.30 in Billed Charges for Rev 250 = $777.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,777.18,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,295.30 in Billed Charges for Rev 250 = $777.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,PREVEA HEALTH NETWORK,PREVEA360,777.18,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,295.30 in Billed Charges for Rev 250 = $777.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,777.18,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,295.30 in Billed Charges for Rev 250 = $777.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,826.79,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,295.30 in Billed Charges for Rev 250 = $826.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,932.62,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,295.30 in Billed Charges for Rev 250 = $932.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,716.30,,,,,,,629.5200,1295.3000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,295.30 in Billed Charges for Rev 250 = $716.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,716.30,,,,,,,629.5200,1295.3000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,295.30 in Billed Charges for Rev 250 = $716.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,716.30,,,,,,,629.5200,1295.3000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,295.30 in Billed Charges for Rev 250 = $716.30 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,932.62,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,295.30 in Billed Charges for Rev 250 = $932.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,803.09,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,295.30 in Billed Charges for Rev 250 = $803.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,932.62,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,295.30 in Billed Charges for Rev 250 = $932.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,932.62,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,295.30 in Billed Charges for Rev 250 = $932.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,250,RC,50484-010-30,CDM,,,,,,both,30.000000,GR,1295.3000,854.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,777.18,,,,,,,629.5200,1295.3000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,295.30 in Billed Charges for Rev 250 = $777.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,AETNA,AETNA HSHS,343.28,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $531.40 in Billed Charges for Rev 250 = $343.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,AETNA,ALL COMMERCIAL AETNA,531.40,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $531.40 in Billed Charges for Rev 250 = $531.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,ANTHEM,ANTHEM POS/HMO,361.35,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $531.40 in Billed Charges at 68% = $361.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,ANTHEM,ANTHEM PPO,361.35,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $531.40 in Billed Charges at 68% = $361.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,531.40,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $531.40 in Billed Charges for Rev 250 = $531.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,CENPATICO,ALL MEDICAID CENPATICO,531.40,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $531.40 in Billed Charges for Rev 250 = $531.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,451.69,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $531.40 in Billed Charges for Rev 250 = $451.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,CIGNA,ALL COMMERCIAL CIGNA,371.98,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $531.40 in Billed Charges for Rev 250 = $371.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,COFINITY,COFINITY,531.40,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $531.40 in Billed Charges for Rev 250 = $531.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,504.83,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $531.40 in Billed Charges for Rev 250 = $504.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,446.38,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $531.40 in Billed Charges for Rev 250 = $446.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,377.29,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $531.40 in Billed Charges for Rev 250 = $377.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,387.92,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $531.40 in Billed Charges for Rev 250 = $387.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,258.26,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $531.40 in Billed Charges for Rev 250 = $258.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,451.69,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $531.40 in Billed Charges for Rev 250 = $451.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,HUMANA,HUMANA CHOICE CARE HMO,337.44,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $531.40 in Billed Charges at 63.5% = $337.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,HUMANA,HUMANA CHOICE CARE PPO,451.69,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $531.40 in Billed Charges for Rev 250 = $451.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,HUMANA,HUMANA NATIIONAL POS HMO,337.44,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $531.40 in Billed Charges at 63.5% = $337.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,387.92,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $531.40 in Billed Charges for Rev 250 = $387.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,531.40,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $531.40 in Billed Charges for Rev 250 = $531.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,265.70,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $531.40 in Billed Charges for Rev 250 = $265.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,446.38,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $531.40 in Billed Charges for Rev 250 = $446.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,398.55,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $531.40 in Billed Charges for Rev 250 = $398.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,488.89,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $531.40 in Billed Charges for Rev 250 = $488.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,318.84,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $531.40 in Billed Charges for Rev 250 = $318.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,318.84,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $531.40 in Billed Charges for Rev 250 = $318.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,PREVEA HEALTH NETWORK,PREVEA360,318.84,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $531.40 in Billed Charges for Rev 250 = $318.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,318.84,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $531.40 in Billed Charges for Rev 250 = $318.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,339.19,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $531.40 in Billed Charges for Rev 250 = $339.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,382.61,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $531.40 in Billed Charges for Rev 250 = $382.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,293.86,,,,,,,258.2600,531.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $531.40 in Billed Charges for Rev 250 = $293.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,293.86,,,,,,,258.2600,531.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $531.40 in Billed Charges for Rev 250 = $293.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,293.86,,,,,,,258.2600,531.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $531.40 in Billed Charges for Rev 250 = $293.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,382.61,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $531.40 in Billed Charges for Rev 250 = $382.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,329.47,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $531.40 in Billed Charges for Rev 250 = $329.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,382.61,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $531.40 in Billed Charges for Rev 250 = $382.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,382.61,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $531.40 in Billed Charges for Rev 250 = $382.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,55150-209-02,CDM,,,,,,both,2.000000,ML,531.4000,350.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,318.84,,,,,,,258.2600,531.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $531.40 in Billed Charges for Rev 250 = $318.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,250,RC,71288-505-02,CDM,,,,,,both,2.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,AETNA,AETNA HSHS,114.54,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $177.30 in Billed Charges for Rev 250 = $114.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,AETNA,ALL COMMERCIAL AETNA,177.30,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.30 in Billed Charges for Rev 250 = $177.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,ANTHEM,ANTHEM POS/HMO,120.56,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $177.30 in Billed Charges at 68% = $120.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,ANTHEM,ANTHEM PPO,120.56,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $177.30 in Billed Charges at 68% = $120.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,177.30,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.30 in Billed Charges for Rev 250 = $177.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,CENPATICO,ALL MEDICAID CENPATICO,177.30,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.30 in Billed Charges for Rev 250 = $177.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,150.71,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.30 in Billed Charges for Rev 250 = $150.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,CIGNA,ALL COMMERCIAL CIGNA,124.11,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $177.30 in Billed Charges for Rev 250 = $124.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,COFINITY,COFINITY,177.30,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.30 in Billed Charges for Rev 250 = $177.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,168.44,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $177.30 in Billed Charges for Rev 250 = $168.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,148.93,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $177.30 in Billed Charges for Rev 250 = $148.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,125.88,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $177.30 in Billed Charges for Rev 250 = $125.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,129.43,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $177.30 in Billed Charges for Rev 250 = $129.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,86.17,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $177.30 in Billed Charges for Rev 250 = $86.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,150.71,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.30 in Billed Charges for Rev 250 = $150.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,HUMANA,HUMANA CHOICE CARE HMO,112.59,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $177.30 in Billed Charges at 63.5% = $112.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,HUMANA,HUMANA CHOICE CARE PPO,150.71,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $177.30 in Billed Charges for Rev 250 = $150.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,HUMANA,HUMANA NATIIONAL POS HMO,112.59,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $177.30 in Billed Charges at 63.5% = $112.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,129.43,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $177.30 in Billed Charges for Rev 250 = $129.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,177.30,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $177.30 in Billed Charges for Rev 250 = $177.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,88.65,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $177.30 in Billed Charges for Rev 250 = $88.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,148.93,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $177.30 in Billed Charges for Rev 250 = $148.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,132.98,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $177.30 in Billed Charges for Rev 250 = $132.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,163.12,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $177.30 in Billed Charges for Rev 250 = $163.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,106.38,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $177.30 in Billed Charges for Rev 250 = $106.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,106.38,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $177.30 in Billed Charges for Rev 250 = $106.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,PREVEA HEALTH NETWORK,PREVEA360,106.38,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $177.30 in Billed Charges for Rev 250 = $106.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,106.38,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $177.30 in Billed Charges for Rev 250 = $106.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,113.17,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $177.30 in Billed Charges for Rev 250 = $113.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,127.66,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.30 in Billed Charges for Rev 250 = $127.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,98.05,,,,,,,86.1700,177.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $177.30 in Billed Charges for Rev 250 = $98.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,98.05,,,,,,,86.1700,177.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $177.30 in Billed Charges for Rev 250 = $98.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,98.05,,,,,,,86.1700,177.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $177.30 in Billed Charges for Rev 250 = $98.05 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,127.66,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.30 in Billed Charges for Rev 250 = $127.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,109.93,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $177.30 in Billed Charges for Rev 250 = $109.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,127.66,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.30 in Billed Charges for Rev 250 = $127.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,127.66,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $177.30 in Billed Charges for Rev 250 = $127.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0338-9557-12,CDM,,,,,,both,100.000000,ML,177.3000,117.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,106.38,,,,,,,86.1700,177.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $177.30 in Billed Charges for Rev 250 = $106.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,AETNA,AETNA HSHS,93.96,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $145.45 in Billed Charges for Rev 250 = $93.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,AETNA,ALL COMMERCIAL AETNA,145.45,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.45 in Billed Charges for Rev 250 = $145.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,ANTHEM,ANTHEM POS/HMO,98.91,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $145.45 in Billed Charges at 68% = $98.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,ANTHEM,ANTHEM PPO,98.91,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $145.45 in Billed Charges at 68% = $98.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,145.45,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.45 in Billed Charges for Rev 250 = $145.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,CENPATICO,ALL MEDICAID CENPATICO,145.45,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.45 in Billed Charges for Rev 250 = $145.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,123.63,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.45 in Billed Charges for Rev 250 = $123.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,CIGNA,ALL COMMERCIAL CIGNA,101.82,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $145.45 in Billed Charges for Rev 250 = $101.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,COFINITY,COFINITY,145.45,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.45 in Billed Charges for Rev 250 = $145.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.18,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $145.45 in Billed Charges for Rev 250 = $138.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,HEALTH CARE ALLIANCE,THE ALLIANCE,122.18,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.45 in Billed Charges for Rev 250 = $122.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.27,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $145.45 in Billed Charges for Rev 250 = $103.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.18,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.45 in Billed Charges for Rev 250 = $106.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,HSHS EMPLOYEES,HSHS EMPLOYEES,70.69,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $145.45 in Billed Charges for Rev 250 = $70.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,123.63,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.45 in Billed Charges for Rev 250 = $123.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,HUMANA,HUMANA CHOICE CARE HMO,92.36,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $145.45 in Billed Charges at 63.5% = $92.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,HUMANA,HUMANA CHOICE CARE PPO,123.63,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $145.45 in Billed Charges for Rev 250 = $123.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,HUMANA,HUMANA NATIIONAL POS HMO,92.36,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $145.45 in Billed Charges at 63.5% = $92.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.18,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $145.45 in Billed Charges for Rev 250 = $106.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,LIVE360,LIVE360 HSHS HEALTHY PLAN,145.45,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $145.45 in Billed Charges for Rev 250 = $145.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,72.73,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $145.45 in Billed Charges for Rev 250 = $72.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.18,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $145.45 in Billed Charges for Rev 250 = $122.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.09,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $145.45 in Billed Charges for Rev 250 = $109.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,133.81,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $145.45 in Billed Charges for Rev 250 = $133.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,87.27,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.45 in Billed Charges for Rev 250 = $87.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,87.27,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.45 in Billed Charges for Rev 250 = $87.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,PREVEA HEALTH NETWORK,PREVEA360,87.27,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.45 in Billed Charges for Rev 250 = $87.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,87.27,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.45 in Billed Charges for Rev 250 = $87.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,92.84,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $145.45 in Billed Charges for Rev 250 = $92.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,104.72,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.45 in Billed Charges for Rev 250 = $104.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,80.43,,,,,,,70.6900,145.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $145.45 in Billed Charges for Rev 250 = $80.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,UNITED HEALTHCARE,UHC ONEIDA NATION,80.43,,,,,,,70.6900,145.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $145.45 in Billed Charges for Rev 250 = $80.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,UNITED HEALTHCARE,UNITED HEALTHCARE,80.43,,,,,,,70.6900,145.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $145.45 in Billed Charges for Rev 250 = $80.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,104.72,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.45 in Billed Charges for Rev 250 = $104.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.18,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $145.45 in Billed Charges for Rev 250 = $90.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,104.72,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.45 in Billed Charges for Rev 250 = $104.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,104.72,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $145.45 in Billed Charges for Rev 250 = $104.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,0409-7517-66,CDM,,,,,,both,50.000000,ML,145.4500,96.0000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.27,,,,,,,70.6900,145.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $145.45 in Billed Charges for Rev 250 = $87.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,AETNA,AETNA HSHS,96.54,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $149.45 in Billed Charges for Rev 250 = $96.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,AETNA,ALL COMMERCIAL AETNA,149.45,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.45 in Billed Charges for Rev 250 = $149.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,ANTHEM,ANTHEM POS/HMO,101.63,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $149.45 in Billed Charges at 68% = $101.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,ANTHEM,ANTHEM PPO,101.63,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $149.45 in Billed Charges at 68% = $101.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,149.45,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.45 in Billed Charges for Rev 250 = $149.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,CENPATICO,ALL MEDICAID CENPATICO,149.45,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.45 in Billed Charges for Rev 250 = $149.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,127.03,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $149.45 in Billed Charges for Rev 250 = $127.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,CIGNA,ALL COMMERCIAL CIGNA,104.62,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $149.45 in Billed Charges for Rev 250 = $104.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,COFINITY,COFINITY,149.45,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.45 in Billed Charges for Rev 250 = $149.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,141.98,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $149.45 in Billed Charges for Rev 250 = $141.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,125.54,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $149.45 in Billed Charges for Rev 250 = $125.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,106.11,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $149.45 in Billed Charges for Rev 250 = $106.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,109.10,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $149.45 in Billed Charges for Rev 250 = $109.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,72.63,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $149.45 in Billed Charges for Rev 250 = $72.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,127.03,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $149.45 in Billed Charges for Rev 250 = $127.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,HUMANA,HUMANA CHOICE CARE HMO,94.90,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $149.45 in Billed Charges at 63.5% = $94.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,HUMANA,HUMANA CHOICE CARE PPO,127.03,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $149.45 in Billed Charges for Rev 250 = $127.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,HUMANA,HUMANA NATIIONAL POS HMO,94.90,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $149.45 in Billed Charges at 63.5% = $94.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,109.10,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $149.45 in Billed Charges for Rev 250 = $109.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,149.45,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $149.45 in Billed Charges for Rev 250 = $149.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,74.73,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $149.45 in Billed Charges for Rev 250 = $74.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,125.54,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $149.45 in Billed Charges for Rev 250 = $125.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,112.09,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $149.45 in Billed Charges for Rev 250 = $112.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,137.49,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $149.45 in Billed Charges for Rev 250 = $137.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,89.67,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.45 in Billed Charges for Rev 250 = $89.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,89.67,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.45 in Billed Charges for Rev 250 = $89.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,PREVEA HEALTH NETWORK,PREVEA360,89.67,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.45 in Billed Charges for Rev 250 = $89.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,89.67,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.45 in Billed Charges for Rev 250 = $89.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,95.39,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $149.45 in Billed Charges for Rev 250 = $95.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,107.60,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $149.45 in Billed Charges for Rev 250 = $107.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,82.65,,,,,,,72.6300,149.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $149.45 in Billed Charges for Rev 250 = $82.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,82.65,,,,,,,72.6300,149.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $149.45 in Billed Charges for Rev 250 = $82.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,82.65,,,,,,,72.6300,149.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $149.45 in Billed Charges for Rev 250 = $82.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,107.60,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $149.45 in Billed Charges for Rev 250 = $107.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,92.66,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $149.45 in Billed Charges for Rev 250 = $92.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,107.60,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $149.45 in Billed Charges for Rev 250 = $107.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,107.60,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $149.45 in Billed Charges for Rev 250 = $107.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML SYRINGE,250,RC,76329-3302-1,CDM,,,,,,both,50.000000,ML,149.4500,98.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,89.67,,,,,,,72.6300,149.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $149.45 in Billed Charges for Rev 250 = $89.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXTROSE 50 % SOLN 50 ML VIAL,250,RC,0409-6648-16,CDM,,,,,,both,50.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,AETNA,AETNA HSHS,1236.86,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,914.65 in Billed Charges for Rev 250 = $1,236.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,AETNA,ALL COMMERCIAL AETNA,1914.65,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,914.65 in Billed Charges for Rev 250 = $1,914.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,ANTHEM,ANTHEM POS/HMO,1301.96,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,914.65 in Billed Charges at 68% = $1,301.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,ANTHEM,ANTHEM PPO,1301.96,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,914.65 in Billed Charges at 68% = $1,301.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1914.65,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,914.65 in Billed Charges for Rev 250 = $1,914.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,CENPATICO,ALL MEDICAID CENPATICO,1914.65,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,914.65 in Billed Charges for Rev 250 = $1,914.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1627.45,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,914.65 in Billed Charges for Rev 250 = $1,627.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,CIGNA,ALL COMMERCIAL CIGNA,1340.26,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,914.65 in Billed Charges for Rev 250 = $1,340.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,COFINITY,COFINITY,1914.65,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,914.65 in Billed Charges for Rev 250 = $1,914.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1818.92,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,914.65 in Billed Charges for Rev 250 = $1,818.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,1608.31,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,914.65 in Billed Charges for Rev 250 = $1,608.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1359.40,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,914.65 in Billed Charges for Rev 250 = $1,359.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1397.69,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,914.65 in Billed Charges for Rev 250 = $1,397.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,930.52,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,914.65 in Billed Charges for Rev 250 = $930.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1627.45,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,914.65 in Billed Charges for Rev 250 = $1,627.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,HUMANA,HUMANA CHOICE CARE HMO,1215.80,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,914.65 in Billed Charges at 63.5% = $1,215.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,HUMANA,HUMANA CHOICE CARE PPO,1627.45,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,914.65 in Billed Charges for Rev 250 = $1,627.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,HUMANA,HUMANA NATIIONAL POS HMO,1215.80,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,914.65 in Billed Charges at 63.5% = $1,215.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1397.69,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,914.65 in Billed Charges for Rev 250 = $1,397.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,1914.65,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,914.65 in Billed Charges for Rev 250 = $1,914.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,957.33,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,914.65 in Billed Charges for Rev 250 = $957.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1608.31,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,914.65 in Billed Charges for Rev 250 = $1,608.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1435.99,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,914.65 in Billed Charges for Rev 250 = $1,435.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1761.48,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,914.65 in Billed Charges for Rev 250 = $1,761.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1148.79,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,914.65 in Billed Charges for Rev 250 = $1,148.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1148.79,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,914.65 in Billed Charges for Rev 250 = $1,148.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,PREVEA HEALTH NETWORK,PREVEA360,1148.79,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,914.65 in Billed Charges for Rev 250 = $1,148.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1148.79,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,914.65 in Billed Charges for Rev 250 = $1,148.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1222.12,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,914.65 in Billed Charges for Rev 250 = $1,222.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1378.55,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,914.65 in Billed Charges for Rev 250 = $1,378.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1058.80,,,,,,,930.5200,1914.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,914.65 in Billed Charges for Rev 250 = $1,058.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,UNITED HEALTHCARE,UHC ONEIDA NATION,1058.80,,,,,,,930.5200,1914.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,914.65 in Billed Charges for Rev 250 = $1,058.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,UNITED HEALTHCARE,UNITED HEALTHCARE,1058.80,,,,,,,930.5200,1914.6500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,914.65 in Billed Charges for Rev 250 = $1,058.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1378.55,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,914.65 in Billed Charges for Rev 250 = $1,378.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1187.08,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,914.65 in Billed Charges for Rev 250 = $1,187.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1378.55,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,914.65 in Billed Charges for Rev 250 = $1,378.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1378.55,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,914.65 in Billed Charges for Rev 250 = $1,378.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINOPROSTONE 10 MG INST,250,RC,55566-2800-0,CDM,,,,,,both,1.000000,EA,1914.6500,1263.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1148.79,,,,,,,930.5200,1914.6500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,914.65 in Billed Charges for Rev 250 = $1,148.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,AETNA,AETNA HSHS,540.86,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $837.25 in Billed Charges for Rev 250 = $540.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,AETNA,ALL COMMERCIAL AETNA,837.25,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.25 in Billed Charges for Rev 250 = $837.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,ANTHEM,ANTHEM POS/HMO,569.33,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $837.25 in Billed Charges at 68% = $569.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,ANTHEM,ANTHEM PPO,569.33,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $837.25 in Billed Charges at 68% = $569.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,837.25,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.25 in Billed Charges for Rev 250 = $837.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,CENPATICO,ALL MEDICAID CENPATICO,837.25,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.25 in Billed Charges for Rev 250 = $837.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,711.66,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.25 in Billed Charges for Rev 250 = $711.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,CIGNA,ALL COMMERCIAL CIGNA,586.08,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $837.25 in Billed Charges for Rev 250 = $586.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,COFINITY,COFINITY,837.25,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.25 in Billed Charges for Rev 250 = $837.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,795.39,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $837.25 in Billed Charges for Rev 250 = $795.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,HEALTH CARE ALLIANCE,THE ALLIANCE,703.29,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $837.25 in Billed Charges for Rev 250 = $703.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,594.45,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $837.25 in Billed Charges for Rev 250 = $594.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,611.19,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $837.25 in Billed Charges for Rev 250 = $611.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,HSHS EMPLOYEES,HSHS EMPLOYEES,406.90,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $837.25 in Billed Charges for Rev 250 = $406.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,711.66,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.25 in Billed Charges for Rev 250 = $711.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,HUMANA,HUMANA CHOICE CARE HMO,531.65,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $837.25 in Billed Charges at 63.5% = $531.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,HUMANA,HUMANA CHOICE CARE PPO,711.66,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $837.25 in Billed Charges for Rev 250 = $711.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,HUMANA,HUMANA NATIIONAL POS HMO,531.65,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $837.25 in Billed Charges at 63.5% = $531.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,611.19,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $837.25 in Billed Charges for Rev 250 = $611.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,LIVE360,LIVE360 HSHS HEALTHY PLAN,837.25,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $837.25 in Billed Charges for Rev 250 = $837.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,418.63,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $837.25 in Billed Charges for Rev 250 = $418.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,703.29,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $837.25 in Billed Charges for Rev 250 = $703.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,627.94,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $837.25 in Billed Charges for Rev 250 = $627.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,770.27,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $837.25 in Billed Charges for Rev 250 = $770.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,502.35,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $837.25 in Billed Charges for Rev 250 = $502.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,502.35,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $837.25 in Billed Charges for Rev 250 = $502.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,PREVEA HEALTH NETWORK,PREVEA360,502.35,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $837.25 in Billed Charges for Rev 250 = $502.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,502.35,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $837.25 in Billed Charges for Rev 250 = $502.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,534.42,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $837.25 in Billed Charges for Rev 250 = $534.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,602.82,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.25 in Billed Charges for Rev 250 = $602.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,463.00,,,,,,,406.9000,837.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $837.25 in Billed Charges for Rev 250 = $463.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,UNITED HEALTHCARE,UHC ONEIDA NATION,463.00,,,,,,,406.9000,837.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $837.25 in Billed Charges for Rev 250 = $463.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,UNITED HEALTHCARE,UNITED HEALTHCARE,463.00,,,,,,,406.9000,837.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $837.25 in Billed Charges for Rev 250 = $463.00 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,602.82,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.25 in Billed Charges for Rev 250 = $602.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,519.10,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $837.25 in Billed Charges for Rev 250 = $519.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,602.82,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.25 in Billed Charges for Rev 250 = $602.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,602.82,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $837.25 in Billed Charges for Rev 250 = $602.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,250,RC,60505-0815-0,CDM,,,,,,both,5.000000,ML,837.2500,552.5900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,502.35,,,,,,,406.9000,837.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $837.25 in Billed Charges for Rev 250 = $502.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ELECTROLYTE COMBINED SOLN,250,RC,0990-7670-09,CDM,,,,,,both,1000.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9787-01,CDM,,,,,,both,1.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,AETNA,AETNA HSHS,45.22,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $70.00 in Billed Charges for Rev 250 = $45.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,AETNA,ALL COMMERCIAL AETNA,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 250 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,ANTHEM,ANTHEM POS/HMO,47.60,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $70.00 in Billed Charges at 68% = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,ANTHEM,ANTHEM PPO,47.60,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $70.00 in Billed Charges at 68% = $47.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 250 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,CENPATICO,ALL MEDICAID CENPATICO,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 250 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,59.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.00 in Billed Charges for Rev 250 = $59.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,CIGNA,ALL COMMERCIAL CIGNA,49.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $70.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,COFINITY,COFINITY,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 250 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,66.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $70.00 in Billed Charges for Rev 250 = $66.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,HEALTH CARE ALLIANCE,THE ALLIANCE,58.80,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.00 in Billed Charges for Rev 250 = $58.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,49.70,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $70.00 in Billed Charges for Rev 250 = $49.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,51.10,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.00 in Billed Charges for Rev 250 = $51.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,HSHS EMPLOYEES,HSHS EMPLOYEES,34.02,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $70.00 in Billed Charges for Rev 250 = $34.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,59.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.00 in Billed Charges for Rev 250 = $59.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,HUMANA,HUMANA CHOICE CARE HMO,44.45,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $70.00 in Billed Charges at 63.5% = $44.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,HUMANA,HUMANA CHOICE CARE PPO,59.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $70.00 in Billed Charges for Rev 250 = $59.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,HUMANA,HUMANA NATIIONAL POS HMO,44.45,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $70.00 in Billed Charges at 63.5% = $44.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,51.10,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $70.00 in Billed Charges for Rev 250 = $51.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,LIVE360,LIVE360 HSHS HEALTHY PLAN,70.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $70.00 in Billed Charges for Rev 250 = $70.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $70.00 in Billed Charges for Rev 250 = $35.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,58.80,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $70.00 in Billed Charges for Rev 250 = $58.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,52.50,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $70.00 in Billed Charges for Rev 250 = $52.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,64.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $70.00 in Billed Charges for Rev 250 = $64.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 250 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 250 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,PREVEA HEALTH NETWORK,PREVEA360,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 250 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 250 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,44.68,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $70.00 in Billed Charges for Rev 250 = $44.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,50.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.00 in Billed Charges for Rev 250 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,38.71,,,,,,,34.0200,70.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $70.00 in Billed Charges for Rev 250 = $38.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,UNITED HEALTHCARE,UHC ONEIDA NATION,38.71,,,,,,,34.0200,70.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $70.00 in Billed Charges for Rev 250 = $38.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,UNITED HEALTHCARE,UNITED HEALTHCARE,38.71,,,,,,,34.0200,70.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $70.00 in Billed Charges for Rev 250 = $38.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,50.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.00 in Billed Charges for Rev 250 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,43.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $70.00 in Billed Charges for Rev 250 = $43.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,50.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.00 in Billed Charges for Rev 250 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,50.40,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $70.00 in Billed Charges for Rev 250 = $50.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENALAPRILAT 1.25 MG/ML SOLN,250,RC,0143-9786-01,CDM,,,,,,both,2.000000,ML,70.0000,46.2000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42.00,,,,,,,34.0200,70.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $70.00 in Billed Charges for Rev 250 = $42.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,AETNA,AETNA HSHS,47.90,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $74.15 in Billed Charges for Rev 250 = $47.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,AETNA,ALL COMMERCIAL AETNA,74.15,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.15 in Billed Charges for Rev 250 = $74.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,ANTHEM,ANTHEM POS/HMO,50.42,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $74.15 in Billed Charges at 68% = $50.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,ANTHEM,ANTHEM PPO,50.42,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $74.15 in Billed Charges at 68% = $50.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,74.15,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.15 in Billed Charges for Rev 250 = $74.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,CENPATICO,ALL MEDICAID CENPATICO,74.15,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.15 in Billed Charges for Rev 250 = $74.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,63.03,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.15 in Billed Charges for Rev 250 = $63.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,CIGNA,ALL COMMERCIAL CIGNA,51.91,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $74.15 in Billed Charges for Rev 250 = $51.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,COFINITY,COFINITY,74.15,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.15 in Billed Charges for Rev 250 = $74.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,70.44,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $74.15 in Billed Charges for Rev 250 = $70.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,62.29,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.15 in Billed Charges for Rev 250 = $62.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,52.65,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $74.15 in Billed Charges for Rev 250 = $52.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.13,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.15 in Billed Charges for Rev 250 = $54.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,36.04,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $74.15 in Billed Charges for Rev 250 = $36.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,63.03,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.15 in Billed Charges for Rev 250 = $63.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,HUMANA,HUMANA CHOICE CARE HMO,47.09,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $74.15 in Billed Charges at 63.5% = $47.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,HUMANA,HUMANA CHOICE CARE PPO,63.03,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.15 in Billed Charges for Rev 250 = $63.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,HUMANA,HUMANA NATIIONAL POS HMO,47.09,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $74.15 in Billed Charges at 63.5% = $47.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.13,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.15 in Billed Charges for Rev 250 = $54.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,74.15,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.15 in Billed Charges for Rev 250 = $74.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.08,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $74.15 in Billed Charges for Rev 250 = $37.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,62.29,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.15 in Billed Charges for Rev 250 = $62.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,55.61,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $74.15 in Billed Charges for Rev 250 = $55.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,68.22,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $74.15 in Billed Charges for Rev 250 = $68.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,44.49,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.15 in Billed Charges for Rev 250 = $44.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,44.49,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.15 in Billed Charges for Rev 250 = $44.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,PREVEA HEALTH NETWORK,PREVEA360,44.49,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.15 in Billed Charges for Rev 250 = $44.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,44.49,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.15 in Billed Charges for Rev 250 = $44.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.33,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $74.15 in Billed Charges for Rev 250 = $47.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.39,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.15 in Billed Charges for Rev 250 = $53.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,41.01,,,,,,,36.0400,74.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.15 in Billed Charges for Rev 250 = $41.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,41.01,,,,,,,36.0400,74.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.15 in Billed Charges for Rev 250 = $41.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,41.01,,,,,,,36.0400,74.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.15 in Billed Charges for Rev 250 = $41.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.39,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.15 in Billed Charges for Rev 250 = $53.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,45.97,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $74.15 in Billed Charges for Rev 250 = $45.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.39,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.15 in Billed Charges for Rev 250 = $53.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.39,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.15 in Billed Charges for Rev 250 = $53.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ENTERAL FEEDING TUBE DECLOGGING,250,RC,50770-456-09,CDM,,,,,,both,1.000000,EA,74.1500,48.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.49,,,,,,,36.0400,74.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.15 in Billed Charges for Rev 250 = $44.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,AETNA,AETNA HSHS,44.12,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $68.30 in Billed Charges for Rev 250 = $44.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,AETNA,ALL COMMERCIAL AETNA,68.30,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.30 in Billed Charges for Rev 250 = $68.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,ANTHEM,ANTHEM POS/HMO,46.44,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.30 in Billed Charges at 68% = $46.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,ANTHEM,ANTHEM PPO,46.44,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.30 in Billed Charges at 68% = $46.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,68.30,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.30 in Billed Charges for Rev 250 = $68.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,CENPATICO,ALL MEDICAID CENPATICO,68.30,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.30 in Billed Charges for Rev 250 = $68.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,58.06,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.30 in Billed Charges for Rev 250 = $58.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,CIGNA,ALL COMMERCIAL CIGNA,47.81,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $68.30 in Billed Charges for Rev 250 = $47.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,COFINITY,COFINITY,68.30,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.30 in Billed Charges for Rev 250 = $68.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,64.89,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $68.30 in Billed Charges for Rev 250 = $64.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,57.37,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.30 in Billed Charges for Rev 250 = $57.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.49,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $68.30 in Billed Charges for Rev 250 = $48.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,49.86,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.30 in Billed Charges for Rev 250 = $49.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,33.19,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $68.30 in Billed Charges for Rev 250 = $33.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,58.06,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.30 in Billed Charges for Rev 250 = $58.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,HUMANA,HUMANA CHOICE CARE HMO,43.37,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.30 in Billed Charges at 63.5% = $43.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,HUMANA,HUMANA CHOICE CARE PPO,58.06,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.30 in Billed Charges for Rev 250 = $58.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,HUMANA,HUMANA NATIIONAL POS HMO,43.37,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.30 in Billed Charges at 63.5% = $43.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,49.86,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.30 in Billed Charges for Rev 250 = $49.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,68.30,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.30 in Billed Charges for Rev 250 = $68.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.15,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $68.30 in Billed Charges for Rev 250 = $34.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.37,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.30 in Billed Charges for Rev 250 = $57.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.23,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $68.30 in Billed Charges for Rev 250 = $51.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,62.84,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $68.30 in Billed Charges for Rev 250 = $62.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,40.98,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.30 in Billed Charges for Rev 250 = $40.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,40.98,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.30 in Billed Charges for Rev 250 = $40.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,PREVEA HEALTH NETWORK,PREVEA360,40.98,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.30 in Billed Charges for Rev 250 = $40.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,40.98,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.30 in Billed Charges for Rev 250 = $40.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.60,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $68.30 in Billed Charges for Rev 250 = $43.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.18,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.30 in Billed Charges for Rev 250 = $49.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,37.77,,,,,,,33.1900,68.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.30 in Billed Charges for Rev 250 = $37.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,37.77,,,,,,,33.1900,68.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.30 in Billed Charges for Rev 250 = $37.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,37.77,,,,,,,33.1900,68.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.30 in Billed Charges for Rev 250 = $37.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.18,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.30 in Billed Charges for Rev 250 = $49.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.35,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $68.30 in Billed Charges for Rev 250 = $42.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.18,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.30 in Billed Charges for Rev 250 = $49.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.18,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.30 in Billed Charges for Rev 250 = $49.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-222-20,CDM,,,,,,both,20.000000,ML,68.3000,45.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,40.98,,,,,,,33.1900,68.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.30 in Billed Charges for Rev 250 = $40.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-445-01,CDM,,,,,,both,10.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,65219-447-02,CDM,,,,,,both,20.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,AETNA,AETNA HSHS,10.79,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.70 in Billed Charges for Rev 637 = $10.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,AETNA,ALL COMMERCIAL AETNA,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,ANTHEM,ANTHEM POS/HMO,11.36,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $16.70 in Billed Charges for Rev 637 = $11.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,ANTHEM,ANTHEM PPO,11.36,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $16.70 in Billed Charges for Rev 637 = $11.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,CENPATICO,ALL MEDICAID CENPATICO,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.20,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.70 in Billed Charges for Rev 637 = $14.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,CIGNA,ALL COMMERCIAL CIGNA,11.69,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.70 in Billed Charges for Rev 637 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,COFINITY,COFINITY,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.87,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.70 in Billed Charges for Rev 637 = $15.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,14.03,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.70 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.86,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.70 in Billed Charges for Rev 637 = $11.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.19,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.70 in Billed Charges for Rev 637 = $12.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,8.12,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.70 in Billed Charges for Rev 637 = $8.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.20,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.70 in Billed Charges for Rev 637 = $14.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,HUMANA,HUMANA CHOICE CARE HMO,10.60,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $16.70 in Billed Charges at 63.5% = $10.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,HUMANA,HUMANA CHOICE CARE PPO,14.20,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.70 in Billed Charges for Rev 637 = $14.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,HUMANA,HUMANA NATIIONAL POS HMO,10.60,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $16.70 in Billed Charges at 63.5% = $10.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.19,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.70 in Billed Charges for Rev 637 = $12.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.70,,,,,,,8.1200,16.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.35,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.70 in Billed Charges for Rev 637 = $8.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.03,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.70 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.53,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.70 in Billed Charges for Rev 637 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.36,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.70 in Billed Charges for Rev 637 = $15.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,PREVEA HEALTH NETWORK,PREVEA360,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.66,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.70 in Billed Charges for Rev 637 = $10.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.70 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.24,,,,,,,8.1200,16.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.70 in Billed Charges for Rev 637 = $9.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,9.24,,,,,,,8.1200,16.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.70 in Billed Charges for Rev 637 = $9.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,9.24,,,,,,,8.1200,16.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.70 in Billed Charges for Rev 637 = $9.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,UNITY HEALTH PLAN,UNITY HOSPICE,16.70,,,,,,,8.1200,16.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.70 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.35,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.70 in Billed Charges for Rev 637 = $10.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.70 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.70 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN 400 MG/5ML SUSR,637,RC,0143-9887-50,CDM,,,,,,both,50.000000,ML,16.7000,11.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,AETNA,AETNA HSHS,8.08,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $12.50 in Billed Charges for Rev 637 = $8.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,AETNA,ALL COMMERCIAL AETNA,12.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.50 in Billed Charges for Rev 637 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,ANTHEM,ANTHEM POS/HMO,8.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.50 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,ANTHEM,ANTHEM PPO,8.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $12.50 in Billed Charges for Rev 637 = $8.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,12.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.50 in Billed Charges for Rev 637 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,CENPATICO,ALL MEDICAID CENPATICO,12.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.50 in Billed Charges for Rev 637 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,10.63,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.50 in Billed Charges for Rev 637 = $10.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,CIGNA,ALL COMMERCIAL CIGNA,8.75,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $12.50 in Billed Charges for Rev 637 = $8.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,COFINITY,COFINITY,12.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.50 in Billed Charges for Rev 637 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,11.88,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $12.50 in Billed Charges for Rev 637 = $11.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,HEALTH CARE ALLIANCE,THE ALLIANCE,10.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.50 in Billed Charges for Rev 637 = $10.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,8.88,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $12.50 in Billed Charges for Rev 637 = $8.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,9.13,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.50 in Billed Charges for Rev 637 = $9.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,HSHS EMPLOYEES,HSHS EMPLOYEES,6.08,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $12.50 in Billed Charges for Rev 637 = $6.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,10.63,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.50 in Billed Charges for Rev 637 = $10.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,HUMANA,HUMANA CHOICE CARE HMO,7.94,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.50 in Billed Charges at 63.5% = $7.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,HUMANA,HUMANA CHOICE CARE PPO,10.63,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $12.50 in Billed Charges for Rev 637 = $10.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,HUMANA,HUMANA NATIIONAL POS HMO,7.94,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $12.50 in Billed Charges at 63.5% = $7.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,9.13,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $12.50 in Billed Charges for Rev 637 = $9.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,LIVE360,LIVE360 HSHS HEALTHY PLAN,12.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $12.50 in Billed Charges for Rev 637 = $12.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,12.50,,,,,,,6.0800,12.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,6.25,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $12.50 in Billed Charges for Rev 637 = $6.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,10.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $12.50 in Billed Charges for Rev 637 = $10.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,9.38,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $12.50 in Billed Charges for Rev 637 = $9.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,11.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $12.50 in Billed Charges for Rev 637 = $11.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,7.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.50 in Billed Charges for Rev 637 = $7.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,7.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.50 in Billed Charges for Rev 637 = $7.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,PREVEA HEALTH NETWORK,PREVEA360,7.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.50 in Billed Charges for Rev 637 = $7.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,7.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.50 in Billed Charges for Rev 637 = $7.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,7.98,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $12.50 in Billed Charges for Rev 637 = $7.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,9.00,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.50 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,6.91,,,,,,,6.0800,12.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.50 in Billed Charges for Rev 637 = $6.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,UNITED HEALTHCARE,UHC ONEIDA NATION,6.91,,,,,,,6.0800,12.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.50 in Billed Charges for Rev 637 = $6.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,UNITED HEALTHCARE,UNITED HEALTHCARE,6.91,,,,,,,6.0800,12.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $12.50 in Billed Charges for Rev 637 = $6.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,UNITY HEALTH PLAN,UNITY HOSPICE,12.50,,,,,,,6.0800,12.5000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,9.00,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.50 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,7.75,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $12.50 in Billed Charges for Rev 637 = $7.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,9.00,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.50 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,9.00,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $12.50 in Billed Charges for Rev 637 = $9.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,637,RC,0781-1831-01,CDM,,,,,,both,1.000000,EA,12.5000,8.2500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,7.50,,,,,,,6.0800,12.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $12.50 in Billed Charges for Rev 637 = $7.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,AETNA,AETNA HSHS,182.30,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $282.20 in Billed Charges for Rev 637 = $182.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,AETNA,ALL COMMERCIAL AETNA,282.20,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $282.20 in Billed Charges for Rev 637 = $282.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,ANTHEM,ANTHEM POS/HMO,191.90,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $282.20 in Billed Charges for Rev 637 = $191.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,ANTHEM,ANTHEM PPO,191.90,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $282.20 in Billed Charges for Rev 637 = $191.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,282.20,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $282.20 in Billed Charges for Rev 637 = $282.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,CENPATICO,ALL MEDICAID CENPATICO,282.20,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $282.20 in Billed Charges for Rev 637 = $282.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,239.87,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $282.20 in Billed Charges for Rev 637 = $239.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,CIGNA,ALL COMMERCIAL CIGNA,197.54,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $282.20 in Billed Charges for Rev 637 = $197.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,COFINITY,COFINITY,282.20,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $282.20 in Billed Charges for Rev 637 = $282.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,268.09,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $282.20 in Billed Charges for Rev 637 = $268.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,HEALTH CARE ALLIANCE,THE ALLIANCE,237.05,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $282.20 in Billed Charges for Rev 637 = $237.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,200.36,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $282.20 in Billed Charges for Rev 637 = $200.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,206.01,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $282.20 in Billed Charges for Rev 637 = $206.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,HSHS EMPLOYEES,HSHS EMPLOYEES,137.15,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $282.20 in Billed Charges for Rev 637 = $137.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,239.87,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $282.20 in Billed Charges for Rev 637 = $239.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,HUMANA,HUMANA CHOICE CARE HMO,179.20,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $282.20 in Billed Charges at 63.5% = $179.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,HUMANA,HUMANA CHOICE CARE PPO,239.87,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $282.20 in Billed Charges for Rev 637 = $239.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,HUMANA,HUMANA NATIIONAL POS HMO,179.20,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $282.20 in Billed Charges at 63.5% = $179.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,206.01,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $282.20 in Billed Charges for Rev 637 = $206.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,LIVE360,LIVE360 HSHS HEALTHY PLAN,282.20,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $282.20 in Billed Charges for Rev 637 = $282.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,282.20,,,,,,,137.1500,282.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,141.10,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $282.20 in Billed Charges for Rev 637 = $141.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,237.05,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $282.20 in Billed Charges for Rev 637 = $237.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,211.65,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $282.20 in Billed Charges for Rev 637 = $211.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,259.62,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $282.20 in Billed Charges for Rev 637 = $259.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,169.32,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $282.20 in Billed Charges for Rev 637 = $169.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,169.32,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $282.20 in Billed Charges for Rev 637 = $169.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,PREVEA HEALTH NETWORK,PREVEA360,169.32,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $282.20 in Billed Charges for Rev 637 = $169.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,169.32,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $282.20 in Billed Charges for Rev 637 = $169.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,180.13,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $282.20 in Billed Charges for Rev 637 = $180.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,203.18,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $282.20 in Billed Charges for Rev 637 = $203.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,156.06,,,,,,,137.1500,282.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $282.20 in Billed Charges for Rev 637 = $156.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,UNITED HEALTHCARE,UHC ONEIDA NATION,156.06,,,,,,,137.1500,282.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $282.20 in Billed Charges for Rev 637 = $156.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,UNITED HEALTHCARE,UNITED HEALTHCARE,156.06,,,,,,,137.1500,282.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $282.20 in Billed Charges for Rev 637 = $156.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,UNITY HEALTH PLAN,UNITY HOSPICE,282.20,,,,,,,137.1500,282.2000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,203.18,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $282.20 in Billed Charges for Rev 637 = $203.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,174.96,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $282.20 in Billed Charges for Rev 637 = $174.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,203.18,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $282.20 in Billed Charges for Rev 637 = $203.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,203.18,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $282.20 in Billed Charges for Rev 637 = $203.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,637,RC,0781-6139-54,CDM,,,,,,both,125.000000,ML,282.2000,186.2500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,169.32,,,,,,,137.1500,282.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $282.20 in Billed Charges for Rev 637 = $169.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,AETNA,AETNA HSHS,10.79,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $16.70 in Billed Charges for Rev 637 = $10.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,AETNA,ALL COMMERCIAL AETNA,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,ANTHEM,ANTHEM POS/HMO,11.36,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $16.70 in Billed Charges for Rev 637 = $11.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,ANTHEM,ANTHEM PPO,11.36,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $16.70 in Billed Charges for Rev 637 = $11.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,CENPATICO,ALL MEDICAID CENPATICO,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,14.20,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.70 in Billed Charges for Rev 637 = $14.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,CIGNA,ALL COMMERCIAL CIGNA,11.69,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $16.70 in Billed Charges for Rev 637 = $11.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,COFINITY,COFINITY,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,15.87,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $16.70 in Billed Charges for Rev 637 = $15.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,HEALTH CARE ALLIANCE,THE ALLIANCE,14.03,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.70 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,11.86,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $16.70 in Billed Charges for Rev 637 = $11.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,12.19,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.70 in Billed Charges for Rev 637 = $12.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,HSHS EMPLOYEES,HSHS EMPLOYEES,8.12,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $16.70 in Billed Charges for Rev 637 = $8.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,14.20,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.70 in Billed Charges for Rev 637 = $14.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,HUMANA,HUMANA CHOICE CARE HMO,10.60,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $16.70 in Billed Charges at 63.5% = $10.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,HUMANA,HUMANA CHOICE CARE PPO,14.20,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $16.70 in Billed Charges for Rev 637 = $14.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,HUMANA,HUMANA NATIIONAL POS HMO,10.60,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $16.70 in Billed Charges at 63.5% = $10.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,12.19,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $16.70 in Billed Charges for Rev 637 = $12.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,LIVE360,LIVE360 HSHS HEALTHY PLAN,16.70,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $16.70 in Billed Charges for Rev 637 = $16.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,16.70,,,,,,,8.1200,16.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,8.35,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $16.70 in Billed Charges for Rev 637 = $8.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,14.03,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $16.70 in Billed Charges for Rev 637 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,12.53,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $16.70 in Billed Charges for Rev 637 = $12.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,15.36,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $16.70 in Billed Charges for Rev 637 = $15.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,PREVEA HEALTH NETWORK,PREVEA360,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,10.66,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $16.70 in Billed Charges for Rev 637 = $10.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,12.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.70 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,9.24,,,,,,,8.1200,16.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.70 in Billed Charges for Rev 637 = $9.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,UNITED HEALTHCARE,UHC ONEIDA NATION,9.24,,,,,,,8.1200,16.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.70 in Billed Charges for Rev 637 = $9.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,UNITED HEALTHCARE,UNITED HEALTHCARE,9.24,,,,,,,8.1200,16.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $16.70 in Billed Charges for Rev 637 = $9.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,UNITY HEALTH PLAN,UNITY HOSPICE,16.70,,,,,,,8.1200,16.7000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,12.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.70 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,10.35,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $16.70 in Billed Charges for Rev 637 = $10.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,12.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.70 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,12.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $16.70 in Billed Charges for Rev 637 = $12.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,637,RC,0781-1852-01,CDM,,,,,,both,1.000000,EA,16.7000,11.0200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,10.02,,,,,,,8.1200,16.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $16.70 in Billed Charges for Rev 637 = $10.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,AETNA,AETNA HSHS,13.47,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.85 in Billed Charges for Rev 637 = $13.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,AETNA,ALL COMMERCIAL AETNA,20.85,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.85 in Billed Charges for Rev 637 = $20.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,ANTHEM,ANTHEM POS/HMO,14.18,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $20.85 in Billed Charges for Rev 637 = $14.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,ANTHEM,ANTHEM PPO,14.18,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $20.85 in Billed Charges for Rev 637 = $14.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.85,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.85 in Billed Charges for Rev 637 = $20.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,CENPATICO,ALL MEDICAID CENPATICO,20.85,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.85 in Billed Charges for Rev 637 = $20.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.72,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.85 in Billed Charges for Rev 637 = $17.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,CIGNA,ALL COMMERCIAL CIGNA,14.60,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.85 in Billed Charges for Rev 637 = $14.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,COFINITY,COFINITY,20.85,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.85 in Billed Charges for Rev 637 = $20.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.81,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.85 in Billed Charges for Rev 637 = $19.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,17.51,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.85 in Billed Charges for Rev 637 = $17.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.80,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.85 in Billed Charges for Rev 637 = $14.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,15.22,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.85 in Billed Charges for Rev 637 = $15.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,10.13,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.85 in Billed Charges for Rev 637 = $10.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.72,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.85 in Billed Charges for Rev 637 = $17.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,HUMANA,HUMANA CHOICE CARE HMO,13.24,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $20.85 in Billed Charges at 63.5% = $13.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,HUMANA,HUMANA CHOICE CARE PPO,17.72,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.85 in Billed Charges for Rev 637 = $17.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,HUMANA,HUMANA NATIIONAL POS HMO,13.24,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $20.85 in Billed Charges at 63.5% = $13.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,15.22,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.85 in Billed Charges for Rev 637 = $15.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.85,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.85 in Billed Charges for Rev 637 = $20.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,20.85,,,,,,,10.1300,20.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.43,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.85 in Billed Charges for Rev 637 = $10.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.51,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.85 in Billed Charges for Rev 637 = $17.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.64,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.85 in Billed Charges for Rev 637 = $15.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,19.18,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.85 in Billed Charges for Rev 637 = $19.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.51,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.85 in Billed Charges for Rev 637 = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.51,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.85 in Billed Charges for Rev 637 = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,PREVEA HEALTH NETWORK,PREVEA360,12.51,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.85 in Billed Charges for Rev 637 = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.51,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.85 in Billed Charges for Rev 637 = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.31,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.85 in Billed Charges for Rev 637 = $13.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,15.01,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.85 in Billed Charges for Rev 637 = $15.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.53,,,,,,,10.1300,20.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.85 in Billed Charges for Rev 637 = $11.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,11.53,,,,,,,10.1300,20.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.85 in Billed Charges for Rev 637 = $11.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,11.53,,,,,,,10.1300,20.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.85 in Billed Charges for Rev 637 = $11.53 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,UNITY HEALTH PLAN,UNITY HOSPICE,20.85,,,,,,,10.1300,20.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,15.01,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.85 in Billed Charges for Rev 637 = $15.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.93,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.85 in Billed Charges for Rev 637 = $12.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,15.01,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.85 in Billed Charges for Rev 637 = $15.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,15.01,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.85 in Billed Charges for Rev 637 = $15.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24,637,RC,0406-8952-01,CDM,,,,,,both,1.000000,EA,20.8500,13.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.51,,,,,,,10.1300,20.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.85 in Billed Charges for Rev 637 = $12.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,AETNA,AETNA HSHS,227.26,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $351.80 in Billed Charges for Rev 637 = $227.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,AETNA,ALL COMMERCIAL AETNA,351.80,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.80 in Billed Charges for Rev 637 = $351.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,ANTHEM,ANTHEM POS/HMO,239.22,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $351.80 in Billed Charges for Rev 637 = $239.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,ANTHEM,ANTHEM PPO,239.22,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $351.80 in Billed Charges for Rev 637 = $239.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,351.80,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.80 in Billed Charges for Rev 637 = $351.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,CENPATICO,ALL MEDICAID CENPATICO,351.80,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.80 in Billed Charges for Rev 637 = $351.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,299.03,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.80 in Billed Charges for Rev 637 = $299.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,CIGNA,ALL COMMERCIAL CIGNA,246.26,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $351.80 in Billed Charges for Rev 637 = $246.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,COFINITY,COFINITY,351.80,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.80 in Billed Charges for Rev 637 = $351.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,334.21,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $351.80 in Billed Charges for Rev 637 = $334.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,295.51,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.80 in Billed Charges for Rev 637 = $295.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,249.78,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $351.80 in Billed Charges for Rev 637 = $249.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,256.81,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.80 in Billed Charges for Rev 637 = $256.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,170.97,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $351.80 in Billed Charges for Rev 637 = $170.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,299.03,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.80 in Billed Charges for Rev 637 = $299.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,HUMANA,HUMANA CHOICE CARE HMO,223.39,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $351.80 in Billed Charges at 63.5% = $223.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,HUMANA,HUMANA CHOICE CARE PPO,299.03,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $351.80 in Billed Charges for Rev 637 = $299.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,HUMANA,HUMANA NATIIONAL POS HMO,223.39,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $351.80 in Billed Charges at 63.5% = $223.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,256.81,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $351.80 in Billed Charges for Rev 637 = $256.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,351.80,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $351.80 in Billed Charges for Rev 637 = $351.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,351.80,,,,,,,170.9700,351.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,175.90,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $351.80 in Billed Charges for Rev 637 = $175.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,295.51,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $351.80 in Billed Charges for Rev 637 = $295.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,263.85,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $351.80 in Billed Charges for Rev 637 = $263.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,323.66,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $351.80 in Billed Charges for Rev 637 = $323.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,211.08,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.80 in Billed Charges for Rev 637 = $211.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,211.08,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.80 in Billed Charges for Rev 637 = $211.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,PREVEA HEALTH NETWORK,PREVEA360,211.08,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.80 in Billed Charges for Rev 637 = $211.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,211.08,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.80 in Billed Charges for Rev 637 = $211.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,224.55,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $351.80 in Billed Charges for Rev 637 = $224.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,253.30,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.80 in Billed Charges for Rev 637 = $253.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,194.55,,,,,,,170.9700,351.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $351.80 in Billed Charges for Rev 637 = $194.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,UNITED HEALTHCARE,UHC ONEIDA NATION,194.55,,,,,,,170.9700,351.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $351.80 in Billed Charges for Rev 637 = $194.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,UNITED HEALTHCARE,UNITED HEALTHCARE,194.55,,,,,,,170.9700,351.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $351.80 in Billed Charges for Rev 637 = $194.55 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,UNITY HEALTH PLAN,UNITY HOSPICE,351.80,,,,,,,170.9700,351.8000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,253.30,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.80 in Billed Charges for Rev 637 = $253.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,218.12,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $351.80 in Billed Charges for Rev 637 = $218.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,253.30,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.80 in Billed Charges for Rev 637 = $253.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,253.30,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $351.80 in Billed Charges for Rev 637 = $253.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
APREPITANT 40 MG CAPS,637,RC,68462-583-40,CDM,,,,,,both,1.000000,EA,351.8000,232.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,211.08,,,,,,,170.9700,351.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $351.80 in Billed Charges for Rev 637 = $211.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,AETNA,AETNA HSHS,76.62,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.60 in Billed Charges for Rev 637 = $76.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,AETNA,ALL COMMERCIAL AETNA,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,ANTHEM,ANTHEM POS/HMO,80.65,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $118.60 in Billed Charges for Rev 637 = $80.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,ANTHEM,ANTHEM PPO,80.65,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $118.60 in Billed Charges for Rev 637 = $80.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,CENPATICO,ALL MEDICAID CENPATICO,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.81,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.60 in Billed Charges for Rev 637 = $100.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,CIGNA,ALL COMMERCIAL CIGNA,83.02,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.60 in Billed Charges for Rev 637 = $83.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,COFINITY,COFINITY,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.67,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.60 in Billed Charges for Rev 637 = $112.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,99.62,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.60 in Billed Charges for Rev 637 = $99.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,84.21,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.60 in Billed Charges for Rev 637 = $84.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.58,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.60 in Billed Charges for Rev 637 = $86.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,57.64,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.60 in Billed Charges for Rev 637 = $57.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.81,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.60 in Billed Charges for Rev 637 = $100.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,HUMANA,HUMANA CHOICE CARE HMO,75.31,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $118.60 in Billed Charges at 63.5% = $75.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,HUMANA,HUMANA CHOICE CARE PPO,100.81,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.60 in Billed Charges for Rev 637 = $100.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,HUMANA,HUMANA NATIIONAL POS HMO,75.31,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $118.60 in Billed Charges at 63.5% = $75.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.58,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.60 in Billed Charges for Rev 637 = $86.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.60,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.60 in Billed Charges for Rev 637 = $118.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,118.60,,,,,,,57.6400,118.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.30,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.60 in Billed Charges for Rev 637 = $59.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.62,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.60 in Billed Charges for Rev 637 = $99.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.95,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.60 in Billed Charges for Rev 637 = $88.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,109.11,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.60 in Billed Charges for Rev 637 = $109.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,PREVEA HEALTH NETWORK,PREVEA360,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.70,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.60 in Billed Charges for Rev 637 = $75.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,85.39,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.60 in Billed Charges for Rev 637 = $85.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,65.59,,,,,,,57.6400,118.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.60 in Billed Charges for Rev 637 = $65.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,65.59,,,,,,,57.6400,118.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.60 in Billed Charges for Rev 637 = $65.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,65.59,,,,,,,57.6400,118.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.60 in Billed Charges for Rev 637 = $65.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,UNITY HEALTH PLAN,UNITY HOSPICE,118.60,,,,,,,57.6400,118.6000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,85.39,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.60 in Billed Charges for Rev 637 = $85.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.53,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.60 in Billed Charges for Rev 637 = $73.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,85.39,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.60 in Billed Charges for Rev 637 = $85.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,85.39,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.60 in Billed Charges for Rev 637 = $85.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
AZITHROMYCIN 200 MG/5ML SUSR,637,RC,0093-2026-94,CDM,,,,,,both,22.500000,ML,118.6000,78.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,71.16,,,,,,,57.6400,118.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.60 in Billed Charges for Rev 637 = $71.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,AETNA,AETNA HSHS,57.40,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $88.85 in Billed Charges for Rev 637 = $57.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,AETNA,ALL COMMERCIAL AETNA,88.85,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.85 in Billed Charges for Rev 637 = $88.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,ANTHEM,ANTHEM POS/HMO,60.42,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $88.85 in Billed Charges for Rev 637 = $60.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,ANTHEM,ANTHEM PPO,60.42,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $88.85 in Billed Charges for Rev 637 = $60.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,88.85,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.85 in Billed Charges for Rev 637 = $88.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,CENPATICO,ALL MEDICAID CENPATICO,88.85,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.85 in Billed Charges for Rev 637 = $88.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,75.52,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.85 in Billed Charges for Rev 637 = $75.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,CIGNA,ALL COMMERCIAL CIGNA,62.20,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $88.85 in Billed Charges for Rev 637 = $62.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,COFINITY,COFINITY,88.85,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.85 in Billed Charges for Rev 637 = $88.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,84.41,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $88.85 in Billed Charges for Rev 637 = $84.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,74.63,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $88.85 in Billed Charges for Rev 637 = $74.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,63.08,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $88.85 in Billed Charges for Rev 637 = $63.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,64.86,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $88.85 in Billed Charges for Rev 637 = $64.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,43.18,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $88.85 in Billed Charges for Rev 637 = $43.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,75.52,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.85 in Billed Charges for Rev 637 = $75.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,HUMANA,HUMANA CHOICE CARE HMO,56.42,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $88.85 in Billed Charges at 63.5% = $56.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,HUMANA,HUMANA CHOICE CARE PPO,75.52,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $88.85 in Billed Charges for Rev 637 = $75.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,HUMANA,HUMANA NATIIONAL POS HMO,56.42,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $88.85 in Billed Charges at 63.5% = $56.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,64.86,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $88.85 in Billed Charges for Rev 637 = $64.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,88.85,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $88.85 in Billed Charges for Rev 637 = $88.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,88.85,,,,,,,43.1800,88.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,44.43,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $88.85 in Billed Charges for Rev 637 = $44.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,74.63,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $88.85 in Billed Charges for Rev 637 = $74.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,66.64,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $88.85 in Billed Charges for Rev 637 = $66.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,81.74,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $88.85 in Billed Charges for Rev 637 = $81.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,53.31,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $88.85 in Billed Charges for Rev 637 = $53.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,53.31,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $88.85 in Billed Charges for Rev 637 = $53.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,PREVEA HEALTH NETWORK,PREVEA360,53.31,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $88.85 in Billed Charges for Rev 637 = $53.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,53.31,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $88.85 in Billed Charges for Rev 637 = $53.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,56.71,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $88.85 in Billed Charges for Rev 637 = $56.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,63.97,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.85 in Billed Charges for Rev 637 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,49.13,,,,,,,43.1800,88.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $88.85 in Billed Charges for Rev 637 = $49.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,49.13,,,,,,,43.1800,88.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $88.85 in Billed Charges for Rev 637 = $49.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,49.13,,,,,,,43.1800,88.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $88.85 in Billed Charges for Rev 637 = $49.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,UNITY HEALTH PLAN,UNITY HOSPICE,88.85,,,,,,,43.1800,88.8500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,63.97,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.85 in Billed Charges for Rev 637 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,55.09,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $88.85 in Billed Charges for Rev 637 = $55.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,63.97,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.85 in Billed Charges for Rev 637 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,63.97,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $88.85 in Billed Charges for Rev 637 = $63.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACITRACIN-POLYMYXIN B (OPHTH) OINT 3.5 G TUBE,637,RC,0574-4021-35,CDM,,,,,,both,3.500000,GR,88.8500,58.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,53.31,,,,,,,43.1800,88.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $88.85 in Billed Charges for Rev 637 = $53.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,AETNA,AETNA HSHS,5.46,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.45 in Billed Charges for Rev 637 = $5.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,AETNA,ALL COMMERCIAL AETNA,8.45,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.45 in Billed Charges for Rev 637 = $8.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,ANTHEM,ANTHEM POS/HMO,5.75,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.45 in Billed Charges for Rev 637 = $5.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,ANTHEM,ANTHEM PPO,5.75,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $8.45 in Billed Charges for Rev 637 = $5.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.45,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.45 in Billed Charges for Rev 637 = $8.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,CENPATICO,ALL MEDICAID CENPATICO,8.45,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.45 in Billed Charges for Rev 637 = $8.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.18,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.45 in Billed Charges for Rev 637 = $7.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,CIGNA,ALL COMMERCIAL CIGNA,5.92,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.45 in Billed Charges for Rev 637 = $5.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,COFINITY,COFINITY,8.45,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.45 in Billed Charges for Rev 637 = $8.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.03,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.45 in Billed Charges for Rev 637 = $8.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,7.10,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.45 in Billed Charges for Rev 637 = $7.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.00,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.45 in Billed Charges for Rev 637 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.17,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.45 in Billed Charges for Rev 637 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,4.11,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.45 in Billed Charges for Rev 637 = $4.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.18,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.45 in Billed Charges for Rev 637 = $7.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,HUMANA,HUMANA CHOICE CARE HMO,5.37,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.45 in Billed Charges at 63.5% = $5.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,HUMANA,HUMANA CHOICE CARE PPO,7.18,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.45 in Billed Charges for Rev 637 = $7.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,HUMANA,HUMANA NATIIONAL POS HMO,5.37,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $8.45 in Billed Charges at 63.5% = $5.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.17,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.45 in Billed Charges for Rev 637 = $6.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.45,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.45 in Billed Charges for Rev 637 = $8.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,8.45,,,,,,,4.1100,8.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.23,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.45 in Billed Charges for Rev 637 = $4.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.10,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.45 in Billed Charges for Rev 637 = $7.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.34,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.45 in Billed Charges for Rev 637 = $6.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.77,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.45 in Billed Charges for Rev 637 = $7.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.07,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.45 in Billed Charges for Rev 637 = $5.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.07,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.45 in Billed Charges for Rev 637 = $5.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,PREVEA HEALTH NETWORK,PREVEA360,5.07,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.45 in Billed Charges for Rev 637 = $5.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.07,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.45 in Billed Charges for Rev 637 = $5.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.39,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.45 in Billed Charges for Rev 637 = $5.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.08,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.45 in Billed Charges for Rev 637 = $6.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.67,,,,,,,4.1100,8.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.45 in Billed Charges for Rev 637 = $4.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.67,,,,,,,4.1100,8.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.45 in Billed Charges for Rev 637 = $4.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.67,,,,,,,4.1100,8.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.45 in Billed Charges for Rev 637 = $4.67 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,UNITY HEALTH PLAN,UNITY HOSPICE,8.45,,,,,,,4.1100,8.4500,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.08,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.45 in Billed Charges for Rev 637 = $6.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.24,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.45 in Billed Charges for Rev 637 = $5.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.08,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.45 in Billed Charges for Rev 637 = $6.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.08,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.45 in Billed Charges for Rev 637 = $6.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BACLOFEN 10 MG TABS,637,RC,70710-1285-1,CDM,,,,,,both,1.000000,EA,8.4500,5.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.07,,,,,,,4.1100,8.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.45 in Billed Charges for Rev 637 = $5.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,AETNA,AETNA HSHS,31.27,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $48.40 in Billed Charges for Rev 637 = $31.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,AETNA,ALL COMMERCIAL AETNA,48.40,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.40 in Billed Charges for Rev 637 = $48.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,ANTHEM,ANTHEM POS/HMO,32.91,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $48.40 in Billed Charges for Rev 637 = $32.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,ANTHEM,ANTHEM PPO,32.91,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $48.40 in Billed Charges for Rev 637 = $32.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,48.40,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.40 in Billed Charges for Rev 637 = $48.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,CENPATICO,ALL MEDICAID CENPATICO,48.40,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.40 in Billed Charges for Rev 637 = $48.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.14,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.40 in Billed Charges for Rev 637 = $41.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,CIGNA,ALL COMMERCIAL CIGNA,33.88,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $48.40 in Billed Charges for Rev 637 = $33.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,COFINITY,COFINITY,48.40,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.40 in Billed Charges for Rev 637 = $48.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,45.98,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $48.40 in Billed Charges for Rev 637 = $45.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,40.66,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $48.40 in Billed Charges for Rev 637 = $40.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.36,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $48.40 in Billed Charges for Rev 637 = $34.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.33,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $48.40 in Billed Charges for Rev 637 = $35.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.52,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $48.40 in Billed Charges for Rev 637 = $23.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.14,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.40 in Billed Charges for Rev 637 = $41.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,HUMANA,HUMANA CHOICE CARE HMO,30.73,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $48.40 in Billed Charges at 63.5% = $30.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,HUMANA,HUMANA CHOICE CARE PPO,41.14,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $48.40 in Billed Charges for Rev 637 = $41.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,HUMANA,HUMANA NATIIONAL POS HMO,30.73,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 637 $48.40 in Billed Charges at 63.5% = $30.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.33,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $48.40 in Billed Charges for Rev 637 = $35.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,48.40,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $48.40 in Billed Charges for Rev 637 = $48.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,48.40,,,,,,,23.5200,48.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.20,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $48.40 in Billed Charges for Rev 637 = $24.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,40.66,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $48.40 in Billed Charges for Rev 637 = $40.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.30,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $48.40 in Billed Charges for Rev 637 = $36.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,44.53,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $48.40 in Billed Charges for Rev 637 = $44.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.04,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.40 in Billed Charges for Rev 637 = $29.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.04,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.40 in Billed Charges for Rev 637 = $29.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,PREVEA HEALTH NETWORK,PREVEA360,29.04,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.40 in Billed Charges for Rev 637 = $29.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.04,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.40 in Billed Charges for Rev 637 = $29.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,30.89,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $48.40 in Billed Charges for Rev 637 = $30.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,34.85,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.40 in Billed Charges for Rev 637 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,26.77,,,,,,,23.5200,48.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $48.40 in Billed Charges for Rev 637 = $26.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,26.77,,,,,,,23.5200,48.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $48.40 in Billed Charges for Rev 637 = $26.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,26.77,,,,,,,23.5200,48.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $48.40 in Billed Charges for Rev 637 = $26.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,UNITY HEALTH PLAN,UNITY HOSPICE,48.40,,,,,,,23.5200,48.4000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,34.85,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.40 in Billed Charges for Rev 637 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.01,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $48.40 in Billed Charges for Rev 637 = $30.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,34.85,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.40 in Billed Charges for Rev 637 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,34.85,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $48.40 in Billed Charges for Rev 637 = $34.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATOMOXETINE 10 MG CAPS,637,RC,55111-519-30,CDM,,,,,,both,1.000000,EA,48.4000,31.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.04,,,,,,,23.5200,48.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $48.40 in Billed Charges for Rev 637 = $29.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,AETNA,AETNA HSHS,227.39,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $227.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,AETNA,AETNA MEDICARE,172.41,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,AETNA,ALL COMMERCIAL AETNA,352.00,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,ANTHEM,ANTEHM MEDICAID,113.84,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00323 Proc 90791 at $125.60 (Base Rate) * 0.9064 (Relative Weight) = $113.84 (Total Line Payment) at 100% = $113.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,172.41,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,352.00,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,CENPATICO,ALL MEDICAID CENPATICO,352.00,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,299.20,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $299.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,CIGNA,ALL COMMERCIAL CIGNA,246.40,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $246.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,COFINITY,COFINITY,352.00,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,113.84,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00323 Proc 90791 at $125.60 (Base Rate) * 0.9064 (Relative Weight) = $113.84 (Total Line Payment) at 100% = $113.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,113.84,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00323 Proc 90791 at $125.60 (Base Rate) * 0.9064 (Relative Weight) = $113.84 (Total Line Payment) at 100% = $113.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,334.40,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $334.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,295.68,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $295.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,249.92,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $249.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,256.96,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $256.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,171.07,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $171.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,299.20,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $299.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HUMANA,HUMANA CHOICE CARE HMO,223.52,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $223.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HUMANA,HUMANA CHOICE CARE PPO,299.20,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $299.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HUMANA,HUMANA MEDICARE ADVANTAGE,172.41,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,HUMANA,HUMANA NATIIONAL POS HMO,223.52,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $223.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,256.96,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $256.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,352.00,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $352.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,113.84,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00323 Proc 90791 at $125.60 (Base Rate) * 0.9064 (Relative Weight) = $113.84 (Total Line Payment) at 100% = $113.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,172.41,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,113.84,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00323 Proc 90791 at $125.60 (Base Rate) * 0.9064 (Relative Weight) = $113.84 (Total Line Payment) at 100% = $113.84. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,MOLINA HEALTHCARE,MOLINA MEDICAID,120.67,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00323 Proc 90791 at $125.60 (Base Rate) * 0.9064 (Relative Weight) = $113.84 (Total Line Payment) at 100% = $113.84... $113.84 at 106% = $120.67 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,MOLINA HEALTHCARE,MOLINA MEDICARE,172.41,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,176.00,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $176.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,295.68,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $295.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,NAPHCARE,ALL COMMERICAL NAPHCARE,387.92,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,264.00,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $264.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,323.84,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $323.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,211.20,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $211.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,211.20,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $211.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,PREVEA HEALTH NETWORK,PREVEA360,211.20,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $211.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,211.20,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $211.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,224.68,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $224.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,174.13,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,253.44,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $253.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,TRIOLOGY,TRILOGY MEDICAID,120.67,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00323 Proc 90791 at $125.60 (Base Rate) * 0.9064 (Relative Weight) = $113.84 (Total Line Payment) at 106% = $120.67. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,172.41,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,UNITY HEALTH PLAN,UNITY HOSPICE,172.41,,,,,,,113.8400,387.9200,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,253.44,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $253.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,218.24,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $218.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,253.44,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $253.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,253.44,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $253.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,945,RC,94500008,CDM,,,,both,,,352.0000,232.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,211.20,,,,,,,113.8400,387.9200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $352.00 in Billed Charges for Rev 945 Proc 90791 = $211.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,AETNA,AETNA HSHS,217.06,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $217.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,AETNA,AETNA MEDICARE,98.68,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,AETNA,ALL COMMERCIAL AETNA,336.00,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,ANTHEM,ANTEHM MEDICAID,107.98,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00318 Proc 90853 at $125.60 (Base Rate) * 0.8597 (Relative Weight) = $107.98 (Total Line Payment) at 100% = $107.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,98.68,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,336.00,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,CENPATICO,ALL MEDICAID CENPATICO,336.00,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,285.60,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $285.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,CIGNA,ALL COMMERCIAL CIGNA,235.20,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $235.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,COFINITY,COFINITY,336.00,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,107.98,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00318 Proc 90853 at $125.60 (Base Rate) * 0.8597 (Relative Weight) = $107.98 (Total Line Payment) at 100% = $107.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,107.98,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00318 Proc 90853 at $125.60 (Base Rate) * 0.8597 (Relative Weight) = $107.98 (Total Line Payment) at 100% = $107.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,319.20,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $319.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,282.24,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,238.56,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $238.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,245.28,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $245.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,163.30,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $163.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,285.60,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $285.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HUMANA,HUMANA CHOICE CARE HMO,213.36,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $213.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HUMANA,HUMANA CHOICE CARE PPO,285.60,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $285.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HUMANA,HUMANA MEDICARE ADVANTAGE,98.68,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,HUMANA,HUMANA NATIIONAL POS HMO,213.36,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $213.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,245.28,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $245.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,336.00,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $336.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,107.98,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00318 Proc 90853 at $125.60 (Base Rate) * 0.8597 (Relative Weight) = $107.98 (Total Line Payment) at 100% = $107.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,98.68,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,107.98,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00318 Proc 90853 at $125.60 (Base Rate) * 0.8597 (Relative Weight) = $107.98 (Total Line Payment) at 100% = $107.98. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,MOLINA HEALTHCARE,MOLINA MEDICAID,114.46,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00318 Proc 90853 at $125.60 (Base Rate) * 0.8597 (Relative Weight) = $107.98 (Total Line Payment) at 100% = $107.98... $107.98 at 106% = $114.46 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,MOLINA HEALTHCARE,MOLINA MEDICARE,98.68,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,168.00,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $168.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,282.24,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $282.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,NAPHCARE,ALL COMMERICAL NAPHCARE,222.02,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,252.00,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $252.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,309.12,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $309.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,201.60,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,201.60,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,PREVEA HEALTH NETWORK,PREVEA360,201.60,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,201.60,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,214.47,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $214.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,99.67,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,241.92,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $241.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,TRIOLOGY,TRILOGY MEDICAID,114.46,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00318 Proc 90853 at $125.60 (Base Rate) * 0.8597 (Relative Weight) = $107.98 (Total Line Payment) at 106% = $114.46. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,98.68,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,UNITY HEALTH PLAN,UNITY HOSPICE,98.68,,,,,,,98.6800,336.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,241.92,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $241.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,208.32,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $208.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,241.92,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $241.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,241.92,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $241.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC ALCOHOL GROUP THERAPY 120 MIN,90853,CPT,945,RC,94500019,CDM,,,,both,,,336.0000,221.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,201.60,,,,,,,98.6800,336.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $336.00 in Billed Charges for Rev 945 Proc 90853 = $201.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,AETNA,AETNA HSHS,135.01,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $135.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,AETNA,AETNA MEDICARE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,AETNA,ALL COMMERCIAL AETNA,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTEHM MEDICAID,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94626 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM MEDICARE ADVANTAGE HMO,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM POS/HMO,142.12,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $142.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,ANTHEM,ANTHEM PPO,142.12,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $142.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,CENPATICO,ALL MEDICAID CENPATICO,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,177.65,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,CIGNA,ALL COMMERCIAL CIGNA,146.30,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $146.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,COFINITY,COFINITY,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,COMMUNITY CARE FAMILY CARE,COMMUNITY CARE FAMILY CARE MEDICAID MANAGED,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94626 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,CONTINUUS MEDICAID MANAGED,CONTINUUS MEDICAID MANAGED,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94626 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,198.55,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $198.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HEALTH CARE ALLIANCE,THE ALLIANCE,175.56,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $175.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,148.39,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $148.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,152.57,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $152.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HSHS EMPLOYEES,HSHS EMPLOYEES,101.57,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $101.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,177.65,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA CHOICE CARE HMO,132.72,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $132.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA CHOICE CARE PPO,177.65,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $177.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA MEDICARE ADVANTAGE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,HUMANA,HUMANA NATIIONAL POS HMO,132.72,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $132.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,152.57,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $152.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,LIVE360,LIVE360 HSHS HEALTHY PLAN,209.00,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $209.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,MANAGED HEALTH SERVICES,MANAGED HEALTH SERVICES MEDICAID,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94626 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,MEDICARE MANAGED,MANAGED MEDICARE NO SEQUESTRATION,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,MERIDIAN HEALTH PLAN,MERIDIAN HMO MCD,15.65,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94626 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE,MOLINA MEDICAID,16.59,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94626 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 100% = $15.65... $15.65 at 106% = $16.59 Final Expected. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE,MOLINA MEDICARE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,104.50,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $104.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,175.56,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $175.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,NAPHCARE,ALL COMMERICAL NAPHCARE,128.93,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 225.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,156.75,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $156.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,192.28,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $192.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA360,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,133.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $133.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,SECURITY HEALTH PLAN,MEDICARE ADVANTAGE SECURITY HEALTH PLAN OF WI,57.87,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,150.48,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,TRIOLOGY,TRILOGY MEDICAID,16.59,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). APG 00066 Proc 94626 at $125.60 (Base Rate) * 0.1246 (Relative Weight) = $15.65 (Total Line Payment) at 106% = $16.59. The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,97.39,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 46.6% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $97.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UHC ONEIDA NATION,97.39,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 46.6% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $97.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UNITED HEALTH CARE MEDICARE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,UNITED HEALTHCARE,UNITED HEALTHCARE,97.39,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 46.6% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $97.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,UNITY HEALTH PLAN,UNITY HOSPICE,57.30,,,,,,,15.6500,209.0000,fee schedule,ST VINCENT HOSPITAL (ACU). 100.00% of Hospitals Specific Medicare Reimbursement Rate The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,150.48,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,129.58,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $129.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,150.48,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,150.48,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC PHY/QHP OP PULM RHB W/MNTR,94626,CPT,948,RC,94800002,CDM,,,,both,,,209.0000,137.9400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,125.40,,,,,,,15.6500,209.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $209.00 in Billed Charges for Rev 948 Proc 94626 = $125.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,AETNA,AETNA HSHS,674.42,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,044.00 in Billed Charges for Rev 2 = $674.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,AETNA,ALL COMMERCIAL AETNA,1044.00,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,044.00 in Billed Charges for Rev 2 = $1,044.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1044.00,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,044.00 in Billed Charges for Rev 2 = $1,044.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,887.40,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,044.00 in Billed Charges for Rev 2 = $887.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,CIGNA,ALL COMMERCIAL CIGNA,730.80,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,044.00 in Billed Charges for Rev 2 = $730.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,COFINITY,COFINITY,1044.00,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,044.00 in Billed Charges for Rev 2 = $1,044.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,991.80,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,044.00 in Billed Charges for Rev 2 = $991.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,876.96,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,044.00 in Billed Charges for Rev 2 = $876.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,741.24,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,044.00 in Billed Charges for Rev 2 = $741.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,762.12,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,044.00 in Billed Charges for Rev 2 = $762.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,507.38,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,044.00 in Billed Charges for Rev 2 = $507.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,887.40,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,044.00 in Billed Charges for Rev 2 = $887.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,HUMANA,HUMANA CHOICE CARE PPO,887.40,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,044.00 in Billed Charges for Rev 2 = $887.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,762.12,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,044.00 in Billed Charges for Rev 2 = $762.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,1044.00,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,044.00 in Billed Charges for Rev 2 = $1,044.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,522.00,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,044.00 in Billed Charges for Rev 2 = $522.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,876.96,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,044.00 in Billed Charges for Rev 2 = $876.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,783.00,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,044.00 in Billed Charges for Rev 2 = $783.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,960.48,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,044.00 in Billed Charges for Rev 2 = $960.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,666.39,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,044.00 in Billed Charges for Rev 2 = $666.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,751.68,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,044.00 in Billed Charges for Rev 2 = $751.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,1044.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 2
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,751.68,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,044.00 in Billed Charges for Rev 2 = $751.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,647.28,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,044.00 in Billed Charges for Rev 2 = $647.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,751.68,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,044.00 in Billed Charges for Rev 2 = $751.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH RESIDENTIAL CDP,2,RC,10020001,CDM,,,,,,inpatient,,,1044.0000,689.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,751.68,,,,,,,500.0000,1044.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,044.00 in Billed Charges for Rev 2 = $751.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,AETNA,AETNA HSHS,344.96,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $534.00 in Billed Charges for Rev 911 = $344.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,AETNA,ALL COMMERCIAL AETNA,534.00,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $534.00 in Billed Charges for Rev 911 = $534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,534.00,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $534.00 in Billed Charges for Rev 911 = $534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,453.90,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $534.00 in Billed Charges for Rev 911 = $453.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,CIGNA,ALL COMMERCIAL CIGNA,373.80,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $534.00 in Billed Charges for Rev 911 = $373.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,COFINITY,COFINITY,534.00,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $534.00 in Billed Charges for Rev 911 = $534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,507.30,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $534.00 in Billed Charges for Rev 911 = $507.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,448.56,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $534.00 in Billed Charges for Rev 911 = $448.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,379.14,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $534.00 in Billed Charges for Rev 911 = $379.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,389.82,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $534.00 in Billed Charges for Rev 911 = $389.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,259.52,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $534.00 in Billed Charges for Rev 911 = $259.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,453.90,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $534.00 in Billed Charges for Rev 911 = $453.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,HUMANA,HUMANA CHOICE CARE PPO,453.90,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $534.00 in Billed Charges for Rev 911 = $453.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,389.82,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $534.00 in Billed Charges for Rev 911 = $389.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,534.00,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $534.00 in Billed Charges for Rev 911 = $534.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,267.00,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $534.00 in Billed Charges for Rev 911 = $267.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,448.56,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $534.00 in Billed Charges for Rev 911 = $448.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,400.50,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $534.00 in Billed Charges for Rev 911 = $400.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,491.28,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $534.00 in Billed Charges for Rev 911 = $491.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,340.85,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $534.00 in Billed Charges for Rev 911 = $340.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,384.48,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $534.00 in Billed Charges for Rev 911 = $384.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,384.48,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $534.00 in Billed Charges for Rev 911 = $384.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,331.08,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $534.00 in Billed Charges for Rev 911 = $331.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,384.48,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $534.00 in Billed Charges for Rev 911 = $384.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY RESIDENTIAL TREATMENT,911,RC,10020002,CDM,,,,,,inpatient,,,534.0000,352.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,384.48,,,,,,,259.5200,534.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $534.00 in Billed Charges for Rev 911 = $384.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,AETNA,AETNA HSHS,1393.42,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,157.00 in Billed Charges for Rev 121 = $1,393.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,AETNA,ALL COMMERCIAL AETNA,2157.00,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,157.00 in Billed Charges for Rev 121 = $2,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2157.00,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,157.00 in Billed Charges for Rev 121 = $2,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1833.45,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,157.00 in Billed Charges for Rev 121 = $1,833.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,CIGNA,ALL COMMERCIAL CIGNA,1509.90,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,157.00 in Billed Charges for Rev 121 = $1,509.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,COFINITY,COFINITY,2157.00,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,157.00 in Billed Charges for Rev 121 = $2,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2049.15,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,157.00 in Billed Charges for Rev 121 = $2,049.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HEALTH CARE ALLIANCE,THE ALLIANCE,1811.88,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,157.00 in Billed Charges for Rev 121 = $1,811.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1531.47,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,157.00 in Billed Charges for Rev 121 = $1,531.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1574.61,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,157.00 in Billed Charges for Rev 121 = $1,574.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HSHS EMPLOYEES,HSHS EMPLOYEES,1048.30,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,157.00 in Billed Charges for Rev 121 = $1,048.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1833.45,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,157.00 in Billed Charges for Rev 121 = $1,833.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,HUMANA,HUMANA CHOICE CARE PPO,1833.45,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,157.00 in Billed Charges for Rev 121 = $1,833.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1574.61,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,157.00 in Billed Charges for Rev 121 = $1,574.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,LIVE360,LIVE360 HSHS HEALTHY PLAN,2157.00,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,157.00 in Billed Charges for Rev 121 = $2,157.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1078.50,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,157.00 in Billed Charges for Rev 121 = $1,078.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1811.88,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,157.00 in Billed Charges for Rev 121 = $1,811.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1617.75,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,157.00 in Billed Charges for Rev 121 = $1,617.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1984.44,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,157.00 in Billed Charges for Rev 121 = $1,984.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1376.81,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,157.00 in Billed Charges for Rev 121 = $1,376.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1553.04,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,157.00 in Billed Charges for Rev 121 = $1,553.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,2157.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 121
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1553.04,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,157.00 in Billed Charges for Rev 121 = $1,553.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1337.34,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,157.00 in Billed Charges for Rev 121 = $1,337.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1553.04,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,157.00 in Billed Charges for Rev 121 = $1,553.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE,121,RC,12100001,CDM,,,,,,inpatient,,,2157.0000,1423.6200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1553.04,,,,,,,500.0000,2157.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,157.00 in Billed Charges for Rev 121 = $1,553.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,AETNA,AETNA HSHS,1682.18,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,604.00 in Billed Charges for Rev 128 = $1,682.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,AETNA,ALL COMMERCIAL AETNA,2604.00,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,604.00 in Billed Charges for Rev 128 = $2,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,ANTHEM,ANTHEM POS/HMO,2604.00,,,,,,,500.0000,2604.0000,per diem,"ST VINCENT HOSPITAL (ACU). $2,976.00 for 1 day = $2,976.00 for Rev 128... Eligible capped at $2,604.00 (Billed Charges)"
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,ANTHEM,ANTHEM PPO,2604.00,,,,,,,500.0000,2604.0000,per diem,"ST VINCENT HOSPITAL (ACU). $2,976.00 for 1 day = $2,976.00 for Rev 128... Eligible capped at $2,604.00 (Billed Charges)"
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2604.00,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,604.00 in Billed Charges for Rev 128 = $2,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2213.40,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,604.00 in Billed Charges for Rev 128 = $2,213.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,CIGNA,ALL COMMERCIAL CIGNA,1822.80,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,604.00 in Billed Charges for Rev 128 = $1,822.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,COFINITY,COFINITY,2604.00,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,604.00 in Billed Charges for Rev 128 = $2,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2473.80,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,604.00 in Billed Charges for Rev 128 = $2,473.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,2187.36,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,604.00 in Billed Charges for Rev 128 = $2,187.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1848.84,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,604.00 in Billed Charges for Rev 128 = $1,848.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1900.92,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,604.00 in Billed Charges for Rev 128 = $1,900.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,1265.54,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,604.00 in Billed Charges for Rev 128 = $1,265.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2213.40,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,604.00 in Billed Charges for Rev 128 = $2,213.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,HUMANA,HUMANA CHOICE CARE PPO,2213.40,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,604.00 in Billed Charges for Rev 128 = $2,213.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1900.92,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,604.00 in Billed Charges for Rev 128 = $1,900.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2604.00,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,604.00 in Billed Charges for Rev 128 = $2,604.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1302.00,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,604.00 in Billed Charges for Rev 128 = $1,302.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2187.36,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,604.00 in Billed Charges for Rev 128 = $2,187.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1953.00,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,604.00 in Billed Charges for Rev 128 = $1,953.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2395.68,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,604.00 in Billed Charges for Rev 128 = $2,395.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1662.13,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,604.00 in Billed Charges for Rev 128 = $1,662.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1874.88,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,604.00 in Billed Charges for Rev 128 = $1,874.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,2604.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 128
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1874.88,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,604.00 in Billed Charges for Rev 128 = $1,874.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1614.48,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,604.00 in Billed Charges for Rev 128 = $1,614.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1874.88,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,604.00 in Billed Charges for Rev 128 = $1,874.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE LIBERTAS,128,RC,12800002,CDM,,,,,,inpatient,,,2604.0000,1718.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1874.88,,,,,,,500.0000,2604.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,604.00 in Billed Charges for Rev 128 = $1,874.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,AETNA,AETNA HSHS,1104.66,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,710.00 in Billed Charges for Rev 128 = $1,104.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,AETNA,ALL COMMERCIAL AETNA,1710.00,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,710.00 in Billed Charges for Rev 128 = $1,710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,ANTHEM,ANTHEM POS/HMO,1710.00,,,,,,,500.0000,1710.0000,per diem,"ST VINCENT HOSPITAL (ACU). $2,976.00 for 1 day = $2,976.00 for Rev 128... Eligible capped at $1,710.00 (Billed Charges)"
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,ANTHEM,ANTHEM PPO,1710.00,,,,,,,500.0000,1710.0000,per diem,"ST VINCENT HOSPITAL (ACU). $2,976.00 for 1 day = $2,976.00 for Rev 128... Eligible capped at $1,710.00 (Billed Charges)"
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1710.00,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,710.00 in Billed Charges for Rev 128 = $1,710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1453.50,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,710.00 in Billed Charges for Rev 128 = $1,453.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,CIGNA,ALL COMMERCIAL CIGNA,1197.00,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,710.00 in Billed Charges for Rev 128 = $1,197.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,COFINITY,COFINITY,1710.00,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,710.00 in Billed Charges for Rev 128 = $1,710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1624.50,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,710.00 in Billed Charges for Rev 128 = $1,624.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,1436.40,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,710.00 in Billed Charges for Rev 128 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1214.10,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,710.00 in Billed Charges for Rev 128 = $1,214.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1248.30,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,710.00 in Billed Charges for Rev 128 = $1,248.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,831.06,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,710.00 in Billed Charges for Rev 128 = $831.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1453.50,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,710.00 in Billed Charges for Rev 128 = $1,453.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,HUMANA,HUMANA CHOICE CARE PPO,1453.50,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,710.00 in Billed Charges for Rev 128 = $1,453.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1248.30,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,710.00 in Billed Charges for Rev 128 = $1,248.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,1710.00,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,710.00 in Billed Charges for Rev 128 = $1,710.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,855.00,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,710.00 in Billed Charges for Rev 128 = $855.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1436.40,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,710.00 in Billed Charges for Rev 128 = $1,436.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1282.50,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,710.00 in Billed Charges for Rev 128 = $1,282.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1573.20,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,710.00 in Billed Charges for Rev 128 = $1,573.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1091.49,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,710.00 in Billed Charges for Rev 128 = $1,091.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1231.20,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,710.00 in Billed Charges for Rev 128 = $1,231.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,1710.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 128
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1231.20,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,710.00 in Billed Charges for Rev 128 = $1,231.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1060.20,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,710.00 in Billed Charges for Rev 128 = $1,060.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1231.20,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,710.00 in Billed Charges for Rev 128 = $1,231.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY BEHAVIORAL HLTH MEDICAL MGMT,128,RC,12800003,CDM,,,,,,inpatient,,,1710.0000,1128.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1231.20,,,,,,,500.0000,1710.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,710.00 in Billed Charges for Rev 128 = $1,231.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,AETNA,AETNA HSHS,1056.86,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,636.00 in Billed Charges for Rev 171 = $1,056.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,AETNA,ALL COMMERCIAL AETNA,1636.00,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,636.00 in Billed Charges for Rev 171 = $1,636.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1636.00,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,636.00 in Billed Charges for Rev 171 = $1,636.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1390.60,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,636.00 in Billed Charges for Rev 171 = $1,390.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,CIGNA,ALL COMMERCIAL CIGNA,1145.20,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,636.00 in Billed Charges for Rev 171 = $1,145.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,COFINITY,COFINITY,1636.00,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,636.00 in Billed Charges for Rev 171 = $1,636.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1554.20,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,636.00 in Billed Charges for Rev 171 = $1,554.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,1374.24,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,636.00 in Billed Charges for Rev 171 = $1,374.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1161.56,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,636.00 in Billed Charges for Rev 171 = $1,161.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1194.28,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,636.00 in Billed Charges for Rev 171 = $1,194.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,795.10,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,636.00 in Billed Charges for Rev 171 = $795.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1390.60,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,636.00 in Billed Charges for Rev 171 = $1,390.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,HUMANA,HUMANA CHOICE CARE PPO,1390.60,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,636.00 in Billed Charges for Rev 171 = $1,390.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1194.28,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,636.00 in Billed Charges for Rev 171 = $1,194.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1636.00,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,636.00 in Billed Charges for Rev 171 = $1,636.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,818.00,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,636.00 in Billed Charges for Rev 171 = $818.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1374.24,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,636.00 in Billed Charges for Rev 171 = $1,374.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1227.00,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,636.00 in Billed Charges for Rev 171 = $1,227.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1505.12,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,636.00 in Billed Charges for Rev 171 = $1,505.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1044.26,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,636.00 in Billed Charges for Rev 171 = $1,044.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1177.92,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,636.00 in Billed Charges for Rev 171 = $1,177.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,1636.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 171
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1177.92,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,636.00 in Billed Charges for Rev 171 = $1,177.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1014.32,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,636.00 in Billed Charges for Rev 171 = $1,014.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1177.92,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,636.00 in Billed Charges for Rev 171 = $1,177.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 1,171,RC,17100001,CDM,,,,,,inpatient,,,1636.0000,1079.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1177.92,,,,,,,500.0000,1636.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,636.00 in Billed Charges for Rev 171 = $1,177.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,AETNA,AETNA HSHS,2053.63,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $3,179.00 in Billed Charges for Rev 172 = $2,053.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,AETNA,ALL COMMERCIAL AETNA,3179.00,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,179.00 in Billed Charges for Rev 172 = $3,179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,3179.00,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,179.00 in Billed Charges for Rev 172 = $3,179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2702.15,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,179.00 in Billed Charges for Rev 172 = $2,702.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,CIGNA,ALL COMMERCIAL CIGNA,2225.30,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $3,179.00 in Billed Charges for Rev 172 = $2,225.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,COFINITY,COFINITY,3179.00,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,179.00 in Billed Charges for Rev 172 = $3,179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3020.05,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $3,179.00 in Billed Charges for Rev 172 = $3,020.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,2670.36,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,179.00 in Billed Charges for Rev 172 = $2,670.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2257.09,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $3,179.00 in Billed Charges for Rev 172 = $2,257.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2320.67,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,179.00 in Billed Charges for Rev 172 = $2,320.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,1544.99,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $3,179.00 in Billed Charges for Rev 172 = $1,544.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2702.15,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,179.00 in Billed Charges for Rev 172 = $2,702.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,HUMANA,HUMANA CHOICE CARE PPO,2702.15,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $3,179.00 in Billed Charges for Rev 172 = $2,702.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2320.67,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $3,179.00 in Billed Charges for Rev 172 = $2,320.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,3179.00,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $3,179.00 in Billed Charges for Rev 172 = $3,179.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1589.50,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $3,179.00 in Billed Charges for Rev 172 = $1,589.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2670.36,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $3,179.00 in Billed Charges for Rev 172 = $2,670.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2384.25,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $3,179.00 in Billed Charges for Rev 172 = $2,384.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2924.68,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $3,179.00 in Billed Charges for Rev 172 = $2,924.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2029.16,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $3,179.00 in Billed Charges for Rev 172 = $2,029.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2288.88,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,179.00 in Billed Charges for Rev 172 = $2,288.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,3179.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 172
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2288.88,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,179.00 in Billed Charges for Rev 172 = $2,288.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1970.98,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $3,179.00 in Billed Charges for Rev 172 = $1,970.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2288.88,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,179.00 in Billed Charges for Rev 172 = $2,288.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE NICU LEV 2,172,RC,17200001,CDM,,,,,,inpatient,,,3179.0000,2098.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2288.88,,,,,,,500.0000,3179.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $3,179.00 in Billed Charges for Rev 172 = $2,288.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,AETNA,AETNA HSHS,1339.80,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,074.00 in Billed Charges for Rev 172 = $1,339.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,AETNA,ALL COMMERCIAL AETNA,2074.00,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,074.00 in Billed Charges for Rev 172 = $2,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2074.00,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,074.00 in Billed Charges for Rev 172 = $2,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1762.90,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,074.00 in Billed Charges for Rev 172 = $1,762.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,CIGNA,ALL COMMERCIAL CIGNA,1451.80,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,074.00 in Billed Charges for Rev 172 = $1,451.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,COFINITY,COFINITY,2074.00,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,074.00 in Billed Charges for Rev 172 = $2,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1970.30,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,074.00 in Billed Charges for Rev 172 = $1,970.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,1742.16,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,074.00 in Billed Charges for Rev 172 = $1,742.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1472.54,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,074.00 in Billed Charges for Rev 172 = $1,472.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1514.02,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,074.00 in Billed Charges for Rev 172 = $1,514.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,1007.96,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,074.00 in Billed Charges for Rev 172 = $1,007.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1762.90,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,074.00 in Billed Charges for Rev 172 = $1,762.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,HUMANA,HUMANA CHOICE CARE PPO,1762.90,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,074.00 in Billed Charges for Rev 172 = $1,762.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1514.02,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,074.00 in Billed Charges for Rev 172 = $1,514.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2074.00,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,074.00 in Billed Charges for Rev 172 = $2,074.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1037.00,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,074.00 in Billed Charges for Rev 172 = $1,037.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1742.16,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,074.00 in Billed Charges for Rev 172 = $1,742.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1555.50,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,074.00 in Billed Charges for Rev 172 = $1,555.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1908.08,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,074.00 in Billed Charges for Rev 172 = $1,908.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1323.83,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,074.00 in Billed Charges for Rev 172 = $1,323.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1493.28,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,074.00 in Billed Charges for Rev 172 = $1,493.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,2074.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 172
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1493.28,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,074.00 in Billed Charges for Rev 172 = $1,493.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1285.88,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,074.00 in Billed Charges for Rev 172 = $1,285.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1493.28,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,074.00 in Billed Charges for Rev 172 = $1,493.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY INFANT SERVICE LEV 2,172,RC,17200002,CDM,,,,,,inpatient,,,2074.0000,1368.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1493.28,,,,,,,500.0000,2074.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,074.00 in Billed Charges for Rev 172 = $1,493.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,AETNA,AETNA HSHS,3951.58,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $6,117.00 in Billed Charges for Rev 200 = $3,951.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,AETNA,ALL COMMERCIAL AETNA,6117.00,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,117.00 in Billed Charges for Rev 200 = $6,117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,6117.00,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,117.00 in Billed Charges for Rev 200 = $6,117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,5199.45,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,117.00 in Billed Charges for Rev 200 = $5,199.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,CIGNA,ALL COMMERCIAL CIGNA,4281.90,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $6,117.00 in Billed Charges for Rev 200 = $4,281.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,COFINITY,COFINITY,6117.00,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,117.00 in Billed Charges for Rev 200 = $6,117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5811.15,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $6,117.00 in Billed Charges for Rev 200 = $5,811.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,5138.28,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,117.00 in Billed Charges for Rev 200 = $5,138.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,4343.07,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $6,117.00 in Billed Charges for Rev 200 = $4,343.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4465.41,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,117.00 in Billed Charges for Rev 200 = $4,465.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,2972.86,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $6,117.00 in Billed Charges for Rev 200 = $2,972.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,5199.45,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,117.00 in Billed Charges for Rev 200 = $5,199.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,HUMANA,HUMANA CHOICE CARE PPO,5199.45,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $6,117.00 in Billed Charges for Rev 200 = $5,199.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4465.41,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $6,117.00 in Billed Charges for Rev 200 = $4,465.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,6117.00,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $6,117.00 in Billed Charges for Rev 200 = $6,117.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,3058.50,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $6,117.00 in Billed Charges for Rev 200 = $3,058.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,5138.28,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $6,117.00 in Billed Charges for Rev 200 = $5,138.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4587.75,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $6,117.00 in Billed Charges for Rev 200 = $4,587.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5627.64,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $6,117.00 in Billed Charges for Rev 200 = $5,627.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3904.48,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $6,117.00 in Billed Charges for Rev 200 = $3,904.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4404.24,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,117.00 in Billed Charges for Rev 200 = $4,404.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,6117.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 200
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4404.24,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,117.00 in Billed Charges for Rev 200 = $4,404.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3792.54,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $6,117.00 in Billed Charges for Rev 200 = $3,792.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4404.24,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,117.00 in Billed Charges for Rev 200 = $4,404.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE ICU,200,RC,20000001,CDM,,,,,,inpatient,,,6117.0000,4037.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4404.24,,,,,,,500.0000,6117.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $6,117.00 in Billed Charges for Rev 200 = $4,404.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,AETNA,AETNA HSHS,2890.20,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $4,474.00 in Billed Charges for Rev 206 = $2,890.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,AETNA,ALL COMMERCIAL AETNA,4474.00,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,474.00 in Billed Charges for Rev 206 = $4,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4474.00,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,474.00 in Billed Charges for Rev 206 = $4,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3802.90,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,474.00 in Billed Charges for Rev 206 = $3,802.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,CIGNA,ALL COMMERCIAL CIGNA,3131.80,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $4,474.00 in Billed Charges for Rev 206 = $3,131.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,COFINITY,COFINITY,4474.00,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,474.00 in Billed Charges for Rev 206 = $4,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,4250.30,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $4,474.00 in Billed Charges for Rev 206 = $4,250.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,HEALTH CARE ALLIANCE,THE ALLIANCE,3758.16,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,474.00 in Billed Charges for Rev 206 = $3,758.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3176.54,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $4,474.00 in Billed Charges for Rev 206 = $3,176.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,3266.02,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,474.00 in Billed Charges for Rev 206 = $3,266.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,HSHS EMPLOYEES,HSHS EMPLOYEES,2174.36,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $4,474.00 in Billed Charges for Rev 206 = $2,174.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3802.90,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,474.00 in Billed Charges for Rev 206 = $3,802.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,HUMANA,HUMANA CHOICE CARE PPO,3802.90,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $4,474.00 in Billed Charges for Rev 206 = $3,802.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,3266.02,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $4,474.00 in Billed Charges for Rev 206 = $3,266.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,LIVE360,LIVE360 HSHS HEALTHY PLAN,4474.00,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $4,474.00 in Billed Charges for Rev 206 = $4,474.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2237.00,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $4,474.00 in Billed Charges for Rev 206 = $2,237.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3758.16,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $4,474.00 in Billed Charges for Rev 206 = $3,758.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3355.50,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $4,474.00 in Billed Charges for Rev 206 = $3,355.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,4116.08,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $4,474.00 in Billed Charges for Rev 206 = $4,116.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2855.75,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $4,474.00 in Billed Charges for Rev 206 = $2,855.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,3221.28,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,474.00 in Billed Charges for Rev 206 = $3,221.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,UNITY HEALTH PLAN,UNITY HOSPICE,500.00,,,,,,,500.0000,4474.0000,per diem,ST VINCENT HOSPITAL (ACU). $500.00 for 1 day = $500.00 for Rev 206
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,3221.28,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,474.00 in Billed Charges for Rev 206 = $3,221.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2773.88,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $4,474.00 in Billed Charges for Rev 206 = $2,773.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,3221.28,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,474.00 in Billed Charges for Rev 206 = $3,221.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC DAILY SERVICE CVIMCU,206,RC,20600001,CDM,,,,,,inpatient,,,4474.0000,2952.8400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,3221.28,,,,,,,500.0000,4474.0000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $4,474.00 in Billed Charges for Rev 206 = $3,221.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,AETNA,AETNA HSHS,147.29,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $228.00 in Billed Charges for Rev 233 = $147.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,AETNA,ALL COMMERCIAL AETNA,228.00,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 233 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,ANTHEM,ANTHEM POS/HMO,155.04,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $228.00 in Billed Charges for Rev 233 = $155.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,ANTHEM,ANTHEM PPO,155.04,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $228.00 in Billed Charges for Rev 233 = $155.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,228.00,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 233 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,CENPATICO,ALL MEDICAID CENPATICO,228.00,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 233 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,193.80,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $228.00 in Billed Charges for Rev 233 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,CIGNA,ALL COMMERCIAL CIGNA,159.60,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $228.00 in Billed Charges for Rev 233 = $159.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,COFINITY,COFINITY,228.00,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 233 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,216.60,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $228.00 in Billed Charges for Rev 233 = $216.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,191.52,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $228.00 in Billed Charges for Rev 233 = $191.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,161.88,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $228.00 in Billed Charges for Rev 233 = $161.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,166.44,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $228.00 in Billed Charges for Rev 233 = $166.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,110.81,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $228.00 in Billed Charges for Rev 233 = $110.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,193.80,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $228.00 in Billed Charges for Rev 233 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,HUMANA,HUMANA CHOICE CARE HMO,144.78,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $228.00 in Billed Charges for Rev 233 = $144.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,HUMANA,HUMANA CHOICE CARE PPO,193.80,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $228.00 in Billed Charges for Rev 233 = $193.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,HUMANA,HUMANA NATIIONAL POS HMO,144.78,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $228.00 in Billed Charges for Rev 233 = $144.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,166.44,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $228.00 in Billed Charges for Rev 233 = $166.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,228.00,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $228.00 in Billed Charges for Rev 233 = $228.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,114.00,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $228.00 in Billed Charges for Rev 233 = $114.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,191.52,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $228.00 in Billed Charges for Rev 233 = $191.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,171.00,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $228.00 in Billed Charges for Rev 233 = $171.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,209.76,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $228.00 in Billed Charges for Rev 233 = $209.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,136.80,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $228.00 in Billed Charges for Rev 233 = $136.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,136.80,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $228.00 in Billed Charges for Rev 233 = $136.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,PREVEA HEALTH NETWORK,PREVEA360,136.80,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $228.00 in Billed Charges for Rev 233 = $136.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,136.80,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $228.00 in Billed Charges for Rev 233 = $136.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,145.53,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $228.00 in Billed Charges for Rev 233 = $145.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,164.16,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $228.00 in Billed Charges for Rev 233 = $164.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,126.08,,,,,,,110.8100,228.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $228.00 in Billed Charges for Rev 233 = $126.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,126.08,,,,,,,110.8100,228.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $228.00 in Billed Charges for Rev 233 = $126.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,126.08,,,,,,,110.8100,228.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $228.00 in Billed Charges for Rev 233 = $126.08 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,164.16,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $228.00 in Billed Charges for Rev 233 = $164.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,141.36,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $228.00 in Billed Charges for Rev 233 = $141.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,164.16,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $228.00 in Billed Charges for Rev 233 = $164.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,164.16,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $228.00 in Billed Charges for Rev 233 = $164.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC OPO HOURLY SURCHARGE ROOM,233,RC,23300003,CDM,,,,,,both,,,228.0000,150.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,136.80,,,,,,,110.8100,228.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $228.00 in Billed Charges for Rev 233 = $136.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,AETNA,AETNA HSHS,483.85,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $749.00 in Billed Charges for Rev 239 = $483.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,AETNA,ALL COMMERCIAL AETNA,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 239 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,ANTHEM,ANTHEM POS/HMO,509.32,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $749.00 in Billed Charges for Rev 239 = $509.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,ANTHEM,ANTHEM PPO,509.32,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 68% of $749.00 in Billed Charges for Rev 239 = $509.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 239 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,CENPATICO,ALL MEDICAID CENPATICO,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 239 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,636.65,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.00 in Billed Charges for Rev 239 = $636.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,CIGNA,ALL COMMERCIAL CIGNA,524.30,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $749.00 in Billed Charges for Rev 239 = $524.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,COFINITY,COFINITY,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 239 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,711.55,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $749.00 in Billed Charges for Rev 239 = $711.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,629.16,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $749.00 in Billed Charges for Rev 239 = $629.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,531.79,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $749.00 in Billed Charges for Rev 239 = $531.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,546.77,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $749.00 in Billed Charges for Rev 239 = $546.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,364.01,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $749.00 in Billed Charges for Rev 239 = $364.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,636.65,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.00 in Billed Charges for Rev 239 = $636.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,HUMANA,HUMANA CHOICE CARE HMO,475.62,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $749.00 in Billed Charges for Rev 239 = $475.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,HUMANA,HUMANA CHOICE CARE PPO,636.65,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $749.00 in Billed Charges for Rev 239 = $636.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,HUMANA,HUMANA NATIIONAL POS HMO,475.62,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.5% of $749.00 in Billed Charges for Rev 239 = $475.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,546.77,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $749.00 in Billed Charges for Rev 239 = $546.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,749.00,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $749.00 in Billed Charges for Rev 239 = $749.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,374.50,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $749.00 in Billed Charges for Rev 239 = $374.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,629.16,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $749.00 in Billed Charges for Rev 239 = $629.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,561.75,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $749.00 in Billed Charges for Rev 239 = $561.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,689.08,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $749.00 in Billed Charges for Rev 239 = $689.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 239 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 239 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,PREVEA HEALTH NETWORK,PREVEA360,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 239 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 239 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,478.09,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $749.00 in Billed Charges for Rev 239 = $478.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,539.28,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.00 in Billed Charges for Rev 239 = $539.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,414.20,,,,,,,364.0100,749.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $749.00 in Billed Charges for Rev 239 = $414.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,414.20,,,,,,,364.0100,749.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $749.00 in Billed Charges for Rev 239 = $414.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,414.20,,,,,,,364.0100,749.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $749.00 in Billed Charges for Rev 239 = $414.20 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,539.28,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.00 in Billed Charges for Rev 239 = $539.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,464.38,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $749.00 in Billed Charges for Rev 239 = $464.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,539.28,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.00 in Billed Charges for Rev 239 = $539.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,539.28,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $749.00 in Billed Charges for Rev 239 = $539.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
HC HIGH RISK BABY TRANS/HR,239,RC,23900001,CDM,,,,,,both,,,749.0000,494.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,449.40,,,,,,,364.0100,749.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $749.00 in Billed Charges for Rev 239 = $449.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,AETNA,AETNA HSHS,68.48,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $106.00 in Billed Charges for Rev 250 = $68.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,AETNA,ALL COMMERCIAL AETNA,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM POS/HMO,72.08,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $106.00 in Billed Charges at 68% = $72.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,ANTHEM,ANTHEM PPO,72.08,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $106.00 in Billed Charges at 68% = $72.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,CENPATICO,ALL MEDICAID CENPATICO,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,90.10,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 250 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,CIGNA,ALL COMMERCIAL CIGNA,74.20,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $106.00 in Billed Charges for Rev 250 = $74.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,COFINITY,COFINITY,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,100.70,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $106.00 in Billed Charges for Rev 250 = $100.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,HEALTH CARE ALLIANCE,THE ALLIANCE,89.04,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 250 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,75.26,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $106.00 in Billed Charges for Rev 250 = $75.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,77.38,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 250 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,HSHS EMPLOYEES,HSHS EMPLOYEES,51.52,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $106.00 in Billed Charges for Rev 250 = $51.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,90.10,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 250 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE HMO,67.31,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $106.00 in Billed Charges at 63.5% = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA CHOICE CARE PPO,90.10,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $106.00 in Billed Charges for Rev 250 = $90.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,HUMANA,HUMANA NATIIONAL POS HMO,67.31,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $106.00 in Billed Charges at 63.5% = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,77.38,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $106.00 in Billed Charges for Rev 250 = $77.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,LIVE360,LIVE360 HSHS HEALTHY PLAN,106.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $106.00 in Billed Charges for Rev 250 = $106.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,53.00,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $106.00 in Billed Charges for Rev 250 = $53.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,89.04,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $106.00 in Billed Charges for Rev 250 = $89.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,79.50,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $106.00 in Billed Charges for Rev 250 = $79.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,97.52,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $106.00 in Billed Charges for Rev 250 = $97.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,67.66,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $106.00 in Billed Charges for Rev 250 = $67.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,76.32,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 250 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,58.62,,,,,,,51.5200,106.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $106.00 in Billed Charges for Rev 250 = $58.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UHC ONEIDA NATION,58.62,,,,,,,51.5200,106.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $106.00 in Billed Charges for Rev 250 = $58.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,UNITED HEALTHCARE,UNITED HEALTHCARE,58.62,,,,,,,51.5200,106.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $106.00 in Billed Charges for Rev 250 = $58.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,76.32,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 250 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,65.72,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $106.00 in Billed Charges for Rev 250 = $65.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,76.32,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 250 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,76.32,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $106.00 in Billed Charges for Rev 250 = $76.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",250,RC,0264-2304-00,CDM,,,,,,both,1000.000000,ML,106.0000,69.9600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,63.60,,,,,,,51.5200,106.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $106.00 in Billed Charges for Rev 250 = $63.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,AETNA,AETNA HSHS,29.94,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $46.35 in Billed Charges for Rev 250 = $29.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,AETNA,ALL COMMERCIAL AETNA,46.35,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.35 in Billed Charges for Rev 250 = $46.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,ANTHEM,ANTHEM POS/HMO,31.52,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $46.35 in Billed Charges at 68% = $31.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,ANTHEM,ANTHEM PPO,31.52,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $46.35 in Billed Charges at 68% = $31.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,46.35,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.35 in Billed Charges for Rev 250 = $46.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,CENPATICO,ALL MEDICAID CENPATICO,46.35,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.35 in Billed Charges for Rev 250 = $46.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,39.40,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $46.35 in Billed Charges for Rev 250 = $39.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,CIGNA,ALL COMMERCIAL CIGNA,32.45,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $46.35 in Billed Charges for Rev 250 = $32.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,COFINITY,COFINITY,46.35,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.35 in Billed Charges for Rev 250 = $46.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,44.03,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $46.35 in Billed Charges for Rev 250 = $44.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,HEALTH CARE ALLIANCE,THE ALLIANCE,38.93,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $46.35 in Billed Charges for Rev 250 = $38.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,32.91,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $46.35 in Billed Charges for Rev 250 = $32.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,33.84,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $46.35 in Billed Charges for Rev 250 = $33.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,HSHS EMPLOYEES,HSHS EMPLOYEES,22.53,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $46.35 in Billed Charges for Rev 250 = $22.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,39.40,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $46.35 in Billed Charges for Rev 250 = $39.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,HUMANA,HUMANA CHOICE CARE HMO,29.43,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $46.35 in Billed Charges at 63.5% = $29.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,HUMANA,HUMANA CHOICE CARE PPO,39.40,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $46.35 in Billed Charges for Rev 250 = $39.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,HUMANA,HUMANA NATIIONAL POS HMO,29.43,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $46.35 in Billed Charges at 63.5% = $29.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,33.84,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $46.35 in Billed Charges for Rev 250 = $33.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,LIVE360,LIVE360 HSHS HEALTHY PLAN,46.35,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $46.35 in Billed Charges for Rev 250 = $46.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,23.18,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $46.35 in Billed Charges for Rev 250 = $23.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,38.93,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $46.35 in Billed Charges for Rev 250 = $38.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,34.76,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $46.35 in Billed Charges for Rev 250 = $34.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,42.64,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $46.35 in Billed Charges for Rev 250 = $42.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,27.81,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $46.35 in Billed Charges for Rev 250 = $27.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,27.81,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $46.35 in Billed Charges for Rev 250 = $27.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,PREVEA HEALTH NETWORK,PREVEA360,27.81,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $46.35 in Billed Charges for Rev 250 = $27.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,27.81,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $46.35 in Billed Charges for Rev 250 = $27.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,29.59,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $46.35 in Billed Charges for Rev 250 = $29.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,33.37,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $46.35 in Billed Charges for Rev 250 = $33.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,25.63,,,,,,,22.5300,46.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $46.35 in Billed Charges for Rev 250 = $25.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,UNITED HEALTHCARE,UHC ONEIDA NATION,25.63,,,,,,,22.5300,46.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $46.35 in Billed Charges for Rev 250 = $25.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,UNITED HEALTHCARE,UNITED HEALTHCARE,25.63,,,,,,,22.5300,46.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $46.35 in Billed Charges for Rev 250 = $25.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,33.37,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $46.35 in Billed Charges for Rev 250 = $33.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,28.74,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $46.35 in Billed Charges for Rev 250 = $28.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,33.37,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $46.35 in Billed Charges for Rev 250 = $33.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,33.37,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $46.35 in Billed Charges for Rev 250 = $33.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ACETYLCYSTEINE 10 % SOLN,250,RC,0517-7504-01,CDM,,,,,,both,4.000000,ML,46.3500,30.5900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,27.81,,,,,,,22.5300,46.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $46.35 in Billed Charges for Rev 250 = $27.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 250 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 250 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 250 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 250 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 250 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 250 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 250 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 250 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 250 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 250 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ALBUTEROL (5 MG/ML) 0.5% NEBU 0.5 ML PLAS CONT,250,RC,0487-9901-30,CDM,,,,,,both,0.500000,ML,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,AETNA,AETNA HSHS,200.26,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $310.00 in Billed Charges for Rev 250 = $200.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,AETNA,ALL COMMERCIAL AETNA,310.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 250 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,ANTHEM,ANTHEM POS/HMO,210.80,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $310.00 in Billed Charges at 68% = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,ANTHEM,ANTHEM PPO,210.80,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $310.00 in Billed Charges at 68% = $210.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,310.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 250 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,CENPATICO,ALL MEDICAID CENPATICO,310.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 250 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,263.50,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 250 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,CIGNA,ALL COMMERCIAL CIGNA,217.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $310.00 in Billed Charges for Rev 250 = $217.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,COFINITY,COFINITY,310.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 250 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,294.50,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $310.00 in Billed Charges for Rev 250 = $294.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,HEALTH CARE ALLIANCE,THE ALLIANCE,260.40,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $310.00 in Billed Charges for Rev 250 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,220.10,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $310.00 in Billed Charges for Rev 250 = $220.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,226.30,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $310.00 in Billed Charges for Rev 250 = $226.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,HSHS EMPLOYEES,HSHS EMPLOYEES,150.66,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $310.00 in Billed Charges for Rev 250 = $150.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,263.50,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 250 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,HUMANA,HUMANA CHOICE CARE HMO,196.85,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $310.00 in Billed Charges at 63.5% = $196.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,HUMANA,HUMANA CHOICE CARE PPO,263.50,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $310.00 in Billed Charges for Rev 250 = $263.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,HUMANA,HUMANA NATIIONAL POS HMO,196.85,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $310.00 in Billed Charges at 63.5% = $196.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,226.30,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $310.00 in Billed Charges for Rev 250 = $226.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,LIVE360,LIVE360 HSHS HEALTHY PLAN,310.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $310.00 in Billed Charges for Rev 250 = $310.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,155.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $310.00 in Billed Charges for Rev 250 = $155.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,260.40,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $310.00 in Billed Charges for Rev 250 = $260.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,232.50,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $310.00 in Billed Charges for Rev 250 = $232.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,285.20,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $310.00 in Billed Charges for Rev 250 = $285.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,186.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $310.00 in Billed Charges for Rev 250 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,186.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $310.00 in Billed Charges for Rev 250 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA360,186.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $310.00 in Billed Charges for Rev 250 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,186.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $310.00 in Billed Charges for Rev 250 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,197.87,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $310.00 in Billed Charges for Rev 250 = $197.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,223.20,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 250 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,171.43,,,,,,,150.6600,310.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $310.00 in Billed Charges for Rev 250 = $171.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,UNITED HEALTHCARE,UHC ONEIDA NATION,171.43,,,,,,,150.6600,310.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $310.00 in Billed Charges for Rev 250 = $171.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,UNITED HEALTHCARE,UNITED HEALTHCARE,171.43,,,,,,,150.6600,310.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $310.00 in Billed Charges for Rev 250 = $171.43 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,223.20,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 250 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,192.20,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $310.00 in Billed Charges for Rev 250 = $192.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,223.20,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 250 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,223.20,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $310.00 in Billed Charges for Rev 250 = $223.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ARGININE (L-ARGININE) 10 % SOLN,250,RC,0009-0436-01,CDM,,,,,,both,300.000000,ML,310.0000,204.6000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,186.00,,,,,,,150.6600,310.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $310.00 in Billed Charges for Rev 250 = $186.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,AETNA,AETNA HSHS,128.23,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $198.50 in Billed Charges for Rev 250 = $128.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,AETNA,ALL COMMERCIAL AETNA,198.50,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.50 in Billed Charges for Rev 250 = $198.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,ANTHEM,ANTHEM POS/HMO,134.98,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $198.50 in Billed Charges at 68% = $134.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,ANTHEM,ANTHEM PPO,134.98,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $198.50 in Billed Charges at 68% = $134.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,198.50,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.50 in Billed Charges for Rev 250 = $198.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,CENPATICO,ALL MEDICAID CENPATICO,198.50,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.50 in Billed Charges for Rev 250 = $198.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,168.73,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $198.50 in Billed Charges for Rev 250 = $168.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,CIGNA,ALL COMMERCIAL CIGNA,138.95,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $198.50 in Billed Charges for Rev 250 = $138.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,COFINITY,COFINITY,198.50,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.50 in Billed Charges for Rev 250 = $198.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,188.58,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $198.50 in Billed Charges for Rev 250 = $188.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,166.74,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $198.50 in Billed Charges for Rev 250 = $166.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,140.94,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $198.50 in Billed Charges for Rev 250 = $140.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,144.91,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $198.50 in Billed Charges for Rev 250 = $144.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,96.47,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $198.50 in Billed Charges for Rev 250 = $96.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,168.73,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $198.50 in Billed Charges for Rev 250 = $168.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,HUMANA,HUMANA CHOICE CARE HMO,126.05,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $198.50 in Billed Charges at 63.5% = $126.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,HUMANA,HUMANA CHOICE CARE PPO,168.73,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $198.50 in Billed Charges for Rev 250 = $168.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,HUMANA,HUMANA NATIIONAL POS HMO,126.05,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $198.50 in Billed Charges at 63.5% = $126.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,144.91,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $198.50 in Billed Charges for Rev 250 = $144.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,198.50,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $198.50 in Billed Charges for Rev 250 = $198.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,99.25,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $198.50 in Billed Charges for Rev 250 = $99.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,166.74,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $198.50 in Billed Charges for Rev 250 = $166.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,148.88,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $198.50 in Billed Charges for Rev 250 = $148.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,182.62,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $198.50 in Billed Charges for Rev 250 = $182.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,119.10,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $198.50 in Billed Charges for Rev 250 = $119.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,119.10,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $198.50 in Billed Charges for Rev 250 = $119.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,PREVEA HEALTH NETWORK,PREVEA360,119.10,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $198.50 in Billed Charges for Rev 250 = $119.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,119.10,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $198.50 in Billed Charges for Rev 250 = $119.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,126.70,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $198.50 in Billed Charges for Rev 250 = $126.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,142.92,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $198.50 in Billed Charges for Rev 250 = $142.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,109.77,,,,,,,96.4700,198.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $198.50 in Billed Charges for Rev 250 = $109.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,UNITED HEALTHCARE,UHC ONEIDA NATION,109.77,,,,,,,96.4700,198.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $198.50 in Billed Charges for Rev 250 = $109.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,UNITED HEALTHCARE,UNITED HEALTHCARE,109.77,,,,,,,96.4700,198.5000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $198.50 in Billed Charges for Rev 250 = $109.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,142.92,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $198.50 in Billed Charges for Rev 250 = $142.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,123.07,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $198.50 in Billed Charges for Rev 250 = $123.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,142.92,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $198.50 in Billed Charges for Rev 250 = $142.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,142.92,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $198.50 in Billed Charges for Rev 250 = $142.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ATROPINE 1 % SOLN 5 ML BOTTLE,250,RC,60219-1749-3,CDM,,,,,,both,5.000000,ML,198.5000,131.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,119.10,,,,,,,96.4700,198.5000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $198.50 in Billed Charges for Rev 250 = $119.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,AETNA,AETNA HSHS,33.37,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $51.65 in Billed Charges for Rev 250 = $33.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,AETNA,ALL COMMERCIAL AETNA,51.65,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.65 in Billed Charges for Rev 250 = $51.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,ANTHEM,ANTHEM POS/HMO,35.12,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $51.65 in Billed Charges at 68% = $35.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,ANTHEM,ANTHEM PPO,35.12,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $51.65 in Billed Charges at 68% = $35.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,51.65,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.65 in Billed Charges for Rev 250 = $51.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,CENPATICO,ALL MEDICAID CENPATICO,51.65,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.65 in Billed Charges for Rev 250 = $51.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,43.90,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.65 in Billed Charges for Rev 250 = $43.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,CIGNA,ALL COMMERCIAL CIGNA,36.16,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $51.65 in Billed Charges for Rev 250 = $36.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,COFINITY,COFINITY,51.65,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.65 in Billed Charges for Rev 250 = $51.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,49.07,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $51.65 in Billed Charges for Rev 250 = $49.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,HEALTH CARE ALLIANCE,THE ALLIANCE,43.39,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $51.65 in Billed Charges for Rev 250 = $43.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,36.67,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $51.65 in Billed Charges for Rev 250 = $36.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,37.70,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $51.65 in Billed Charges for Rev 250 = $37.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,HSHS EMPLOYEES,HSHS EMPLOYEES,25.10,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $51.65 in Billed Charges for Rev 250 = $25.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,43.90,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.65 in Billed Charges for Rev 250 = $43.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,HUMANA,HUMANA CHOICE CARE HMO,32.80,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $51.65 in Billed Charges at 63.5% = $32.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,HUMANA,HUMANA CHOICE CARE PPO,43.90,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $51.65 in Billed Charges for Rev 250 = $43.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,HUMANA,HUMANA NATIIONAL POS HMO,32.80,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $51.65 in Billed Charges at 63.5% = $32.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,37.70,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $51.65 in Billed Charges for Rev 250 = $37.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,LIVE360,LIVE360 HSHS HEALTHY PLAN,51.65,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $51.65 in Billed Charges for Rev 250 = $51.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,25.83,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $51.65 in Billed Charges for Rev 250 = $25.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,43.39,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $51.65 in Billed Charges for Rev 250 = $43.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,38.74,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $51.65 in Billed Charges for Rev 250 = $38.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,47.52,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $51.65 in Billed Charges for Rev 250 = $47.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,30.99,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.65 in Billed Charges for Rev 250 = $30.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,30.99,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.65 in Billed Charges for Rev 250 = $30.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,PREVEA HEALTH NETWORK,PREVEA360,30.99,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.65 in Billed Charges for Rev 250 = $30.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,30.99,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.65 in Billed Charges for Rev 250 = $30.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,32.97,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $51.65 in Billed Charges for Rev 250 = $32.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,37.19,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.65 in Billed Charges for Rev 250 = $37.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,28.56,,,,,,,25.1000,51.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $51.65 in Billed Charges for Rev 250 = $28.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,UNITED HEALTHCARE,UHC ONEIDA NATION,28.56,,,,,,,25.1000,51.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $51.65 in Billed Charges for Rev 250 = $28.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,UNITED HEALTHCARE,UNITED HEALTHCARE,28.56,,,,,,,25.1000,51.6500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $51.65 in Billed Charges for Rev 250 = $28.56 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,37.19,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.65 in Billed Charges for Rev 250 = $37.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.02,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $51.65 in Billed Charges for Rev 250 = $32.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,37.19,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.65 in Billed Charges for Rev 250 = $37.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,37.19,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $51.65 in Billed Charges for Rev 250 = $37.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 15 ML BOTTLE,250,RC,0065-0795-15,CDM,,,,,,both,15.000000,ML,51.6500,34.0900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,30.99,,,,,,,25.1000,51.6500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $51.65 in Billed Charges for Rev 250 = $30.99. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,AETNA,AETNA HSHS,52.58,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $81.40 in Billed Charges for Rev 250 = $52.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,AETNA,ALL COMMERCIAL AETNA,81.40,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.40 in Billed Charges for Rev 250 = $81.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,ANTHEM,ANTHEM POS/HMO,55.35,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $81.40 in Billed Charges at 68% = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,ANTHEM,ANTHEM PPO,55.35,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $81.40 in Billed Charges at 68% = $55.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,81.40,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.40 in Billed Charges for Rev 250 = $81.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,CENPATICO,ALL MEDICAID CENPATICO,81.40,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.40 in Billed Charges for Rev 250 = $81.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,69.19,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.40 in Billed Charges for Rev 250 = $69.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,CIGNA,ALL COMMERCIAL CIGNA,56.98,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $81.40 in Billed Charges for Rev 250 = $56.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,COFINITY,COFINITY,81.40,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.40 in Billed Charges for Rev 250 = $81.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,77.33,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $81.40 in Billed Charges for Rev 250 = $77.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,68.38,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.40 in Billed Charges for Rev 250 = $68.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,57.79,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $81.40 in Billed Charges for Rev 250 = $57.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,59.42,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.40 in Billed Charges for Rev 250 = $59.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,39.56,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $81.40 in Billed Charges for Rev 250 = $39.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,69.19,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.40 in Billed Charges for Rev 250 = $69.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,HUMANA,HUMANA CHOICE CARE HMO,51.69,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $81.40 in Billed Charges at 63.5% = $51.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,HUMANA,HUMANA CHOICE CARE PPO,69.19,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $81.40 in Billed Charges for Rev 250 = $69.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,HUMANA,HUMANA NATIIONAL POS HMO,51.69,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $81.40 in Billed Charges at 63.5% = $51.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,59.42,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $81.40 in Billed Charges for Rev 250 = $59.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,81.40,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $81.40 in Billed Charges for Rev 250 = $81.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,40.70,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $81.40 in Billed Charges for Rev 250 = $40.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,68.38,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $81.40 in Billed Charges for Rev 250 = $68.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,61.05,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $81.40 in Billed Charges for Rev 250 = $61.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,74.89,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $81.40 in Billed Charges for Rev 250 = $74.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,48.84,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.40 in Billed Charges for Rev 250 = $48.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,48.84,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.40 in Billed Charges for Rev 250 = $48.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,PREVEA HEALTH NETWORK,PREVEA360,48.84,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.40 in Billed Charges for Rev 250 = $48.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,48.84,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.40 in Billed Charges for Rev 250 = $48.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,51.96,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $81.40 in Billed Charges for Rev 250 = $51.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,58.61,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.40 in Billed Charges for Rev 250 = $58.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,45.01,,,,,,,39.5600,81.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $81.40 in Billed Charges for Rev 250 = $45.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,45.01,,,,,,,39.5600,81.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $81.40 in Billed Charges for Rev 250 = $45.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,45.01,,,,,,,39.5600,81.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $81.40 in Billed Charges for Rev 250 = $45.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,58.61,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.40 in Billed Charges for Rev 250 = $58.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.47,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $81.40 in Billed Charges for Rev 250 = $50.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,58.61,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.40 in Billed Charges for Rev 250 = $58.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,58.61,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $81.40 in Billed Charges for Rev 250 = $58.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BALANCED SALTS SOLN 30 ML BOTTLE,250,RC,0065-0530-01,CDM,,,,,,both,30.000000,ML,81.4000,53.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,48.84,,,,,,,39.5600,81.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $81.40 in Billed Charges for Rev 250 = $48.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,AETNA,AETNA HSHS,15.31,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $23.70 in Billed Charges for Rev 250 = $15.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,AETNA,ALL COMMERCIAL AETNA,23.70,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.70 in Billed Charges for Rev 250 = $23.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,ANTHEM,ANTHEM POS/HMO,16.12,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $23.70 in Billed Charges at 68% = $16.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,ANTHEM,ANTHEM PPO,16.12,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $23.70 in Billed Charges at 68% = $16.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,23.70,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.70 in Billed Charges for Rev 250 = $23.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,CENPATICO,ALL MEDICAID CENPATICO,23.70,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.70 in Billed Charges for Rev 250 = $23.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.15,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.70 in Billed Charges for Rev 250 = $20.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,CIGNA,ALL COMMERCIAL CIGNA,16.59,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $23.70 in Billed Charges for Rev 250 = $16.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,COFINITY,COFINITY,23.70,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.70 in Billed Charges for Rev 250 = $23.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,22.52,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $23.70 in Billed Charges for Rev 250 = $22.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,19.91,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.70 in Billed Charges for Rev 250 = $19.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,16.83,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $23.70 in Billed Charges for Rev 250 = $16.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.30,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.70 in Billed Charges for Rev 250 = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,11.52,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $23.70 in Billed Charges for Rev 250 = $11.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.15,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.70 in Billed Charges for Rev 250 = $20.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,HUMANA,HUMANA CHOICE CARE HMO,15.05,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $23.70 in Billed Charges at 63.5% = $15.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,HUMANA,HUMANA CHOICE CARE PPO,20.15,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $23.70 in Billed Charges for Rev 250 = $20.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,HUMANA,HUMANA NATIIONAL POS HMO,15.05,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $23.70 in Billed Charges at 63.5% = $15.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.30,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $23.70 in Billed Charges for Rev 250 = $17.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,23.70,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $23.70 in Billed Charges for Rev 250 = $23.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,11.85,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $23.70 in Billed Charges for Rev 250 = $11.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,19.91,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $23.70 in Billed Charges for Rev 250 = $19.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,17.78,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $23.70 in Billed Charges for Rev 250 = $17.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,21.80,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $23.70 in Billed Charges for Rev 250 = $21.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.22,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.70 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.22,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.70 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,PREVEA HEALTH NETWORK,PREVEA360,14.22,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.70 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.22,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.70 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.13,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $23.70 in Billed Charges for Rev 250 = $15.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.06,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.70 in Billed Charges for Rev 250 = $17.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,13.11,,,,,,,11.5200,23.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.70 in Billed Charges for Rev 250 = $13.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,13.11,,,,,,,11.5200,23.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.70 in Billed Charges for Rev 250 = $13.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,13.11,,,,,,,11.5200,23.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $23.70 in Billed Charges for Rev 250 = $13.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.06,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.70 in Billed Charges for Rev 250 = $17.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,14.69,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $23.70 in Billed Charges for Rev 250 = $14.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.06,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.70 in Billed Charges for Rev 250 = $17.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.06,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $23.70 in Billed Charges for Rev 250 = $17.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CAN,250,RC,16864-68003,CDM,,,,,,both,85.000000,GR,23.7000,15.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.22,,,,,,,11.5200,23.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $23.70 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,AETNA,AETNA HSHS,20.87,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $32.30 in Billed Charges for Rev 250 = $20.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,AETNA,ALL COMMERCIAL AETNA,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,ANTHEM,ANTHEM POS/HMO,21.96,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $32.30 in Billed Charges at 68% = $21.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,ANTHEM,ANTHEM PPO,21.96,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $32.30 in Billed Charges at 68% = $21.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,CENPATICO,ALL MEDICAID CENPATICO,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,27.46,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.30 in Billed Charges for Rev 250 = $27.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,CIGNA,ALL COMMERCIAL CIGNA,22.61,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $32.30 in Billed Charges for Rev 250 = $22.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,COFINITY,COFINITY,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,30.69,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $32.30 in Billed Charges for Rev 250 = $30.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,HEALTH CARE ALLIANCE,THE ALLIANCE,27.13,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.30 in Billed Charges for Rev 250 = $27.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,22.93,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $32.30 in Billed Charges for Rev 250 = $22.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,23.58,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.30 in Billed Charges for Rev 250 = $23.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,HSHS EMPLOYEES,HSHS EMPLOYEES,15.70,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $32.30 in Billed Charges for Rev 250 = $15.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,27.46,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.30 in Billed Charges for Rev 250 = $27.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,HUMANA,HUMANA CHOICE CARE HMO,20.51,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $32.30 in Billed Charges at 63.5% = $20.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,HUMANA,HUMANA CHOICE CARE PPO,27.46,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $32.30 in Billed Charges for Rev 250 = $27.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,HUMANA,HUMANA NATIIONAL POS HMO,20.51,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $32.30 in Billed Charges at 63.5% = $20.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,23.58,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $32.30 in Billed Charges for Rev 250 = $23.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,LIVE360,LIVE360 HSHS HEALTHY PLAN,32.30,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $32.30 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,16.15,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $32.30 in Billed Charges for Rev 250 = $16.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,27.13,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $32.30 in Billed Charges for Rev 250 = $27.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,24.23,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $32.30 in Billed Charges for Rev 250 = $24.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,29.72,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $32.30 in Billed Charges for Rev 250 = $29.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.30 in Billed Charges for Rev 250 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.30 in Billed Charges for Rev 250 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,PREVEA HEALTH NETWORK,PREVEA360,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.30 in Billed Charges for Rev 250 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.30 in Billed Charges for Rev 250 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,20.62,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $32.30 in Billed Charges for Rev 250 = $20.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,23.26,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.30 in Billed Charges for Rev 250 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,17.86,,,,,,,15.7000,32.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $32.30 in Billed Charges for Rev 250 = $17.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,UNITED HEALTHCARE,UHC ONEIDA NATION,17.86,,,,,,,15.7000,32.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $32.30 in Billed Charges for Rev 250 = $17.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,UNITED HEALTHCARE,UNITED HEALTHCARE,17.86,,,,,,,15.7000,32.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $32.30 in Billed Charges for Rev 250 = $17.86 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,23.26,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.30 in Billed Charges for Rev 250 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,20.03,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $32.30 in Billed Charges for Rev 250 = $20.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,23.26,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.30 in Billed Charges for Rev 250 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,23.26,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $32.30 in Billed Charges for Rev 250 = $23.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.25 MG/2ML SUSP,250,RC,0487-9601-01,CDM,,,,,,both,2.000000,ML,32.3000,21.3200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,19.38,,,,,,,15.7000,32.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $32.30 in Billed Charges for Rev 250 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,AETNA,AETNA HSHS,24.55,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $38.00 in Billed Charges for Rev 250 = $24.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,AETNA,ALL COMMERCIAL AETNA,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 250 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,ANTHEM,ANTHEM POS/HMO,25.84,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $38.00 in Billed Charges at 68% = $25.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,ANTHEM,ANTHEM PPO,25.84,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $38.00 in Billed Charges at 68% = $25.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 250 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,CENPATICO,ALL MEDICAID CENPATICO,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 250 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,32.30,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,CIGNA,ALL COMMERCIAL CIGNA,26.60,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $38.00 in Billed Charges for Rev 250 = $26.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,COFINITY,COFINITY,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 250 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,36.10,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $38.00 in Billed Charges for Rev 250 = $36.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,HEALTH CARE ALLIANCE,THE ALLIANCE,31.92,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.00 in Billed Charges for Rev 250 = $31.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,26.98,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $38.00 in Billed Charges for Rev 250 = $26.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,27.74,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.00 in Billed Charges for Rev 250 = $27.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,HSHS EMPLOYEES,HSHS EMPLOYEES,18.47,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $38.00 in Billed Charges for Rev 250 = $18.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,32.30,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,HUMANA,HUMANA CHOICE CARE HMO,24.13,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $38.00 in Billed Charges at 63.5% = $24.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,HUMANA,HUMANA CHOICE CARE PPO,32.30,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $38.00 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,HUMANA,HUMANA NATIIONAL POS HMO,24.13,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $38.00 in Billed Charges at 63.5% = $24.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,27.74,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $38.00 in Billed Charges for Rev 250 = $27.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,LIVE360,LIVE360 HSHS HEALTHY PLAN,38.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $38.00 in Billed Charges for Rev 250 = $38.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,19.00,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $38.00 in Billed Charges for Rev 250 = $19.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,31.92,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $38.00 in Billed Charges for Rev 250 = $31.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,28.50,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $38.00 in Billed Charges for Rev 250 = $28.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,34.96,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $38.00 in Billed Charges for Rev 250 = $34.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 250 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 250 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA360,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 250 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 250 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,24.26,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $38.00 in Billed Charges for Rev 250 = $24.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,27.36,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 250 = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,21.01,,,,,,,18.4700,38.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.00 in Billed Charges for Rev 250 = $21.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,UNITED HEALTHCARE,UHC ONEIDA NATION,21.01,,,,,,,18.4700,38.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.00 in Billed Charges for Rev 250 = $21.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,UNITED HEALTHCARE,UNITED HEALTHCARE,21.01,,,,,,,18.4700,38.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $38.00 in Billed Charges for Rev 250 = $21.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,27.36,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 250 = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,23.56,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $38.00 in Billed Charges for Rev 250 = $23.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,27.36,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 250 = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,27.36,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $38.00 in Billed Charges for Rev 250 = $27.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUDESONIDE 0.5 MG/2ML SUSP,250,RC,69097-319-32,CDM,,,,,,both,2.000000,ML,38.0000,25.0800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,22.80,,,,,,,18.4700,38.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $38.00 in Billed Charges for Rev 250 = $22.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,AETNA,AETNA HSHS,62.11,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $96.15 in Billed Charges for Rev 250 = $62.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,AETNA,ALL COMMERCIAL AETNA,96.15,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.15 in Billed Charges for Rev 250 = $96.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,ANTHEM,ANTHEM POS/HMO,65.38,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $96.15 in Billed Charges at 68% = $65.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,ANTHEM,ANTHEM PPO,65.38,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $96.15 in Billed Charges at 68% = $65.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,96.15,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.15 in Billed Charges for Rev 250 = $96.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,CENPATICO,ALL MEDICAID CENPATICO,96.15,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.15 in Billed Charges for Rev 250 = $96.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,81.73,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.15 in Billed Charges for Rev 250 = $81.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,CIGNA,ALL COMMERCIAL CIGNA,67.31,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $96.15 in Billed Charges for Rev 250 = $67.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,COFINITY,COFINITY,96.15,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.15 in Billed Charges for Rev 250 = $96.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,91.34,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $96.15 in Billed Charges for Rev 250 = $91.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,80.77,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $96.15 in Billed Charges for Rev 250 = $80.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,68.27,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $96.15 in Billed Charges for Rev 250 = $68.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,70.19,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $96.15 in Billed Charges for Rev 250 = $70.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,46.73,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $96.15 in Billed Charges for Rev 250 = $46.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,81.73,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.15 in Billed Charges for Rev 250 = $81.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,HUMANA,HUMANA CHOICE CARE HMO,61.06,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $96.15 in Billed Charges at 63.5% = $61.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,HUMANA,HUMANA CHOICE CARE PPO,81.73,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $96.15 in Billed Charges for Rev 250 = $81.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,HUMANA,HUMANA NATIIONAL POS HMO,61.06,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $96.15 in Billed Charges at 63.5% = $61.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,70.19,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $96.15 in Billed Charges for Rev 250 = $70.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,96.15,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $96.15 in Billed Charges for Rev 250 = $96.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,48.08,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $96.15 in Billed Charges for Rev 250 = $48.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,80.77,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $96.15 in Billed Charges for Rev 250 = $80.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,72.11,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $96.15 in Billed Charges for Rev 250 = $72.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,88.46,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $96.15 in Billed Charges for Rev 250 = $88.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,57.69,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $96.15 in Billed Charges for Rev 250 = $57.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,57.69,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $96.15 in Billed Charges for Rev 250 = $57.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,PREVEA HEALTH NETWORK,PREVEA360,57.69,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $96.15 in Billed Charges for Rev 250 = $57.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,57.69,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $96.15 in Billed Charges for Rev 250 = $57.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,61.37,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $96.15 in Billed Charges for Rev 250 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,69.23,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.15 in Billed Charges for Rev 250 = $69.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,53.17,,,,,,,46.7300,96.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $96.15 in Billed Charges for Rev 250 = $53.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,53.17,,,,,,,46.7300,96.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $96.15 in Billed Charges for Rev 250 = $53.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,53.17,,,,,,,46.7300,96.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $96.15 in Billed Charges for Rev 250 = $53.17 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,69.23,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.15 in Billed Charges for Rev 250 = $69.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,59.61,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $96.15 in Billed Charges for Rev 250 = $59.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,69.23,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.15 in Billed Charges for Rev 250 = $69.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,69.23,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $96.15 in Billed Charges for Rev 250 = $69.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
BUPIVACAINE-EPINEPHRINE PF 0.5% -1:200000 SOLN,250,RC,63323-462-37,CDM,,,,,,both,30.000000,ML,96.1500,63.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,57.69,,,,,,,46.7300,96.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $96.15 in Billed Charges for Rev 250 = $57.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,AETNA,AETNA HSHS,186.63,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $288.90 in Billed Charges for Rev 250 = $186.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,AETNA,ALL COMMERCIAL AETNA,288.90,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.90 in Billed Charges for Rev 250 = $288.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,ANTHEM,ANTHEM POS/HMO,196.45,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $288.90 in Billed Charges at 68% = $196.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,ANTHEM,ANTHEM PPO,196.45,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $288.90 in Billed Charges at 68% = $196.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,288.90,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.90 in Billed Charges for Rev 250 = $288.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,CENPATICO,ALL MEDICAID CENPATICO,288.90,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.90 in Billed Charges for Rev 250 = $288.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,245.57,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $288.90 in Billed Charges for Rev 250 = $245.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,CIGNA,ALL COMMERCIAL CIGNA,202.23,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $288.90 in Billed Charges for Rev 250 = $202.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,COFINITY,COFINITY,288.90,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.90 in Billed Charges for Rev 250 = $288.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,274.46,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $288.90 in Billed Charges for Rev 250 = $274.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,HEALTH CARE ALLIANCE,THE ALLIANCE,242.68,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $288.90 in Billed Charges for Rev 250 = $242.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,205.12,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $288.90 in Billed Charges for Rev 250 = $205.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,210.90,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $288.90 in Billed Charges for Rev 250 = $210.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,HSHS EMPLOYEES,HSHS EMPLOYEES,140.41,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $288.90 in Billed Charges for Rev 250 = $140.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,245.57,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $288.90 in Billed Charges for Rev 250 = $245.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,HUMANA,HUMANA CHOICE CARE HMO,183.45,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $288.90 in Billed Charges at 63.5% = $183.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,HUMANA,HUMANA CHOICE CARE PPO,245.57,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $288.90 in Billed Charges for Rev 250 = $245.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,HUMANA,HUMANA NATIIONAL POS HMO,183.45,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $288.90 in Billed Charges at 63.5% = $183.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,210.90,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $288.90 in Billed Charges for Rev 250 = $210.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,LIVE360,LIVE360 HSHS HEALTHY PLAN,288.90,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $288.90 in Billed Charges for Rev 250 = $288.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,144.45,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $288.90 in Billed Charges for Rev 250 = $144.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,242.68,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $288.90 in Billed Charges for Rev 250 = $242.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,216.68,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $288.90 in Billed Charges for Rev 250 = $216.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,265.79,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $288.90 in Billed Charges for Rev 250 = $265.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,173.34,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $288.90 in Billed Charges for Rev 250 = $173.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,173.34,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $288.90 in Billed Charges for Rev 250 = $173.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,PREVEA HEALTH NETWORK,PREVEA360,173.34,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $288.90 in Billed Charges for Rev 250 = $173.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,173.34,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $288.90 in Billed Charges for Rev 250 = $173.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,184.40,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $288.90 in Billed Charges for Rev 250 = $184.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,208.01,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $288.90 in Billed Charges for Rev 250 = $208.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,159.76,,,,,,,140.4100,288.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $288.90 in Billed Charges for Rev 250 = $159.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,UNITED HEALTHCARE,UHC ONEIDA NATION,159.76,,,,,,,140.4100,288.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $288.90 in Billed Charges for Rev 250 = $159.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,UNITED HEALTHCARE,UNITED HEALTHCARE,159.76,,,,,,,140.4100,288.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $288.90 in Billed Charges for Rev 250 = $159.76 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,208.01,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $288.90 in Billed Charges for Rev 250 = $208.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,179.12,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $288.90 in Billed Charges for Rev 250 = $179.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,208.01,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $288.90 in Billed Charges for Rev 250 = $208.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,208.01,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $288.90 in Billed Charges for Rev 250 = $208.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML SOLN 2 ML VIAL,250,RC,0517-2502-01,CDM,,,,,,both,2.000000,ML,288.9000,190.6700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,173.34,,,,,,,140.4100,288.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $288.90 in Billed Charges for Rev 250 = $173.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,AETNA,AETNA HSHS,122.48,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $189.60 in Billed Charges for Rev 250 = $122.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,AETNA,ALL COMMERCIAL AETNA,189.60,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.60 in Billed Charges for Rev 250 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,ANTHEM,ANTHEM POS/HMO,128.93,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $189.60 in Billed Charges at 68% = $128.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,ANTHEM,ANTHEM PPO,128.93,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $189.60 in Billed Charges at 68% = $128.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,189.60,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.60 in Billed Charges for Rev 250 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,CENPATICO,ALL MEDICAID CENPATICO,189.60,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.60 in Billed Charges for Rev 250 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,161.16,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.60 in Billed Charges for Rev 250 = $161.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,CIGNA,ALL COMMERCIAL CIGNA,132.72,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $189.60 in Billed Charges for Rev 250 = $132.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,COFINITY,COFINITY,189.60,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.60 in Billed Charges for Rev 250 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,180.12,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $189.60 in Billed Charges for Rev 250 = $180.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,HEALTH CARE ALLIANCE,THE ALLIANCE,159.26,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $189.60 in Billed Charges for Rev 250 = $159.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,134.62,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $189.60 in Billed Charges for Rev 250 = $134.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,138.41,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $189.60 in Billed Charges for Rev 250 = $138.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,HSHS EMPLOYEES,HSHS EMPLOYEES,92.15,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $189.60 in Billed Charges for Rev 250 = $92.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,161.16,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.60 in Billed Charges for Rev 250 = $161.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,HUMANA,HUMANA CHOICE CARE HMO,120.40,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $189.60 in Billed Charges at 63.5% = $120.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,HUMANA,HUMANA CHOICE CARE PPO,161.16,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $189.60 in Billed Charges for Rev 250 = $161.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,HUMANA,HUMANA NATIIONAL POS HMO,120.40,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $189.60 in Billed Charges at 63.5% = $120.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,138.41,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $189.60 in Billed Charges for Rev 250 = $138.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,LIVE360,LIVE360 HSHS HEALTHY PLAN,189.60,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $189.60 in Billed Charges for Rev 250 = $189.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,94.80,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $189.60 in Billed Charges for Rev 250 = $94.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,159.26,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $189.60 in Billed Charges for Rev 250 = $159.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,142.20,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $189.60 in Billed Charges for Rev 250 = $142.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,174.43,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $189.60 in Billed Charges for Rev 250 = $174.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,113.76,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.60 in Billed Charges for Rev 250 = $113.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,113.76,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.60 in Billed Charges for Rev 250 = $113.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,PREVEA HEALTH NETWORK,PREVEA360,113.76,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.60 in Billed Charges for Rev 250 = $113.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,113.76,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.60 in Billed Charges for Rev 250 = $113.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,121.02,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $189.60 in Billed Charges for Rev 250 = $121.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,136.51,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.60 in Billed Charges for Rev 250 = $136.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,104.85,,,,,,,92.1500,189.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.60 in Billed Charges for Rev 250 = $104.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,UNITED HEALTHCARE,UHC ONEIDA NATION,104.85,,,,,,,92.1500,189.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.60 in Billed Charges for Rev 250 = $104.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,UNITED HEALTHCARE,UNITED HEALTHCARE,104.85,,,,,,,92.1500,189.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $189.60 in Billed Charges for Rev 250 = $104.85 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,136.51,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.60 in Billed Charges for Rev 250 = $136.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,117.55,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $189.60 in Billed Charges for Rev 250 = $117.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,136.51,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.60 in Billed Charges for Rev 250 = $136.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,136.51,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $189.60 in Billed Charges for Rev 250 = $136.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CARBACHOL 0.01 % SOLN 1.5 ML VIAL,250,RC,0065-0023-15,CDM,,,,,,both,1.500000,ML,189.6000,125.1400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,113.76,,,,,,,92.1500,189.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $189.60 in Billed Charges for Rev 250 = $113.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,AETNA,AETNA HSHS,52.20,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $80.80 in Billed Charges for Rev 250 = $52.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,AETNA,ALL COMMERCIAL AETNA,80.80,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.80 in Billed Charges for Rev 250 = $80.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,ANTHEM,ANTHEM POS/HMO,54.94,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $80.80 in Billed Charges at 68% = $54.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,ANTHEM,ANTHEM PPO,54.94,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $80.80 in Billed Charges at 68% = $54.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,80.80,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.80 in Billed Charges for Rev 250 = $80.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,CENPATICO,ALL MEDICAID CENPATICO,80.80,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.80 in Billed Charges for Rev 250 = $80.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,CHOICECARE,ALL COMMERCIAL CHOICE CARE,68.68,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $80.80 in Billed Charges for Rev 250 = $68.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,CIGNA,ALL COMMERCIAL CIGNA,56.56,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $80.80 in Billed Charges for Rev 250 = $56.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,COFINITY,COFINITY,80.80,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.80 in Billed Charges for Rev 250 = $80.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,76.76,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $80.80 in Billed Charges for Rev 250 = $76.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,HEALTH CARE ALLIANCE,THE ALLIANCE,67.87,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $80.80 in Billed Charges for Rev 250 = $67.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,57.37,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $80.80 in Billed Charges for Rev 250 = $57.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,58.98,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $80.80 in Billed Charges for Rev 250 = $58.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,HSHS EMPLOYEES,HSHS EMPLOYEES,39.27,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $80.80 in Billed Charges for Rev 250 = $39.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,68.68,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $80.80 in Billed Charges for Rev 250 = $68.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,HUMANA,HUMANA CHOICE CARE HMO,51.31,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $80.80 in Billed Charges at 63.5% = $51.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,HUMANA,HUMANA CHOICE CARE PPO,68.68,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $80.80 in Billed Charges for Rev 250 = $68.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,HUMANA,HUMANA NATIIONAL POS HMO,51.31,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $80.80 in Billed Charges at 63.5% = $51.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,58.98,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $80.80 in Billed Charges for Rev 250 = $58.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,LIVE360,LIVE360 HSHS HEALTHY PLAN,80.80,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.80 in Billed Charges for Rev 250 = $80.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,40.40,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $80.80 in Billed Charges for Rev 250 = $40.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,67.87,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $80.80 in Billed Charges for Rev 250 = $67.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,60.60,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $80.80 in Billed Charges for Rev 250 = $60.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,74.34,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $80.80 in Billed Charges for Rev 250 = $74.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,48.48,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.80 in Billed Charges for Rev 250 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,48.48,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.80 in Billed Charges for Rev 250 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,PREVEA HEALTH NETWORK,PREVEA360,48.48,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.80 in Billed Charges for Rev 250 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,48.48,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.80 in Billed Charges for Rev 250 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,51.57,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $80.80 in Billed Charges for Rev 250 = $51.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,58.18,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $80.80 in Billed Charges for Rev 250 = $58.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,44.68,,,,,,,39.2700,80.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $80.80 in Billed Charges for Rev 250 = $44.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,UNITED HEALTHCARE,UHC ONEIDA NATION,44.68,,,,,,,39.2700,80.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $80.80 in Billed Charges for Rev 250 = $44.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,UNITED HEALTHCARE,UNITED HEALTHCARE,44.68,,,,,,,39.2700,80.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $80.80 in Billed Charges for Rev 250 = $44.68 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,58.18,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $80.80 in Billed Charges for Rev 250 = $58.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,50.10,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $80.80 in Billed Charges for Rev 250 = $50.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,58.18,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $80.80 in Billed Charges for Rev 250 = $58.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,58.18,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $80.80 in Billed Charges for Rev 250 = $58.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHARCOAL ACTIVATED LIQD 240 ML TUBE,250,RC,0574-0521-76,CDM,,,,,,both,240.000000,ML,80.8000,53.3300,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,48.48,,,,,,,39.2700,80.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.80 in Billed Charges for Rev 250 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 250 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 250 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 250 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 250 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 250 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 250 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 250 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 250 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 250 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 250 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CHLORHEXIDINE 0.12 % SOLN,250,RC,0904-7035-87,CDM,,,,,,both,15.000000,ML,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,AETNA,AETNA HSHS,103.94,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $160.90 in Billed Charges for Rev 250 = $103.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,AETNA,ALL COMMERCIAL AETNA,160.90,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.90 in Billed Charges for Rev 250 = $160.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,ANTHEM,ANTHEM POS/HMO,109.41,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $160.90 in Billed Charges at 68% = $109.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,ANTHEM,ANTHEM PPO,109.41,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $160.90 in Billed Charges at 68% = $109.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,160.90,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.90 in Billed Charges for Rev 250 = $160.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,CENPATICO,ALL MEDICAID CENPATICO,160.90,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.90 in Billed Charges for Rev 250 = $160.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,136.77,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $160.90 in Billed Charges for Rev 250 = $136.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,CIGNA,ALL COMMERCIAL CIGNA,112.63,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $160.90 in Billed Charges for Rev 250 = $112.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,COFINITY,COFINITY,160.90,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.90 in Billed Charges for Rev 250 = $160.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,152.86,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $160.90 in Billed Charges for Rev 250 = $152.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,135.16,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $160.90 in Billed Charges for Rev 250 = $135.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,114.24,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $160.90 in Billed Charges for Rev 250 = $114.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,117.46,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $160.90 in Billed Charges for Rev 250 = $117.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,78.20,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $160.90 in Billed Charges for Rev 250 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,136.77,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $160.90 in Billed Charges for Rev 250 = $136.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,HUMANA,HUMANA CHOICE CARE HMO,102.17,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $160.90 in Billed Charges at 63.5% = $102.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,HUMANA,HUMANA CHOICE CARE PPO,136.77,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $160.90 in Billed Charges for Rev 250 = $136.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,HUMANA,HUMANA NATIIONAL POS HMO,102.17,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $160.90 in Billed Charges at 63.5% = $102.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,117.46,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $160.90 in Billed Charges for Rev 250 = $117.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,160.90,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.90 in Billed Charges for Rev 250 = $160.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,80.45,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $160.90 in Billed Charges for Rev 250 = $80.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,135.16,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $160.90 in Billed Charges for Rev 250 = $135.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,120.68,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $160.90 in Billed Charges for Rev 250 = $120.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,148.03,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $160.90 in Billed Charges for Rev 250 = $148.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,96.54,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.90 in Billed Charges for Rev 250 = $96.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,96.54,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.90 in Billed Charges for Rev 250 = $96.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,PREVEA HEALTH NETWORK,PREVEA360,96.54,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.90 in Billed Charges for Rev 250 = $96.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,96.54,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.90 in Billed Charges for Rev 250 = $96.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,102.70,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $160.90 in Billed Charges for Rev 250 = $102.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,115.85,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $160.90 in Billed Charges for Rev 250 = $115.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,88.98,,,,,,,78.2000,160.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $160.90 in Billed Charges for Rev 250 = $88.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,UNITED HEALTHCARE,UHC ONEIDA NATION,88.98,,,,,,,78.2000,160.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $160.90 in Billed Charges for Rev 250 = $88.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,UNITED HEALTHCARE,UNITED HEALTHCARE,88.98,,,,,,,78.2000,160.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $160.90 in Billed Charges for Rev 250 = $88.98 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,115.85,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $160.90 in Billed Charges for Rev 250 = $115.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,99.76,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $160.90 in Billed Charges for Rev 250 = $99.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,115.85,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $160.90 in Billed Charges for Rev 250 = $115.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,115.85,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $160.90 in Billed Charges for Rev 250 = $115.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,61314-656-05,CDM,,,,,,both,5.000000,ML,160.9000,106.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,96.54,,,,,,,78.2000,160.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.90 in Billed Charges for Rev 250 = $96.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,AETNA,AETNA HSHS,88.95,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $137.70 in Billed Charges for Rev 250 = $88.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,AETNA,ALL COMMERCIAL AETNA,137.70,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.70 in Billed Charges for Rev 250 = $137.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,ANTHEM,ANTHEM POS/HMO,93.64,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $137.70 in Billed Charges at 68% = $93.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,ANTHEM,ANTHEM PPO,93.64,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $137.70 in Billed Charges at 68% = $93.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,137.70,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.70 in Billed Charges for Rev 250 = $137.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,CENPATICO,ALL MEDICAID CENPATICO,137.70,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.70 in Billed Charges for Rev 250 = $137.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,117.05,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.70 in Billed Charges for Rev 250 = $117.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,CIGNA,ALL COMMERCIAL CIGNA,96.39,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $137.70 in Billed Charges for Rev 250 = $96.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,COFINITY,COFINITY,137.70,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.70 in Billed Charges for Rev 250 = $137.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,130.82,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $137.70 in Billed Charges for Rev 250 = $130.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,115.67,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $137.70 in Billed Charges for Rev 250 = $115.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,97.77,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $137.70 in Billed Charges for Rev 250 = $97.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,100.52,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $137.70 in Billed Charges for Rev 250 = $100.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,66.92,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $137.70 in Billed Charges for Rev 250 = $66.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,117.05,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.70 in Billed Charges for Rev 250 = $117.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,HUMANA,HUMANA CHOICE CARE HMO,87.44,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $137.70 in Billed Charges at 63.5% = $87.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,HUMANA,HUMANA CHOICE CARE PPO,117.05,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $137.70 in Billed Charges for Rev 250 = $117.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,HUMANA,HUMANA NATIIONAL POS HMO,87.44,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $137.70 in Billed Charges at 63.5% = $87.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,100.52,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $137.70 in Billed Charges for Rev 250 = $100.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,137.70,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $137.70 in Billed Charges for Rev 250 = $137.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,68.85,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $137.70 in Billed Charges for Rev 250 = $68.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,115.67,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $137.70 in Billed Charges for Rev 250 = $115.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,103.28,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $137.70 in Billed Charges for Rev 250 = $103.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,126.68,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $137.70 in Billed Charges for Rev 250 = $126.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,82.62,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.70 in Billed Charges for Rev 250 = $82.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,82.62,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.70 in Billed Charges for Rev 250 = $82.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,PREVEA HEALTH NETWORK,PREVEA360,82.62,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.70 in Billed Charges for Rev 250 = $82.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,82.62,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.70 in Billed Charges for Rev 250 = $82.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,87.89,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $137.70 in Billed Charges for Rev 250 = $87.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,99.14,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.70 in Billed Charges for Rev 250 = $99.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,76.15,,,,,,,66.9200,137.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $137.70 in Billed Charges for Rev 250 = $76.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,76.15,,,,,,,66.9200,137.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $137.70 in Billed Charges for Rev 250 = $76.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,76.15,,,,,,,66.9200,137.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $137.70 in Billed Charges for Rev 250 = $76.15 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,99.14,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.70 in Billed Charges for Rev 250 = $99.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,85.37,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $137.70 in Billed Charges for Rev 250 = $85.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,99.14,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.70 in Billed Charges for Rev 250 = $99.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,99.14,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $137.70 in Billed Charges for Rev 250 = $99.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,61314-396-03,CDM,,,,,,both,15.000000,ML,137.7000,90.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,82.62,,,,,,,66.9200,137.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $137.70 in Billed Charges for Rev 250 = $82.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,AETNA,AETNA HSHS,84.08,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $130.15 in Billed Charges for Rev 250 = $84.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,AETNA,ALL COMMERCIAL AETNA,130.15,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.15 in Billed Charges for Rev 250 = $130.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,ANTHEM,ANTHEM POS/HMO,88.50,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $130.15 in Billed Charges at 68% = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,ANTHEM,ANTHEM PPO,88.50,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $130.15 in Billed Charges at 68% = $88.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,130.15,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.15 in Billed Charges for Rev 250 = $130.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,CENPATICO,ALL MEDICAID CENPATICO,130.15,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.15 in Billed Charges for Rev 250 = $130.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,110.63,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.15 in Billed Charges for Rev 250 = $110.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,CIGNA,ALL COMMERCIAL CIGNA,91.11,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $130.15 in Billed Charges for Rev 250 = $91.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,COFINITY,COFINITY,130.15,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.15 in Billed Charges for Rev 250 = $130.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,123.64,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $130.15 in Billed Charges for Rev 250 = $123.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,HEALTH CARE ALLIANCE,THE ALLIANCE,109.33,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.15 in Billed Charges for Rev 250 = $109.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,92.41,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $130.15 in Billed Charges for Rev 250 = $92.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,95.01,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.15 in Billed Charges for Rev 250 = $95.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,HSHS EMPLOYEES,HSHS EMPLOYEES,63.25,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $130.15 in Billed Charges for Rev 250 = $63.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,110.63,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.15 in Billed Charges for Rev 250 = $110.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,HUMANA,HUMANA CHOICE CARE HMO,82.65,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $130.15 in Billed Charges at 63.5% = $82.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,HUMANA,HUMANA CHOICE CARE PPO,110.63,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $130.15 in Billed Charges for Rev 250 = $110.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,HUMANA,HUMANA NATIIONAL POS HMO,82.65,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $130.15 in Billed Charges at 63.5% = $82.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,95.01,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $130.15 in Billed Charges for Rev 250 = $95.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,LIVE360,LIVE360 HSHS HEALTHY PLAN,130.15,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $130.15 in Billed Charges for Rev 250 = $130.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,65.08,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $130.15 in Billed Charges for Rev 250 = $65.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,109.33,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $130.15 in Billed Charges for Rev 250 = $109.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,97.61,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $130.15 in Billed Charges for Rev 250 = $97.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,119.74,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $130.15 in Billed Charges for Rev 250 = $119.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,78.09,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.15 in Billed Charges for Rev 250 = $78.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,78.09,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.15 in Billed Charges for Rev 250 = $78.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,PREVEA HEALTH NETWORK,PREVEA360,78.09,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.15 in Billed Charges for Rev 250 = $78.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,78.09,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.15 in Billed Charges for Rev 250 = $78.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,83.07,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $130.15 in Billed Charges for Rev 250 = $83.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,93.71,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.15 in Billed Charges for Rev 250 = $93.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,71.97,,,,,,,63.2500,130.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $130.15 in Billed Charges for Rev 250 = $71.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,UNITED HEALTHCARE,UHC ONEIDA NATION,71.97,,,,,,,63.2500,130.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $130.15 in Billed Charges for Rev 250 = $71.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,UNITED HEALTHCARE,UNITED HEALTHCARE,71.97,,,,,,,63.2500,130.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $130.15 in Billed Charges for Rev 250 = $71.97 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,93.71,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.15 in Billed Charges for Rev 250 = $93.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,80.69,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $130.15 in Billed Charges for Rev 250 = $80.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,93.71,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.15 in Billed Charges for Rev 250 = $93.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,93.71,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $130.15 in Billed Charges for Rev 250 = $93.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
CYCLOPENTOLATE 1 % SOLN 15 ML BOTTLE,250,RC,24208-735-06,CDM,,,,,,both,15.000000,ML,130.1500,85.9000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,78.09,,,,,,,63.2500,130.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $130.15 in Billed Charges for Rev 250 = $78.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,AETNA,AETNA HSHS,376.42,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $582.70 in Billed Charges for Rev 250 = $376.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,AETNA,ALL COMMERCIAL AETNA,582.70,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $582.70 in Billed Charges for Rev 250 = $582.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,ANTHEM,ANTHEM POS/HMO,396.24,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $582.70 in Billed Charges at 68% = $396.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,ANTHEM,ANTHEM PPO,396.24,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $582.70 in Billed Charges at 68% = $396.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,582.70,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $582.70 in Billed Charges for Rev 250 = $582.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,CENPATICO,ALL MEDICAID CENPATICO,582.70,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $582.70 in Billed Charges for Rev 250 = $582.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,495.30,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $582.70 in Billed Charges for Rev 250 = $495.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,CIGNA,ALL COMMERCIAL CIGNA,407.89,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $582.70 in Billed Charges for Rev 250 = $407.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,COFINITY,COFINITY,582.70,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $582.70 in Billed Charges for Rev 250 = $582.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,553.57,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $582.70 in Billed Charges for Rev 250 = $553.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,489.47,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $582.70 in Billed Charges for Rev 250 = $489.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,413.72,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $582.70 in Billed Charges for Rev 250 = $413.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,425.37,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $582.70 in Billed Charges for Rev 250 = $425.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,283.19,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $582.70 in Billed Charges for Rev 250 = $283.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,495.30,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $582.70 in Billed Charges for Rev 250 = $495.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,HUMANA,HUMANA CHOICE CARE HMO,370.01,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $582.70 in Billed Charges at 63.5% = $370.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,HUMANA,HUMANA CHOICE CARE PPO,495.30,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $582.70 in Billed Charges for Rev 250 = $495.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,HUMANA,HUMANA NATIIONAL POS HMO,370.01,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $582.70 in Billed Charges at 63.5% = $370.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,425.37,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $582.70 in Billed Charges for Rev 250 = $425.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,582.70,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $582.70 in Billed Charges for Rev 250 = $582.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,291.35,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $582.70 in Billed Charges for Rev 250 = $291.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,489.47,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $582.70 in Billed Charges for Rev 250 = $489.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,437.03,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $582.70 in Billed Charges for Rev 250 = $437.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,536.08,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $582.70 in Billed Charges for Rev 250 = $536.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,349.62,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $582.70 in Billed Charges for Rev 250 = $349.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,349.62,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $582.70 in Billed Charges for Rev 250 = $349.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,PREVEA HEALTH NETWORK,PREVEA360,349.62,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $582.70 in Billed Charges for Rev 250 = $349.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,349.62,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $582.70 in Billed Charges for Rev 250 = $349.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,371.94,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $582.70 in Billed Charges for Rev 250 = $371.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,419.54,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $582.70 in Billed Charges for Rev 250 = $419.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,322.23,,,,,,,283.1900,582.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $582.70 in Billed Charges for Rev 250 = $322.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,322.23,,,,,,,283.1900,582.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $582.70 in Billed Charges for Rev 250 = $322.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,322.23,,,,,,,283.1900,582.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $582.70 in Billed Charges for Rev 250 = $322.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,419.54,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $582.70 in Billed Charges for Rev 250 = $419.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,361.27,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $582.70 in Billed Charges for Rev 250 = $361.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,419.54,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $582.70 in Billed Charges for Rev 250 = $419.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,419.54,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $582.70 in Billed Charges for Rev 250 = $419.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 200 MCG/2ML SOLN 4 ML VIAL,250,RC,44567-600-04,CDM,,,,,,both,4.000000,ML,582.7000,384.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,349.62,,,,,,,283.1900,582.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $582.70 in Billed Charges for Rev 250 = $349.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,AETNA,AETNA HSHS,172.55,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $267.10 in Billed Charges for Rev 250 = $172.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,AETNA,ALL COMMERCIAL AETNA,267.10,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $267.10 in Billed Charges for Rev 250 = $267.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,ANTHEM,ANTHEM POS/HMO,181.63,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $267.10 in Billed Charges at 68% = $181.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,ANTHEM,ANTHEM PPO,181.63,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $267.10 in Billed Charges at 68% = $181.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,267.10,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $267.10 in Billed Charges for Rev 250 = $267.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,CENPATICO,ALL MEDICAID CENPATICO,267.10,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $267.10 in Billed Charges for Rev 250 = $267.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,227.04,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $267.10 in Billed Charges for Rev 250 = $227.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,CIGNA,ALL COMMERCIAL CIGNA,186.97,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $267.10 in Billed Charges for Rev 250 = $186.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,COFINITY,COFINITY,267.10,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $267.10 in Billed Charges for Rev 250 = $267.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,253.75,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $267.10 in Billed Charges for Rev 250 = $253.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,HEALTH CARE ALLIANCE,THE ALLIANCE,224.36,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $267.10 in Billed Charges for Rev 250 = $224.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,189.64,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $267.10 in Billed Charges for Rev 250 = $189.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,194.98,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $267.10 in Billed Charges for Rev 250 = $194.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,HSHS EMPLOYEES,HSHS EMPLOYEES,129.81,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $267.10 in Billed Charges for Rev 250 = $129.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,227.04,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $267.10 in Billed Charges for Rev 250 = $227.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,HUMANA,HUMANA CHOICE CARE HMO,169.61,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $267.10 in Billed Charges at 63.5% = $169.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,HUMANA,HUMANA CHOICE CARE PPO,227.04,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $267.10 in Billed Charges for Rev 250 = $227.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,HUMANA,HUMANA NATIIONAL POS HMO,169.61,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $267.10 in Billed Charges at 63.5% = $169.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,194.98,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $267.10 in Billed Charges for Rev 250 = $194.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,LIVE360,LIVE360 HSHS HEALTHY PLAN,267.10,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $267.10 in Billed Charges for Rev 250 = $267.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,133.55,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $267.10 in Billed Charges for Rev 250 = $133.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,224.36,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $267.10 in Billed Charges for Rev 250 = $224.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,200.33,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $267.10 in Billed Charges for Rev 250 = $200.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,245.73,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $267.10 in Billed Charges for Rev 250 = $245.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,160.26,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $267.10 in Billed Charges for Rev 250 = $160.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,160.26,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $267.10 in Billed Charges for Rev 250 = $160.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,PREVEA HEALTH NETWORK,PREVEA360,160.26,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $267.10 in Billed Charges for Rev 250 = $160.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,160.26,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $267.10 in Billed Charges for Rev 250 = $160.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,170.49,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $267.10 in Billed Charges for Rev 250 = $170.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,192.31,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $267.10 in Billed Charges for Rev 250 = $192.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,147.71,,,,,,,129.8100,267.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $267.10 in Billed Charges for Rev 250 = $147.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,UNITED HEALTHCARE,UHC ONEIDA NATION,147.71,,,,,,,129.8100,267.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $267.10 in Billed Charges for Rev 250 = $147.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,UNITED HEALTHCARE,UNITED HEALTHCARE,147.71,,,,,,,129.8100,267.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $267.10 in Billed Charges for Rev 250 = $147.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,192.31,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $267.10 in Billed Charges for Rev 250 = $192.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,165.60,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $267.10 in Billed Charges for Rev 250 = $165.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,192.31,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $267.10 in Billed Charges for Rev 250 = $192.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,192.31,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $267.10 in Billed Charges for Rev 250 = $192.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DEXMEDETOMIDINE 400 MCG/100ML SOLN,250,RC,0143-9525-01,CDM,,,,,,both,100.000000,ML,267.1000,176.2900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,160.26,,,,,,,129.8100,267.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $267.10 in Billed Charges for Rev 250 = $160.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,AETNA,AETNA HSHS,51.97,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $80.45 in Billed Charges for Rev 250 = $51.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,AETNA,ALL COMMERCIAL AETNA,80.45,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.45 in Billed Charges for Rev 250 = $80.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,ANTHEM,ANTHEM POS/HMO,54.71,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $80.45 in Billed Charges at 68% = $54.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,ANTHEM,ANTHEM PPO,54.71,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $80.45 in Billed Charges at 68% = $54.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,80.45,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.45 in Billed Charges for Rev 250 = $80.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,CENPATICO,ALL MEDICAID CENPATICO,80.45,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.45 in Billed Charges for Rev 250 = $80.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,68.38,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $80.45 in Billed Charges for Rev 250 = $68.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,CIGNA,ALL COMMERCIAL CIGNA,56.32,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $80.45 in Billed Charges for Rev 250 = $56.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,COFINITY,COFINITY,80.45,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.45 in Billed Charges for Rev 250 = $80.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,76.43,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $80.45 in Billed Charges for Rev 250 = $76.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,67.58,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $80.45 in Billed Charges for Rev 250 = $67.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,57.12,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $80.45 in Billed Charges for Rev 250 = $57.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,58.73,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $80.45 in Billed Charges for Rev 250 = $58.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,39.10,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $80.45 in Billed Charges for Rev 250 = $39.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,68.38,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $80.45 in Billed Charges for Rev 250 = $68.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,HUMANA,HUMANA CHOICE CARE HMO,51.09,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $80.45 in Billed Charges at 63.5% = $51.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,HUMANA,HUMANA CHOICE CARE PPO,68.38,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $80.45 in Billed Charges for Rev 250 = $68.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,HUMANA,HUMANA NATIIONAL POS HMO,51.09,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $80.45 in Billed Charges at 63.5% = $51.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,58.73,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $80.45 in Billed Charges for Rev 250 = $58.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,80.45,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $80.45 in Billed Charges for Rev 250 = $80.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,40.23,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $80.45 in Billed Charges for Rev 250 = $40.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,67.58,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $80.45 in Billed Charges for Rev 250 = $67.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,60.34,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $80.45 in Billed Charges for Rev 250 = $60.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,74.01,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $80.45 in Billed Charges for Rev 250 = $74.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,48.27,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.45 in Billed Charges for Rev 250 = $48.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,48.27,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.45 in Billed Charges for Rev 250 = $48.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,PREVEA HEALTH NETWORK,PREVEA360,48.27,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.45 in Billed Charges for Rev 250 = $48.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,48.27,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.45 in Billed Charges for Rev 250 = $48.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,51.35,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $80.45 in Billed Charges for Rev 250 = $51.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,57.92,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $80.45 in Billed Charges for Rev 250 = $57.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,44.49,,,,,,,39.1000,80.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $80.45 in Billed Charges for Rev 250 = $44.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,44.49,,,,,,,39.1000,80.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $80.45 in Billed Charges for Rev 250 = $44.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,44.49,,,,,,,39.1000,80.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $80.45 in Billed Charges for Rev 250 = $44.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,57.92,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $80.45 in Billed Charges for Rev 250 = $57.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,49.88,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $80.45 in Billed Charges for Rev 250 = $49.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,57.92,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $80.45 in Billed Charges for Rev 250 = $57.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,57.92,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $80.45 in Billed Charges for Rev 250 = $57.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,67457-903-00,CDM,,,,,,both,20.000000,ML,80.4500,53.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,48.27,,,,,,,39.1000,80.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $80.45 in Billed Charges for Rev 250 = $48.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,AETNA,AETNA HSHS,150.97,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $233.70 in Billed Charges for Rev 250 = $150.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,AETNA,ALL COMMERCIAL AETNA,233.70,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.70 in Billed Charges for Rev 250 = $233.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,ANTHEM,ANTHEM POS/HMO,158.92,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $233.70 in Billed Charges at 68% = $158.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,ANTHEM,ANTHEM PPO,158.92,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $233.70 in Billed Charges at 68% = $158.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,233.70,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.70 in Billed Charges for Rev 250 = $233.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,CENPATICO,ALL MEDICAID CENPATICO,233.70,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.70 in Billed Charges for Rev 250 = $233.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,198.65,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $233.70 in Billed Charges for Rev 250 = $198.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,CIGNA,ALL COMMERCIAL CIGNA,163.59,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $233.70 in Billed Charges for Rev 250 = $163.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,COFINITY,COFINITY,233.70,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.70 in Billed Charges for Rev 250 = $233.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,222.02,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $233.70 in Billed Charges for Rev 250 = $222.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,HEALTH CARE ALLIANCE,THE ALLIANCE,196.31,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $233.70 in Billed Charges for Rev 250 = $196.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,165.93,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $233.70 in Billed Charges for Rev 250 = $165.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,170.60,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $233.70 in Billed Charges for Rev 250 = $170.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,HSHS EMPLOYEES,HSHS EMPLOYEES,113.58,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $233.70 in Billed Charges for Rev 250 = $113.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,198.65,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $233.70 in Billed Charges for Rev 250 = $198.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,HUMANA,HUMANA CHOICE CARE HMO,148.40,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $233.70 in Billed Charges at 63.5% = $148.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,HUMANA,HUMANA CHOICE CARE PPO,198.65,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $233.70 in Billed Charges for Rev 250 = $198.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,HUMANA,HUMANA NATIIONAL POS HMO,148.40,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $233.70 in Billed Charges at 63.5% = $148.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,170.60,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $233.70 in Billed Charges for Rev 250 = $170.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,LIVE360,LIVE360 HSHS HEALTHY PLAN,233.70,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $233.70 in Billed Charges for Rev 250 = $233.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,116.85,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $233.70 in Billed Charges for Rev 250 = $116.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,196.31,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $233.70 in Billed Charges for Rev 250 = $196.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,175.28,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $233.70 in Billed Charges for Rev 250 = $175.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,215.00,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $233.70 in Billed Charges for Rev 250 = $215.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,140.22,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $233.70 in Billed Charges for Rev 250 = $140.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,140.22,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $233.70 in Billed Charges for Rev 250 = $140.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,PREVEA HEALTH NETWORK,PREVEA360,140.22,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $233.70 in Billed Charges for Rev 250 = $140.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,140.22,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $233.70 in Billed Charges for Rev 250 = $140.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,149.17,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $233.70 in Billed Charges for Rev 250 = $149.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,168.26,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $233.70 in Billed Charges for Rev 250 = $168.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,129.24,,,,,,,113.5800,233.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $233.70 in Billed Charges for Rev 250 = $129.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,UNITED HEALTHCARE,UHC ONEIDA NATION,129.24,,,,,,,113.5800,233.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $233.70 in Billed Charges for Rev 250 = $129.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,UNITED HEALTHCARE,UNITED HEALTHCARE,129.24,,,,,,,113.5800,233.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $233.70 in Billed Charges for Rev 250 = $129.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,168.26,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $233.70 in Billed Charges for Rev 250 = $168.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,144.89,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $233.70 in Billed Charges for Rev 250 = $144.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,168.26,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $233.70 in Billed Charges for Rev 250 = $168.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,168.26,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $233.70 in Billed Charges for Rev 250 = $168.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-531-01,CDM,,,,,,both,100.000000,ML,233.7000,154.2400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,140.22,,,,,,,113.5800,233.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $233.70 in Billed Charges for Rev 250 = $140.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,AETNA,AETNA HSHS,149.81,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $231.90 in Billed Charges for Rev 250 = $149.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,AETNA,ALL COMMERCIAL AETNA,231.90,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.90 in Billed Charges for Rev 250 = $231.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,ANTHEM,ANTHEM POS/HMO,157.69,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $231.90 in Billed Charges at 68% = $157.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,ANTHEM,ANTHEM PPO,157.69,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $231.90 in Billed Charges at 68% = $157.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,231.90,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.90 in Billed Charges for Rev 250 = $231.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,CENPATICO,ALL MEDICAID CENPATICO,231.90,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.90 in Billed Charges for Rev 250 = $231.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,197.12,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $231.90 in Billed Charges for Rev 250 = $197.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,CIGNA,ALL COMMERCIAL CIGNA,162.33,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $231.90 in Billed Charges for Rev 250 = $162.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,COFINITY,COFINITY,231.90,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.90 in Billed Charges for Rev 250 = $231.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,220.31,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $231.90 in Billed Charges for Rev 250 = $220.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,HEALTH CARE ALLIANCE,THE ALLIANCE,194.80,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $231.90 in Billed Charges for Rev 250 = $194.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,164.65,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $231.90 in Billed Charges for Rev 250 = $164.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,169.29,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $231.90 in Billed Charges for Rev 250 = $169.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,HSHS EMPLOYEES,HSHS EMPLOYEES,112.70,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $231.90 in Billed Charges for Rev 250 = $112.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,197.12,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $231.90 in Billed Charges for Rev 250 = $197.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,HUMANA,HUMANA CHOICE CARE HMO,147.26,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $231.90 in Billed Charges at 63.5% = $147.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,HUMANA,HUMANA CHOICE CARE PPO,197.12,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $231.90 in Billed Charges for Rev 250 = $197.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,HUMANA,HUMANA NATIIONAL POS HMO,147.26,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $231.90 in Billed Charges at 63.5% = $147.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,169.29,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $231.90 in Billed Charges for Rev 250 = $169.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,LIVE360,LIVE360 HSHS HEALTHY PLAN,231.90,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $231.90 in Billed Charges for Rev 250 = $231.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,115.95,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $231.90 in Billed Charges for Rev 250 = $115.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,194.80,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $231.90 in Billed Charges for Rev 250 = $194.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,173.93,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $231.90 in Billed Charges for Rev 250 = $173.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,213.35,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $231.90 in Billed Charges for Rev 250 = $213.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,139.14,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $231.90 in Billed Charges for Rev 250 = $139.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,139.14,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $231.90 in Billed Charges for Rev 250 = $139.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,PREVEA HEALTH NETWORK,PREVEA360,139.14,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $231.90 in Billed Charges for Rev 250 = $139.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,139.14,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $231.90 in Billed Charges for Rev 250 = $139.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,148.02,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $231.90 in Billed Charges for Rev 250 = $148.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,166.97,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $231.90 in Billed Charges for Rev 250 = $166.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,128.24,,,,,,,112.7000,231.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $231.90 in Billed Charges for Rev 250 = $128.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,UNITED HEALTHCARE,UHC ONEIDA NATION,128.24,,,,,,,112.7000,231.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $231.90 in Billed Charges for Rev 250 = $128.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,UNITED HEALTHCARE,UNITED HEALTHCARE,128.24,,,,,,,112.7000,231.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $231.90 in Billed Charges for Rev 250 = $128.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,166.97,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $231.90 in Billed Charges for Rev 250 = $166.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,143.78,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $231.90 in Billed Charges for Rev 250 = $143.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,166.97,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $231.90 in Billed Charges for Rev 250 = $166.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,166.97,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $231.90 in Billed Charges for Rev 250 = $166.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,0338-0519-58,CDM,,,,,,both,100.000000,ML,231.9000,153.0500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,139.14,,,,,,,112.7000,231.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $231.90 in Billed Charges for Rev 250 = $139.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,AETNA,AETNA HSHS,230.43,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $356.70 in Billed Charges for Rev 250 = $230.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,AETNA,ALL COMMERCIAL AETNA,356.70,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.70 in Billed Charges for Rev 250 = $356.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,ANTHEM,ANTHEM POS/HMO,242.56,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $356.70 in Billed Charges at 68% = $242.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,ANTHEM,ANTHEM PPO,242.56,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $356.70 in Billed Charges at 68% = $242.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,356.70,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.70 in Billed Charges for Rev 250 = $356.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,CENPATICO,ALL MEDICAID CENPATICO,356.70,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.70 in Billed Charges for Rev 250 = $356.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,303.20,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.70 in Billed Charges for Rev 250 = $303.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,CIGNA,ALL COMMERCIAL CIGNA,249.69,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $356.70 in Billed Charges for Rev 250 = $249.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,COFINITY,COFINITY,356.70,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.70 in Billed Charges for Rev 250 = $356.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,338.87,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $356.70 in Billed Charges for Rev 250 = $338.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,299.63,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $356.70 in Billed Charges for Rev 250 = $299.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,253.26,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $356.70 in Billed Charges for Rev 250 = $253.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,260.39,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $356.70 in Billed Charges for Rev 250 = $260.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,173.36,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $356.70 in Billed Charges for Rev 250 = $173.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,303.20,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.70 in Billed Charges for Rev 250 = $303.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,HUMANA,HUMANA CHOICE CARE HMO,226.50,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $356.70 in Billed Charges at 63.5% = $226.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,HUMANA,HUMANA CHOICE CARE PPO,303.20,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $356.70 in Billed Charges for Rev 250 = $303.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,HUMANA,HUMANA NATIIONAL POS HMO,226.50,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $356.70 in Billed Charges at 63.5% = $226.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,260.39,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $356.70 in Billed Charges for Rev 250 = $260.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,356.70,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $356.70 in Billed Charges for Rev 250 = $356.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,178.35,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $356.70 in Billed Charges for Rev 250 = $178.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,299.63,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $356.70 in Billed Charges for Rev 250 = $299.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,267.53,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $356.70 in Billed Charges for Rev 250 = $267.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,328.16,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $356.70 in Billed Charges for Rev 250 = $328.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,214.02,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $356.70 in Billed Charges for Rev 250 = $214.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,214.02,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $356.70 in Billed Charges for Rev 250 = $214.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,PREVEA HEALTH NETWORK,PREVEA360,214.02,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $356.70 in Billed Charges for Rev 250 = $214.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,214.02,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $356.70 in Billed Charges for Rev 250 = $214.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,227.68,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $356.70 in Billed Charges for Rev 250 = $227.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,256.82,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.70 in Billed Charges for Rev 250 = $256.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,197.26,,,,,,,173.3600,356.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $356.70 in Billed Charges for Rev 250 = $197.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,197.26,,,,,,,173.3600,356.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $356.70 in Billed Charges for Rev 250 = $197.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,197.26,,,,,,,173.3600,356.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $356.70 in Billed Charges for Rev 250 = $197.26 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,256.82,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.70 in Billed Charges for Rev 250 = $256.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,221.15,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $356.70 in Billed Charges for Rev 250 = $221.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,256.82,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.70 in Billed Charges for Rev 250 = $256.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,256.82,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $356.70 in Billed Charges for Rev 250 = $256.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION 20 % EMUL,250,RC,65219-533-01,CDM,,,,,,both,250.000000,ML,356.7000,235.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,214.02,,,,,,,173.3600,356.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $356.70 in Billed Charges for Rev 250 = $214.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,AETNA,AETNA HSHS,115.21,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $178.35 in Billed Charges for Rev 250 = $115.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,AETNA,ALL COMMERCIAL AETNA,178.35,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.35 in Billed Charges for Rev 250 = $178.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,ANTHEM,ANTHEM POS/HMO,121.28,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $178.35 in Billed Charges at 68% = $121.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,ANTHEM,ANTHEM PPO,121.28,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $178.35 in Billed Charges at 68% = $121.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,178.35,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.35 in Billed Charges for Rev 250 = $178.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,CENPATICO,ALL MEDICAID CENPATICO,178.35,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.35 in Billed Charges for Rev 250 = $178.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,151.60,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $178.35 in Billed Charges for Rev 250 = $151.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,CIGNA,ALL COMMERCIAL CIGNA,124.85,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $178.35 in Billed Charges for Rev 250 = $124.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,COFINITY,COFINITY,178.35,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.35 in Billed Charges for Rev 250 = $178.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,169.43,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $178.35 in Billed Charges for Rev 250 = $169.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,HEALTH CARE ALLIANCE,THE ALLIANCE,149.81,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $178.35 in Billed Charges for Rev 250 = $149.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,126.63,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $178.35 in Billed Charges for Rev 250 = $126.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,130.20,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $178.35 in Billed Charges for Rev 250 = $130.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,HSHS EMPLOYEES,HSHS EMPLOYEES,86.68,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $178.35 in Billed Charges for Rev 250 = $86.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,151.60,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $178.35 in Billed Charges for Rev 250 = $151.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,HUMANA,HUMANA CHOICE CARE HMO,113.25,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $178.35 in Billed Charges at 63.5% = $113.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,HUMANA,HUMANA CHOICE CARE PPO,151.60,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $178.35 in Billed Charges for Rev 250 = $151.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,HUMANA,HUMANA NATIIONAL POS HMO,113.25,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $178.35 in Billed Charges at 63.5% = $113.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,130.20,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $178.35 in Billed Charges for Rev 250 = $130.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,LIVE360,LIVE360 HSHS HEALTHY PLAN,178.35,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $178.35 in Billed Charges for Rev 250 = $178.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,89.18,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $178.35 in Billed Charges for Rev 250 = $89.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,149.81,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $178.35 in Billed Charges for Rev 250 = $149.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,133.76,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $178.35 in Billed Charges for Rev 250 = $133.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,164.08,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $178.35 in Billed Charges for Rev 250 = $164.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,107.01,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $178.35 in Billed Charges for Rev 250 = $107.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,107.01,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $178.35 in Billed Charges for Rev 250 = $107.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,PREVEA HEALTH NETWORK,PREVEA360,107.01,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $178.35 in Billed Charges for Rev 250 = $107.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,107.01,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $178.35 in Billed Charges for Rev 250 = $107.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,113.84,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $178.35 in Billed Charges for Rev 250 = $113.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,128.41,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $178.35 in Billed Charges for Rev 250 = $128.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,98.63,,,,,,,86.6800,178.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $178.35 in Billed Charges for Rev 250 = $98.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,UNITED HEALTHCARE,UHC ONEIDA NATION,98.63,,,,,,,86.6800,178.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $178.35 in Billed Charges for Rev 250 = $98.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,UNITED HEALTHCARE,UNITED HEALTHCARE,98.63,,,,,,,86.6800,178.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $178.35 in Billed Charges for Rev 250 = $98.63 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,128.41,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $178.35 in Billed Charges for Rev 250 = $128.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,110.58,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $178.35 in Billed Charges for Rev 250 = $110.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,128.41,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $178.35 in Billed Charges for Rev 250 = $128.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,128.41,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $178.35 in Billed Charges for Rev 250 = $128.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FAT EMULSION SMOF 20 % EMUL,250,RC,63323-820-01,CDM,,,,,,both,100.000000,ML,178.3500,117.7100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,107.01,,,,,,,86.6800,178.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $178.35 in Billed Charges for Rev 250 = $107.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,AETNA,AETNA HSHS,369.58,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $572.10 in Billed Charges for Rev 250 = $369.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,AETNA,ALL COMMERCIAL AETNA,572.10,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.10 in Billed Charges for Rev 250 = $572.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,ANTHEM,ANTHEM POS/HMO,389.03,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $572.10 in Billed Charges at 68% = $389.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,ANTHEM,ANTHEM PPO,389.03,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $572.10 in Billed Charges at 68% = $389.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,572.10,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.10 in Billed Charges for Rev 250 = $572.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,CENPATICO,ALL MEDICAID CENPATICO,572.10,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.10 in Billed Charges for Rev 250 = $572.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,486.29,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.10 in Billed Charges for Rev 250 = $486.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,CIGNA,ALL COMMERCIAL CIGNA,400.47,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $572.10 in Billed Charges for Rev 250 = $400.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,COFINITY,COFINITY,572.10,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.10 in Billed Charges for Rev 250 = $572.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,543.50,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $572.10 in Billed Charges for Rev 250 = $543.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,HEALTH CARE ALLIANCE,THE ALLIANCE,480.56,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $572.10 in Billed Charges for Rev 250 = $480.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,406.19,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $572.10 in Billed Charges for Rev 250 = $406.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,417.63,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $572.10 in Billed Charges for Rev 250 = $417.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,HSHS EMPLOYEES,HSHS EMPLOYEES,278.04,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $572.10 in Billed Charges for Rev 250 = $278.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,486.29,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.10 in Billed Charges for Rev 250 = $486.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,HUMANA,HUMANA CHOICE CARE HMO,363.28,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $572.10 in Billed Charges at 63.5% = $363.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,HUMANA,HUMANA CHOICE CARE PPO,486.29,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $572.10 in Billed Charges for Rev 250 = $486.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,HUMANA,HUMANA NATIIONAL POS HMO,363.28,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $572.10 in Billed Charges at 63.5% = $363.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,417.63,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $572.10 in Billed Charges for Rev 250 = $417.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,LIVE360,LIVE360 HSHS HEALTHY PLAN,572.10,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $572.10 in Billed Charges for Rev 250 = $572.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,286.05,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $572.10 in Billed Charges for Rev 250 = $286.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,480.56,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $572.10 in Billed Charges for Rev 250 = $480.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,429.08,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $572.10 in Billed Charges for Rev 250 = $429.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,526.33,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $572.10 in Billed Charges for Rev 250 = $526.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,343.26,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $572.10 in Billed Charges for Rev 250 = $343.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,343.26,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $572.10 in Billed Charges for Rev 250 = $343.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,PREVEA HEALTH NETWORK,PREVEA360,343.26,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $572.10 in Billed Charges for Rev 250 = $343.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,343.26,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $572.10 in Billed Charges for Rev 250 = $343.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,365.17,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $572.10 in Billed Charges for Rev 250 = $365.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,411.91,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.10 in Billed Charges for Rev 250 = $411.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,316.37,,,,,,,278.0400,572.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $572.10 in Billed Charges for Rev 250 = $316.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,UNITED HEALTHCARE,UHC ONEIDA NATION,316.37,,,,,,,278.0400,572.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $572.10 in Billed Charges for Rev 250 = $316.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,UNITED HEALTHCARE,UNITED HEALTHCARE,316.37,,,,,,,278.0400,572.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $572.10 in Billed Charges for Rev 250 = $316.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,411.91,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.10 in Billed Charges for Rev 250 = $411.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,354.70,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $572.10 in Billed Charges for Rev 250 = $354.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,411.91,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.10 in Billed Charges for Rev 250 = $411.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,411.91,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $572.10 in Billed Charges for Rev 250 = $411.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FISH OIL TRIGLYCERIDES 5 GM/50ML EMUL,250,RC,63323-205-21,CDM,,,,,,both,50.000000,ML,572.1000,377.5900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,343.26,,,,,,,278.0400,572.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $572.10 in Billed Charges for Rev 250 = $343.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,AETNA,AETNA HSHS,44.06,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $68.20 in Billed Charges for Rev 250 = $44.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,AETNA,ALL COMMERCIAL AETNA,68.20,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.20 in Billed Charges for Rev 250 = $68.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,ANTHEM,ANTHEM POS/HMO,46.38,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.20 in Billed Charges at 68% = $46.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,ANTHEM,ANTHEM PPO,46.38,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.20 in Billed Charges at 68% = $46.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,68.20,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.20 in Billed Charges for Rev 250 = $68.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,CENPATICO,ALL MEDICAID CENPATICO,68.20,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.20 in Billed Charges for Rev 250 = $68.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,57.97,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.20 in Billed Charges for Rev 250 = $57.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,CIGNA,ALL COMMERCIAL CIGNA,47.74,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $68.20 in Billed Charges for Rev 250 = $47.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,COFINITY,COFINITY,68.20,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.20 in Billed Charges for Rev 250 = $68.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,64.79,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $68.20 in Billed Charges for Rev 250 = $64.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,HEALTH CARE ALLIANCE,THE ALLIANCE,57.29,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.20 in Billed Charges for Rev 250 = $57.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,48.42,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $68.20 in Billed Charges for Rev 250 = $48.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,49.79,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.20 in Billed Charges for Rev 250 = $49.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,HSHS EMPLOYEES,HSHS EMPLOYEES,33.15,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $68.20 in Billed Charges for Rev 250 = $33.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,57.97,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.20 in Billed Charges for Rev 250 = $57.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,HUMANA,HUMANA CHOICE CARE HMO,43.31,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.20 in Billed Charges at 63.5% = $43.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,HUMANA,HUMANA CHOICE CARE PPO,57.97,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $68.20 in Billed Charges for Rev 250 = $57.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,HUMANA,HUMANA NATIIONAL POS HMO,43.31,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $68.20 in Billed Charges at 63.5% = $43.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,49.79,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $68.20 in Billed Charges for Rev 250 = $49.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,LIVE360,LIVE360 HSHS HEALTHY PLAN,68.20,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $68.20 in Billed Charges for Rev 250 = $68.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,34.10,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $68.20 in Billed Charges for Rev 250 = $34.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,57.29,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $68.20 in Billed Charges for Rev 250 = $57.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,51.15,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $68.20 in Billed Charges for Rev 250 = $51.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,62.74,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $68.20 in Billed Charges for Rev 250 = $62.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,40.92,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.20 in Billed Charges for Rev 250 = $40.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,40.92,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.20 in Billed Charges for Rev 250 = $40.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,PREVEA HEALTH NETWORK,PREVEA360,40.92,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.20 in Billed Charges for Rev 250 = $40.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,40.92,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.20 in Billed Charges for Rev 250 = $40.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.53,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $68.20 in Billed Charges for Rev 250 = $43.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,49.10,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.20 in Billed Charges for Rev 250 = $49.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,37.71,,,,,,,33.1500,68.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.20 in Billed Charges for Rev 250 = $37.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,UNITED HEALTHCARE,UHC ONEIDA NATION,37.71,,,,,,,33.1500,68.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.20 in Billed Charges for Rev 250 = $37.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,UNITED HEALTHCARE,UNITED HEALTHCARE,37.71,,,,,,,33.1500,68.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $68.20 in Billed Charges for Rev 250 = $37.71 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,49.10,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.20 in Billed Charges for Rev 250 = $49.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,42.28,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $68.20 in Billed Charges for Rev 250 = $42.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,49.10,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.20 in Billed Charges for Rev 250 = $49.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,49.10,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $68.20 in Billed Charges for Rev 250 = $49.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FORMOTEROL 20 MCG/2ML NEBU,250,RC,0378-1631-93,CDM,,,,,,both,2.000000,ML,68.2000,45.0100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,40.92,,,,,,,33.1500,68.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $68.20 in Billed Charges for Rev 250 = $40.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 250 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 250 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 250 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 250 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 250 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 250 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 250 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 250 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 250 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 250 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
FLUORESCEIN 1 MG STRP,250,RC,17238-900-99,CDM,,,,,,both,1.000000,EA,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,AETNA,AETNA HSHS,60.27,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $93.30 in Billed Charges for Rev 250 = $60.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,AETNA,ALL COMMERCIAL AETNA,93.30,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.30 in Billed Charges for Rev 250 = $93.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,ANTHEM,ANTHEM POS/HMO,63.44,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $93.30 in Billed Charges at 68% = $63.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,ANTHEM,ANTHEM PPO,63.44,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $93.30 in Billed Charges at 68% = $63.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,93.30,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.30 in Billed Charges for Rev 250 = $93.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,CENPATICO,ALL MEDICAID CENPATICO,93.30,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.30 in Billed Charges for Rev 250 = $93.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,79.31,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.30 in Billed Charges for Rev 250 = $79.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,CIGNA,ALL COMMERCIAL CIGNA,65.31,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $93.30 in Billed Charges for Rev 250 = $65.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,COFINITY,COFINITY,93.30,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.30 in Billed Charges for Rev 250 = $93.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,88.64,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $93.30 in Billed Charges for Rev 250 = $88.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,78.37,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.30 in Billed Charges for Rev 250 = $78.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,66.24,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $93.30 in Billed Charges for Rev 250 = $66.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,68.11,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.30 in Billed Charges for Rev 250 = $68.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,45.34,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $93.30 in Billed Charges for Rev 250 = $45.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,79.31,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.30 in Billed Charges for Rev 250 = $79.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,HUMANA,HUMANA CHOICE CARE HMO,59.25,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $93.30 in Billed Charges at 63.5% = $59.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,HUMANA,HUMANA CHOICE CARE PPO,79.31,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $93.30 in Billed Charges for Rev 250 = $79.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,HUMANA,HUMANA NATIIONAL POS HMO,59.25,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $93.30 in Billed Charges at 63.5% = $59.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,68.11,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $93.30 in Billed Charges for Rev 250 = $68.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,93.30,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $93.30 in Billed Charges for Rev 250 = $93.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,46.65,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $93.30 in Billed Charges for Rev 250 = $46.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,78.37,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $93.30 in Billed Charges for Rev 250 = $78.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,69.98,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $93.30 in Billed Charges for Rev 250 = $69.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,85.84,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $93.30 in Billed Charges for Rev 250 = $85.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,55.98,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.30 in Billed Charges for Rev 250 = $55.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,55.98,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.30 in Billed Charges for Rev 250 = $55.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,PREVEA HEALTH NETWORK,PREVEA360,55.98,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.30 in Billed Charges for Rev 250 = $55.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,55.98,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.30 in Billed Charges for Rev 250 = $55.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,59.55,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $93.30 in Billed Charges for Rev 250 = $59.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,67.18,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.30 in Billed Charges for Rev 250 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,51.59,,,,,,,45.3400,93.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $93.30 in Billed Charges for Rev 250 = $51.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,51.59,,,,,,,45.3400,93.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $93.30 in Billed Charges for Rev 250 = $51.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,51.59,,,,,,,45.3400,93.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $93.30 in Billed Charges for Rev 250 = $51.59 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,67.18,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.30 in Billed Charges for Rev 250 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,57.85,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $93.30 in Billed Charges for Rev 250 = $57.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,67.18,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.30 in Billed Charges for Rev 250 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,67.18,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $93.30 in Billed Charges for Rev 250 = $67.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
GLYCERIN LIQD,250,RC,0395-1031-16,CDM,,,,,,both,473.000000,ML,93.3000,61.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,55.98,,,,,,,45.3400,93.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $93.30 in Billed Charges for Rev 250 = $55.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,AETNA,AETNA HSHS,166.86,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $258.30 in Billed Charges for Rev 250 = $166.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,AETNA,ALL COMMERCIAL AETNA,258.30,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $258.30 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,ANTHEM,ANTHEM POS/HMO,175.64,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $258.30 in Billed Charges at 68% = $175.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,ANTHEM,ANTHEM PPO,175.64,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $258.30 in Billed Charges at 68% = $175.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,258.30,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $258.30 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,CENPATICO,ALL MEDICAID CENPATICO,258.30,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $258.30 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,219.56,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $258.30 in Billed Charges for Rev 250 = $219.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,CIGNA,ALL COMMERCIAL CIGNA,180.81,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $258.30 in Billed Charges for Rev 250 = $180.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,COFINITY,COFINITY,258.30,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $258.30 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,245.39,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $258.30 in Billed Charges for Rev 250 = $245.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,HEALTH CARE ALLIANCE,THE ALLIANCE,216.97,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $258.30 in Billed Charges for Rev 250 = $216.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,183.39,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $258.30 in Billed Charges for Rev 250 = $183.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,188.56,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $258.30 in Billed Charges for Rev 250 = $188.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,HSHS EMPLOYEES,HSHS EMPLOYEES,125.53,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $258.30 in Billed Charges for Rev 250 = $125.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,219.56,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $258.30 in Billed Charges for Rev 250 = $219.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,HUMANA,HUMANA CHOICE CARE HMO,164.02,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $258.30 in Billed Charges at 63.5% = $164.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,HUMANA,HUMANA CHOICE CARE PPO,219.56,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $258.30 in Billed Charges for Rev 250 = $219.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,HUMANA,HUMANA NATIIONAL POS HMO,164.02,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $258.30 in Billed Charges at 63.5% = $164.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,188.56,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $258.30 in Billed Charges for Rev 250 = $188.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,LIVE360,LIVE360 HSHS HEALTHY PLAN,258.30,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $258.30 in Billed Charges for Rev 250 = $258.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,129.15,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $258.30 in Billed Charges for Rev 250 = $129.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,216.97,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $258.30 in Billed Charges for Rev 250 = $216.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,193.73,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $258.30 in Billed Charges for Rev 250 = $193.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,237.64,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $258.30 in Billed Charges for Rev 250 = $237.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,154.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $258.30 in Billed Charges for Rev 250 = $154.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,154.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $258.30 in Billed Charges for Rev 250 = $154.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,PREVEA HEALTH NETWORK,PREVEA360,154.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $258.30 in Billed Charges for Rev 250 = $154.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,154.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $258.30 in Billed Charges for Rev 250 = $154.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,164.87,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $258.30 in Billed Charges for Rev 250 = $164.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,185.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $258.30 in Billed Charges for Rev 250 = $185.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,142.84,,,,,,,125.5300,258.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $258.30 in Billed Charges for Rev 250 = $142.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,UNITED HEALTHCARE,UHC ONEIDA NATION,142.84,,,,,,,125.5300,258.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $258.30 in Billed Charges for Rev 250 = $142.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,UNITED HEALTHCARE,UNITED HEALTHCARE,142.84,,,,,,,125.5300,258.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $258.30 in Billed Charges for Rev 250 = $142.84 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,185.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $258.30 in Billed Charges for Rev 250 = $185.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,160.15,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $258.30 in Billed Charges for Rev 250 = $160.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,185.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $258.30 in Billed Charges for Rev 250 = $185.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,185.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $258.30 in Billed Charges for Rev 250 = $185.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INSULIN REGULAR 100 UNITS/100 ML NS SOLN,250,RC,0338-0126-12,CDM,,,,,,both,100.000000,ML,258.3000,170.4800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,154.98,,,,,,,125.5300,258.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $258.30 in Billed Charges for Rev 250 = $154.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,AETNA,AETNA HSHS,911.73,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,411.35 in Billed Charges for Rev 250 = $911.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,AETNA,ALL COMMERCIAL AETNA,1411.35,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.35 in Billed Charges for Rev 250 = $1,411.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,ANTHEM,ANTHEM POS/HMO,959.72,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,411.35 in Billed Charges at 68% = $959.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,ANTHEM,ANTHEM PPO,959.72,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,411.35 in Billed Charges at 68% = $959.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1411.35,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.35 in Billed Charges for Rev 250 = $1,411.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,CENPATICO,ALL MEDICAID CENPATICO,1411.35,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.35 in Billed Charges for Rev 250 = $1,411.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1199.65,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,411.35 in Billed Charges for Rev 250 = $1,199.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,CIGNA,ALL COMMERCIAL CIGNA,987.95,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,411.35 in Billed Charges for Rev 250 = $987.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,COFINITY,COFINITY,1411.35,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.35 in Billed Charges for Rev 250 = $1,411.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1340.78,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,411.35 in Billed Charges for Rev 250 = $1,340.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,HEALTH CARE ALLIANCE,THE ALLIANCE,1185.53,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,411.35 in Billed Charges for Rev 250 = $1,185.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1002.06,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,411.35 in Billed Charges for Rev 250 = $1,002.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1030.29,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,411.35 in Billed Charges for Rev 250 = $1,030.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,HSHS EMPLOYEES,HSHS EMPLOYEES,685.92,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,411.35 in Billed Charges for Rev 250 = $685.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1199.65,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,411.35 in Billed Charges for Rev 250 = $1,199.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,HUMANA,HUMANA CHOICE CARE HMO,896.21,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,411.35 in Billed Charges at 63.5% = $896.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,HUMANA,HUMANA CHOICE CARE PPO,1199.65,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,411.35 in Billed Charges for Rev 250 = $1,199.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,HUMANA,HUMANA NATIIONAL POS HMO,896.21,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,411.35 in Billed Charges at 63.5% = $896.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1030.29,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,411.35 in Billed Charges for Rev 250 = $1,030.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,LIVE360,LIVE360 HSHS HEALTHY PLAN,1411.35,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,411.35 in Billed Charges for Rev 250 = $1,411.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,705.68,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,411.35 in Billed Charges for Rev 250 = $705.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1185.53,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,411.35 in Billed Charges for Rev 250 = $1,185.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1058.51,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,411.35 in Billed Charges for Rev 250 = $1,058.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1298.44,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,411.35 in Billed Charges for Rev 250 = $1,298.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,846.81,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,411.35 in Billed Charges for Rev 250 = $846.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,846.81,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,411.35 in Billed Charges for Rev 250 = $846.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,PREVEA HEALTH NETWORK,PREVEA360,846.81,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,411.35 in Billed Charges for Rev 250 = $846.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,846.81,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,411.35 in Billed Charges for Rev 250 = $846.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,900.86,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,411.35 in Billed Charges for Rev 250 = $900.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1016.17,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,411.35 in Billed Charges for Rev 250 = $1,016.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,780.48,,,,,,,685.9200,1411.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,411.35 in Billed Charges for Rev 250 = $780.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,UNITED HEALTHCARE,UHC ONEIDA NATION,780.48,,,,,,,685.9200,1411.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,411.35 in Billed Charges for Rev 250 = $780.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,UNITED HEALTHCARE,UNITED HEALTHCARE,780.48,,,,,,,685.9200,1411.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,411.35 in Billed Charges for Rev 250 = $780.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1016.17,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,411.35 in Billed Charges for Rev 250 = $1,016.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,875.04,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,411.35 in Billed Charges for Rev 250 = $875.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1016.17,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,411.35 in Billed Charges for Rev 250 = $1,016.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1016.17,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,411.35 in Billed Charges for Rev 250 = $1,016.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
INDOCYANINE GREEN 25 MG SOLR,250,RC,70100-725-01,CDM,,,,,,both,1.000000,EA,1411.3500,931.4900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,846.81,,,,,,,685.9200,1411.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,411.35 in Billed Charges for Rev 250 = $846.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,AETNA,AETNA HSHS,5.17,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.00 in Billed Charges for Rev 250 = $5.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,AETNA,ALL COMMERCIAL AETNA,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,ANTHEM,ANTHEM POS/HMO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,ANTHEM,ANTHEM PPO,5.44,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 68% = $5.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,CENPATICO,ALL MEDICAID CENPATICO,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,CIGNA,ALL COMMERCIAL CIGNA,5.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.00 in Billed Charges for Rev 250 = $5.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,COFINITY,COFINITY,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,7.60,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.00 in Billed Charges for Rev 250 = $7.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,HEALTH CARE ALLIANCE,THE ALLIANCE,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,5.68,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.00 in Billed Charges for Rev 250 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,HSHS EMPLOYEES,HSHS EMPLOYEES,3.89,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.00 in Billed Charges for Rev 250 = $3.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,HUMANA,HUMANA CHOICE CARE PPO,6.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.00 in Billed Charges for Rev 250 = $6.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,HUMANA,HUMANA NATIIONAL POS HMO,5.08,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.00 in Billed Charges at 63.5% = $5.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,5.84,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.00 in Billed Charges for Rev 250 = $5.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.00 in Billed Charges for Rev 250 = $8.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.00 in Billed Charges for Rev 250 = $4.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,6.72,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.00 in Billed Charges for Rev 250 = $6.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.00,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.00 in Billed Charges for Rev 250 = $6.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,7.36,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.00 in Billed Charges for Rev 250 = $7.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.11,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.00 in Billed Charges for Rev 250 = $5.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,UNITED HEALTHCARE,UHC ONEIDA NATION,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,UNITED HEALTHCARE,UNITED HEALTHCARE,4.42,,,,,,,3.8900,8.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.00 in Billed Charges for Rev 250 = $4.42 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,4.96,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.00 in Billed Charges for Rev 250 = $4.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,5.76,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.00 in Billed Charges for Rev 250 = $5.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.02 % SOLN,250,RC,60687-394-79,CDM,,,,,,both,2.500000,ML,8.0000,5.2800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,4.80,,,,,,,3.8900,8.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.00 in Billed Charges for Rev 250 = $4.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,AETNA,AETNA HSHS,100.23,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $155.15 in Billed Charges for Rev 250 = $100.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,AETNA,ALL COMMERCIAL AETNA,155.15,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $155.15 in Billed Charges for Rev 250 = $155.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,ANTHEM,ANTHEM POS/HMO,105.50,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $155.15 in Billed Charges at 68% = $105.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,ANTHEM,ANTHEM PPO,105.50,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $155.15 in Billed Charges at 68% = $105.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,155.15,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $155.15 in Billed Charges for Rev 250 = $155.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,CENPATICO,ALL MEDICAID CENPATICO,155.15,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $155.15 in Billed Charges for Rev 250 = $155.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,131.88,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $155.15 in Billed Charges for Rev 250 = $131.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,CIGNA,ALL COMMERCIAL CIGNA,108.61,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $155.15 in Billed Charges for Rev 250 = $108.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,COFINITY,COFINITY,155.15,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $155.15 in Billed Charges for Rev 250 = $155.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,147.39,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $155.15 in Billed Charges for Rev 250 = $147.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,HEALTH CARE ALLIANCE,THE ALLIANCE,130.33,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $155.15 in Billed Charges for Rev 250 = $130.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,110.16,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $155.15 in Billed Charges for Rev 250 = $110.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,113.26,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $155.15 in Billed Charges for Rev 250 = $113.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,HSHS EMPLOYEES,HSHS EMPLOYEES,75.40,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $155.15 in Billed Charges for Rev 250 = $75.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,131.88,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $155.15 in Billed Charges for Rev 250 = $131.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,HUMANA,HUMANA CHOICE CARE HMO,98.52,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $155.15 in Billed Charges at 63.5% = $98.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,HUMANA,HUMANA CHOICE CARE PPO,131.88,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $155.15 in Billed Charges for Rev 250 = $131.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,HUMANA,HUMANA NATIIONAL POS HMO,98.52,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $155.15 in Billed Charges at 63.5% = $98.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,113.26,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $155.15 in Billed Charges for Rev 250 = $113.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,LIVE360,LIVE360 HSHS HEALTHY PLAN,155.15,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $155.15 in Billed Charges for Rev 250 = $155.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,77.58,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $155.15 in Billed Charges for Rev 250 = $77.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,130.33,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $155.15 in Billed Charges for Rev 250 = $130.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,116.36,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $155.15 in Billed Charges for Rev 250 = $116.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,142.74,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $155.15 in Billed Charges for Rev 250 = $142.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,93.09,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $155.15 in Billed Charges for Rev 250 = $93.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,93.09,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $155.15 in Billed Charges for Rev 250 = $93.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,PREVEA HEALTH NETWORK,PREVEA360,93.09,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $155.15 in Billed Charges for Rev 250 = $93.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,93.09,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $155.15 in Billed Charges for Rev 250 = $93.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,99.03,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $155.15 in Billed Charges for Rev 250 = $99.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,111.71,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $155.15 in Billed Charges for Rev 250 = $111.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,85.80,,,,,,,75.4000,155.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $155.15 in Billed Charges for Rev 250 = $85.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,UNITED HEALTHCARE,UHC ONEIDA NATION,85.80,,,,,,,75.4000,155.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $155.15 in Billed Charges for Rev 250 = $85.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,UNITED HEALTHCARE,UNITED HEALTHCARE,85.80,,,,,,,75.4000,155.1500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $155.15 in Billed Charges for Rev 250 = $85.80 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,111.71,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $155.15 in Billed Charges for Rev 250 = $111.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,96.19,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $155.15 in Billed Charges for Rev 250 = $96.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,111.71,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $155.15 in Billed Charges for Rev 250 = $111.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,111.71,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $155.15 in Billed Charges for Rev 250 = $111.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
IPRATROPIUM 0.03 % SOLN,250,RC,24208-398-30,CDM,,,,,,both,30.000000,ML,155.1500,102.4000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,93.09,,,,,,,75.4000,155.1500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $155.15 in Billed Charges for Rev 250 = $93.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,69374-308-05,CDM,,,,,,both,5.000000,ML,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,AETNA,AETNA HSHS,94.35,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $146.05 in Billed Charges for Rev 250 = $94.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,AETNA,ALL COMMERCIAL AETNA,146.05,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.05 in Billed Charges for Rev 250 = $146.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,ANTHEM,ANTHEM POS/HMO,99.31,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $146.05 in Billed Charges at 68% = $99.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,ANTHEM,ANTHEM PPO,99.31,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $146.05 in Billed Charges at 68% = $99.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,146.05,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.05 in Billed Charges for Rev 250 = $146.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,CENPATICO,ALL MEDICAID CENPATICO,146.05,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.05 in Billed Charges for Rev 250 = $146.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,124.14,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.05 in Billed Charges for Rev 250 = $124.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,CIGNA,ALL COMMERCIAL CIGNA,102.24,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $146.05 in Billed Charges for Rev 250 = $102.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,COFINITY,COFINITY,146.05,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.05 in Billed Charges for Rev 250 = $146.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,138.75,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $146.05 in Billed Charges for Rev 250 = $138.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,HEALTH CARE ALLIANCE,THE ALLIANCE,122.68,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.05 in Billed Charges for Rev 250 = $122.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,103.70,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $146.05 in Billed Charges for Rev 250 = $103.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,106.62,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.05 in Billed Charges for Rev 250 = $106.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,HSHS EMPLOYEES,HSHS EMPLOYEES,70.98,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $146.05 in Billed Charges for Rev 250 = $70.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,124.14,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.05 in Billed Charges for Rev 250 = $124.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,HUMANA,HUMANA CHOICE CARE HMO,92.74,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $146.05 in Billed Charges at 63.5% = $92.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,HUMANA,HUMANA CHOICE CARE PPO,124.14,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $146.05 in Billed Charges for Rev 250 = $124.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,HUMANA,HUMANA NATIIONAL POS HMO,92.74,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $146.05 in Billed Charges at 63.5% = $92.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,106.62,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $146.05 in Billed Charges for Rev 250 = $106.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,LIVE360,LIVE360 HSHS HEALTHY PLAN,146.05,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $146.05 in Billed Charges for Rev 250 = $146.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.03,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $146.05 in Billed Charges for Rev 250 = $73.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,122.68,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $146.05 in Billed Charges for Rev 250 = $122.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,109.54,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $146.05 in Billed Charges for Rev 250 = $109.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,134.37,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $146.05 in Billed Charges for Rev 250 = $134.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,87.63,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.05 in Billed Charges for Rev 250 = $87.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,87.63,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.05 in Billed Charges for Rev 250 = $87.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,PREVEA HEALTH NETWORK,PREVEA360,87.63,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.05 in Billed Charges for Rev 250 = $87.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,87.63,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.05 in Billed Charges for Rev 250 = $87.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,93.22,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $146.05 in Billed Charges for Rev 250 = $93.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,105.16,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.05 in Billed Charges for Rev 250 = $105.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,80.77,,,,,,,70.9800,146.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $146.05 in Billed Charges for Rev 250 = $80.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,UNITED HEALTHCARE,UHC ONEIDA NATION,80.77,,,,,,,70.9800,146.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $146.05 in Billed Charges for Rev 250 = $80.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,UNITED HEALTHCARE,UNITED HEALTHCARE,80.77,,,,,,,70.9800,146.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $146.05 in Billed Charges for Rev 250 = $80.77 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,105.16,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.05 in Billed Charges for Rev 250 = $105.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,90.55,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $146.05 in Billed Charges for Rev 250 = $90.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,105.16,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.05 in Billed Charges for Rev 250 = $105.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,105.16,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $146.05 in Billed Charges for Rev 250 = $105.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
KETAMINE 10 MG/ML SOLN,250,RC,42023-113-10,CDM,,,,,,both,20.000000,ML,146.0500,96.3900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,87.63,,,,,,,70.9800,146.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $146.05 in Billed Charges for Rev 250 = $87.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,AETNA,AETNA HSHS,12.76,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $19.75 in Billed Charges for Rev 250 = $12.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,AETNA,ALL COMMERCIAL AETNA,19.75,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.75 in Billed Charges for Rev 250 = $19.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,ANTHEM,ANTHEM POS/HMO,13.43,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $19.75 in Billed Charges at 68% = $13.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,ANTHEM,ANTHEM PPO,13.43,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $19.75 in Billed Charges at 68% = $13.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,19.75,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.75 in Billed Charges for Rev 250 = $19.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,CENPATICO,ALL MEDICAID CENPATICO,19.75,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.75 in Billed Charges for Rev 250 = $19.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,16.79,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.75 in Billed Charges for Rev 250 = $16.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,CIGNA,ALL COMMERCIAL CIGNA,13.83,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $19.75 in Billed Charges for Rev 250 = $13.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,COFINITY,COFINITY,19.75,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.75 in Billed Charges for Rev 250 = $19.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,18.76,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $19.75 in Billed Charges for Rev 250 = $18.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,HEALTH CARE ALLIANCE,THE ALLIANCE,16.59,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.75 in Billed Charges for Rev 250 = $16.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.02,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $19.75 in Billed Charges for Rev 250 = $14.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.42,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.75 in Billed Charges for Rev 250 = $14.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,HSHS EMPLOYEES,HSHS EMPLOYEES,9.60,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $19.75 in Billed Charges for Rev 250 = $9.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,16.79,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.75 in Billed Charges for Rev 250 = $16.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,HUMANA,HUMANA CHOICE CARE HMO,12.54,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $19.75 in Billed Charges at 63.5% = $12.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,HUMANA,HUMANA CHOICE CARE PPO,16.79,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $19.75 in Billed Charges for Rev 250 = $16.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,HUMANA,HUMANA NATIIONAL POS HMO,12.54,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $19.75 in Billed Charges at 63.5% = $12.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.42,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $19.75 in Billed Charges for Rev 250 = $14.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,LIVE360,LIVE360 HSHS HEALTHY PLAN,19.75,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $19.75 in Billed Charges for Rev 250 = $19.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.88,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $19.75 in Billed Charges for Rev 250 = $9.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,16.59,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $19.75 in Billed Charges for Rev 250 = $16.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.81,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $19.75 in Billed Charges for Rev 250 = $14.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.17,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $19.75 in Billed Charges for Rev 250 = $18.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.85,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.75 in Billed Charges for Rev 250 = $11.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.85,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.75 in Billed Charges for Rev 250 = $11.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,PREVEA HEALTH NETWORK,PREVEA360,11.85,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.75 in Billed Charges for Rev 250 = $11.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.85,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.75 in Billed Charges for Rev 250 = $11.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,12.61,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $19.75 in Billed Charges for Rev 250 = $12.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.22,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.75 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.92,,,,,,,9.6000,19.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.75 in Billed Charges for Rev 250 = $10.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,UNITED HEALTHCARE,UHC ONEIDA NATION,10.92,,,,,,,9.6000,19.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.75 in Billed Charges for Rev 250 = $10.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,UNITED HEALTHCARE,UNITED HEALTHCARE,10.92,,,,,,,9.6000,19.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $19.75 in Billed Charges for Rev 250 = $10.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.22,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.75 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.25,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $19.75 in Billed Charges for Rev 250 = $12.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.22,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.75 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.22,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $19.75 in Billed Charges for Rev 250 = $14.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4 % 4 % SOLN,250,RC,0409-4283-01,CDM,,,,,,both,5.000000,ML,19.7500,13.0400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.85,,,,,,,9.6000,19.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $19.75 in Billed Charges for Rev 250 = $11.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,AETNA,AETNA HSHS,48.29,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $74.75 in Billed Charges for Rev 250 = $48.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,AETNA,ALL COMMERCIAL AETNA,74.75,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.75 in Billed Charges for Rev 250 = $74.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,ANTHEM,ANTHEM POS/HMO,50.83,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $74.75 in Billed Charges at 68% = $50.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,ANTHEM,ANTHEM PPO,50.83,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $74.75 in Billed Charges at 68% = $50.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,74.75,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.75 in Billed Charges for Rev 250 = $74.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,CENPATICO,ALL MEDICAID CENPATICO,74.75,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.75 in Billed Charges for Rev 250 = $74.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,63.54,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.75 in Billed Charges for Rev 250 = $63.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,CIGNA,ALL COMMERCIAL CIGNA,52.33,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $74.75 in Billed Charges for Rev 250 = $52.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,COFINITY,COFINITY,74.75,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.75 in Billed Charges for Rev 250 = $74.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,71.01,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $74.75 in Billed Charges for Rev 250 = $71.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,62.79,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.75 in Billed Charges for Rev 250 = $62.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,53.07,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $74.75 in Billed Charges for Rev 250 = $53.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,54.57,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.75 in Billed Charges for Rev 250 = $54.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,36.33,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $74.75 in Billed Charges for Rev 250 = $36.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,63.54,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.75 in Billed Charges for Rev 250 = $63.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,HUMANA,HUMANA CHOICE CARE HMO,47.47,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $74.75 in Billed Charges at 63.5% = $47.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,HUMANA,HUMANA CHOICE CARE PPO,63.54,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $74.75 in Billed Charges for Rev 250 = $63.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,HUMANA,HUMANA NATIIONAL POS HMO,47.47,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $74.75 in Billed Charges at 63.5% = $47.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,54.57,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $74.75 in Billed Charges for Rev 250 = $54.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,74.75,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $74.75 in Billed Charges for Rev 250 = $74.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,37.38,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $74.75 in Billed Charges for Rev 250 = $37.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,62.79,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $74.75 in Billed Charges for Rev 250 = $62.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,56.06,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $74.75 in Billed Charges for Rev 250 = $56.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,68.77,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $74.75 in Billed Charges for Rev 250 = $68.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,44.85,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.75 in Billed Charges for Rev 250 = $44.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,44.85,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.75 in Billed Charges for Rev 250 = $44.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,PREVEA HEALTH NETWORK,PREVEA360,44.85,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.75 in Billed Charges for Rev 250 = $44.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,44.85,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.75 in Billed Charges for Rev 250 = $44.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,47.71,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $74.75 in Billed Charges for Rev 250 = $47.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,53.82,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.75 in Billed Charges for Rev 250 = $53.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,41.34,,,,,,,36.3300,74.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.75 in Billed Charges for Rev 250 = $41.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,41.34,,,,,,,36.3300,74.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.75 in Billed Charges for Rev 250 = $41.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,41.34,,,,,,,36.3300,74.7500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $74.75 in Billed Charges for Rev 250 = $41.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,53.82,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.75 in Billed Charges for Rev 250 = $53.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,46.35,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $74.75 in Billed Charges for Rev 250 = $46.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,53.82,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.75 in Billed Charges for Rev 250 = $53.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,53.82,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $74.75 in Billed Charges for Rev 250 = $53.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE 4%-EPINEPHRINE 0.18%-TETRACAINE 0.5% TOPICAL GEL 4-0.18-0.5 % GEL,250,RC,71266-6290-1,CDM,,,,,,both,3.000000,ML,74.7500,49.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,44.85,,,,,,,36.3300,74.7500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $74.75 in Billed Charges for Rev 250 = $44.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,AETNA,AETNA HSHS,9.24,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $14.30 in Billed Charges for Rev 250 = $9.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,AETNA,ALL COMMERCIAL AETNA,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 250 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,ANTHEM,ANTHEM POS/HMO,9.72,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $14.30 in Billed Charges at 68% = $9.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,ANTHEM,ANTHEM PPO,9.72,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $14.30 in Billed Charges at 68% = $9.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 250 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,CENPATICO,ALL MEDICAID CENPATICO,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 250 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,12.16,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.30 in Billed Charges for Rev 250 = $12.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,CIGNA,ALL COMMERCIAL CIGNA,10.01,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $14.30 in Billed Charges for Rev 250 = $10.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,COFINITY,COFINITY,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 250 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,13.59,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $14.30 in Billed Charges for Rev 250 = $13.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,HEALTH CARE ALLIANCE,THE ALLIANCE,12.01,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.30 in Billed Charges for Rev 250 = $12.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.15,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $14.30 in Billed Charges for Rev 250 = $10.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,10.44,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.30 in Billed Charges for Rev 250 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,HSHS EMPLOYEES,HSHS EMPLOYEES,6.95,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $14.30 in Billed Charges for Rev 250 = $6.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,12.16,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.30 in Billed Charges for Rev 250 = $12.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,HUMANA,HUMANA CHOICE CARE HMO,9.08,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $14.30 in Billed Charges at 63.5% = $9.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,HUMANA,HUMANA CHOICE CARE PPO,12.16,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $14.30 in Billed Charges for Rev 250 = $12.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,HUMANA,HUMANA NATIIONAL POS HMO,9.08,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $14.30 in Billed Charges at 63.5% = $9.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,10.44,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $14.30 in Billed Charges for Rev 250 = $10.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,LIVE360,LIVE360 HSHS HEALTHY PLAN,14.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $14.30 in Billed Charges for Rev 250 = $14.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.15,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $14.30 in Billed Charges for Rev 250 = $7.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.01,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $14.30 in Billed Charges for Rev 250 = $12.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,10.73,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $14.30 in Billed Charges for Rev 250 = $10.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,13.16,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $14.30 in Billed Charges for Rev 250 = $13.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 250 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 250 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,PREVEA HEALTH NETWORK,PREVEA360,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 250 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 250 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.13,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $14.30 in Billed Charges for Rev 250 = $9.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,10.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.30 in Billed Charges for Rev 250 = $10.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,7.91,,,,,,,6.9500,14.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.30 in Billed Charges for Rev 250 = $7.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,UNITED HEALTHCARE,UHC ONEIDA NATION,7.91,,,,,,,6.9500,14.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.30 in Billed Charges for Rev 250 = $7.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,UNITED HEALTHCARE,UNITED HEALTHCARE,7.91,,,,,,,6.9500,14.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $14.30 in Billed Charges for Rev 250 = $7.91 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,10.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.30 in Billed Charges for Rev 250 = $10.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,8.87,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $14.30 in Billed Charges for Rev 250 = $8.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,10.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.30 in Billed Charges for Rev 250 = $10.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,10.30,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $14.30 in Billed Charges for Rev 250 = $10.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
LIDOCAINE CREAM 4 % KIT,250,RC,24357-701-05,CDM,,,,,,both,5.000000,GR,14.3000,9.4400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,8.58,,,,,,,6.9500,14.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $14.30 in Billed Charges for Rev 250 = $8.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,AETNA,AETNA HSHS,111.34,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $172.35 in Billed Charges for Rev 250 = $111.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,AETNA,ALL COMMERCIAL AETNA,172.35,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.35 in Billed Charges for Rev 250 = $172.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,ANTHEM,ANTHEM POS/HMO,117.20,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $172.35 in Billed Charges at 68% = $117.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,ANTHEM,ANTHEM PPO,117.20,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $172.35 in Billed Charges at 68% = $117.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,172.35,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.35 in Billed Charges for Rev 250 = $172.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,CENPATICO,ALL MEDICAID CENPATICO,172.35,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.35 in Billed Charges for Rev 250 = $172.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,146.50,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $172.35 in Billed Charges for Rev 250 = $146.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,CIGNA,ALL COMMERCIAL CIGNA,120.65,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $172.35 in Billed Charges for Rev 250 = $120.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,COFINITY,COFINITY,172.35,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.35 in Billed Charges for Rev 250 = $172.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,163.73,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $172.35 in Billed Charges for Rev 250 = $163.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,HEALTH CARE ALLIANCE,THE ALLIANCE,144.77,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $172.35 in Billed Charges for Rev 250 = $144.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,122.37,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $172.35 in Billed Charges for Rev 250 = $122.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,125.82,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $172.35 in Billed Charges for Rev 250 = $125.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,HSHS EMPLOYEES,HSHS EMPLOYEES,83.76,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $172.35 in Billed Charges for Rev 250 = $83.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,146.50,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $172.35 in Billed Charges for Rev 250 = $146.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,HUMANA,HUMANA CHOICE CARE HMO,109.44,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $172.35 in Billed Charges at 63.5% = $109.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,HUMANA,HUMANA CHOICE CARE PPO,146.50,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $172.35 in Billed Charges for Rev 250 = $146.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,HUMANA,HUMANA NATIIONAL POS HMO,109.44,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $172.35 in Billed Charges at 63.5% = $109.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,125.82,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $172.35 in Billed Charges for Rev 250 = $125.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,LIVE360,LIVE360 HSHS HEALTHY PLAN,172.35,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $172.35 in Billed Charges for Rev 250 = $172.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,86.18,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $172.35 in Billed Charges for Rev 250 = $86.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,144.77,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $172.35 in Billed Charges for Rev 250 = $144.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,129.26,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $172.35 in Billed Charges for Rev 250 = $129.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,158.56,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $172.35 in Billed Charges for Rev 250 = $158.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,103.41,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $172.35 in Billed Charges for Rev 250 = $103.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,103.41,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $172.35 in Billed Charges for Rev 250 = $103.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,PREVEA HEALTH NETWORK,PREVEA360,103.41,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $172.35 in Billed Charges for Rev 250 = $103.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,103.41,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $172.35 in Billed Charges for Rev 250 = $103.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,110.01,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $172.35 in Billed Charges for Rev 250 = $110.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,124.09,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $172.35 in Billed Charges for Rev 250 = $124.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,95.31,,,,,,,83.7600,172.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $172.35 in Billed Charges for Rev 250 = $95.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,UNITED HEALTHCARE,UHC ONEIDA NATION,95.31,,,,,,,83.7600,172.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $172.35 in Billed Charges for Rev 250 = $95.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,UNITED HEALTHCARE,UNITED HEALTHCARE,95.31,,,,,,,83.7600,172.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $172.35 in Billed Charges for Rev 250 = $95.31 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,124.09,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $172.35 in Billed Charges for Rev 250 = $124.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,106.86,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $172.35 in Billed Charges for Rev 250 = $106.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,124.09,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $172.35 in Billed Charges for Rev 250 = $124.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,124.09,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $172.35 in Billed Charges for Rev 250 = $124.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
MANNITOL 20 % SOLN,250,RC,0990-7715-13,CDM,,,,,,both,500.000000,ML,172.3500,113.7500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,103.41,,,,,,,83.7600,172.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $172.35 in Billed Charges for Rev 250 = $103.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,AETNA,AETNA HSHS,43.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $67.55 in Billed Charges for Rev 250 = $43.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,AETNA,ALL COMMERCIAL AETNA,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,ANTHEM,ANTHEM POS/HMO,45.93,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.55 in Billed Charges at 68% = $45.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,ANTHEM,ANTHEM PPO,45.93,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.55 in Billed Charges at 68% = $45.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,CENPATICO,ALL MEDICAID CENPATICO,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,57.42,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.55 in Billed Charges for Rev 250 = $57.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,CIGNA,ALL COMMERCIAL CIGNA,47.29,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $67.55 in Billed Charges for Rev 250 = $47.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,COFINITY,COFINITY,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,64.17,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $67.55 in Billed Charges for Rev 250 = $64.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,56.74,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $67.55 in Billed Charges for Rev 250 = $56.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,47.96,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $67.55 in Billed Charges for Rev 250 = $47.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,49.31,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $67.55 in Billed Charges for Rev 250 = $49.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,32.83,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $67.55 in Billed Charges for Rev 250 = $32.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,57.42,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.55 in Billed Charges for Rev 250 = $57.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,HUMANA,HUMANA CHOICE CARE HMO,42.89,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.55 in Billed Charges at 63.5% = $42.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,HUMANA,HUMANA CHOICE CARE PPO,57.42,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.55 in Billed Charges for Rev 250 = $57.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,HUMANA,HUMANA NATIIONAL POS HMO,42.89,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.55 in Billed Charges at 63.5% = $42.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,49.31,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $67.55 in Billed Charges for Rev 250 = $49.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,33.78,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $67.55 in Billed Charges for Rev 250 = $33.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,56.74,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $67.55 in Billed Charges for Rev 250 = $56.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,50.66,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $67.55 in Billed Charges for Rev 250 = $50.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,62.15,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $67.55 in Billed Charges for Rev 250 = $62.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,PREVEA HEALTH NETWORK,PREVEA360,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.12,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $67.55 in Billed Charges for Rev 250 = $43.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,48.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.55 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,37.36,,,,,,,32.8300,67.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.55 in Billed Charges for Rev 250 = $37.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,37.36,,,,,,,32.8300,67.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.55 in Billed Charges for Rev 250 = $37.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,37.36,,,,,,,32.8300,67.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.55 in Billed Charges for Rev 250 = $37.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,48.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.55 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,41.88,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $67.55 in Billed Charges for Rev 250 = $41.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,48.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.55 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,48.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.55 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 OINT 3.5 G TUBE,250,RC,24208-795-35,CDM,,,,,,both,3.500000,GR,67.5500,44.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,AETNA,AETNA HSHS,43.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $67.55 in Billed Charges for Rev 250 = $43.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,AETNA,ALL COMMERCIAL AETNA,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,ANTHEM,ANTHEM POS/HMO,45.93,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.55 in Billed Charges at 68% = $45.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,ANTHEM,ANTHEM PPO,45.93,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.55 in Billed Charges at 68% = $45.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,CENPATICO,ALL MEDICAID CENPATICO,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,57.42,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.55 in Billed Charges for Rev 250 = $57.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,CIGNA,ALL COMMERCIAL CIGNA,47.29,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $67.55 in Billed Charges for Rev 250 = $47.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,COFINITY,COFINITY,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,64.17,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $67.55 in Billed Charges for Rev 250 = $64.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,HEALTH CARE ALLIANCE,THE ALLIANCE,56.74,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $67.55 in Billed Charges for Rev 250 = $56.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,47.96,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $67.55 in Billed Charges for Rev 250 = $47.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,49.31,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $67.55 in Billed Charges for Rev 250 = $49.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,HSHS EMPLOYEES,HSHS EMPLOYEES,32.83,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $67.55 in Billed Charges for Rev 250 = $32.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,57.42,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.55 in Billed Charges for Rev 250 = $57.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,HUMANA,HUMANA CHOICE CARE HMO,42.89,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.55 in Billed Charges at 63.5% = $42.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,HUMANA,HUMANA CHOICE CARE PPO,57.42,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $67.55 in Billed Charges for Rev 250 = $57.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,HUMANA,HUMANA NATIIONAL POS HMO,42.89,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $67.55 in Billed Charges at 63.5% = $42.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,49.31,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $67.55 in Billed Charges for Rev 250 = $49.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,LIVE360,LIVE360 HSHS HEALTHY PLAN,67.55,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $67.55 in Billed Charges for Rev 250 = $67.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,33.78,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $67.55 in Billed Charges for Rev 250 = $33.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,56.74,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $67.55 in Billed Charges for Rev 250 = $56.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,50.66,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $67.55 in Billed Charges for Rev 250 = $50.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,62.15,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $67.55 in Billed Charges for Rev 250 = $62.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,PREVEA HEALTH NETWORK,PREVEA360,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,43.12,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $67.55 in Billed Charges for Rev 250 = $43.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,48.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.55 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,37.36,,,,,,,32.8300,67.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.55 in Billed Charges for Rev 250 = $37.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,UNITED HEALTHCARE,UHC ONEIDA NATION,37.36,,,,,,,32.8300,67.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.55 in Billed Charges for Rev 250 = $37.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,UNITED HEALTHCARE,UNITED HEALTHCARE,37.36,,,,,,,32.8300,67.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $67.55 in Billed Charges for Rev 250 = $37.36 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,48.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.55 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,41.88,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $67.55 in Billed Charges for Rev 250 = $41.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,48.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.55 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,48.64,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $67.55 in Billed Charges for Rev 250 = $48.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,250,RC,24208-830-60,CDM,,,,,,both,5.000000,ML,67.5500,44.5800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,40.53,,,,,,,32.8300,67.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $67.55 in Billed Charges for Rev 250 = $40.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,AETNA,AETNA HSHS,95.35,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $147.60 in Billed Charges for Rev 250 = $95.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,AETNA,ALL COMMERCIAL AETNA,147.60,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.60 in Billed Charges for Rev 250 = $147.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,ANTHEM,ANTHEM POS/HMO,100.37,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $147.60 in Billed Charges at 68% = $100.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,ANTHEM,ANTHEM PPO,100.37,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $147.60 in Billed Charges at 68% = $100.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,147.60,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.60 in Billed Charges for Rev 250 = $147.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,CENPATICO,ALL MEDICAID CENPATICO,147.60,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.60 in Billed Charges for Rev 250 = $147.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,125.46,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $147.60 in Billed Charges for Rev 250 = $125.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,CIGNA,ALL COMMERCIAL CIGNA,103.32,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $147.60 in Billed Charges for Rev 250 = $103.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,COFINITY,COFINITY,147.60,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.60 in Billed Charges for Rev 250 = $147.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,140.22,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $147.60 in Billed Charges for Rev 250 = $140.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,HEALTH CARE ALLIANCE,THE ALLIANCE,123.98,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $147.60 in Billed Charges for Rev 250 = $123.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,104.80,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $147.60 in Billed Charges for Rev 250 = $104.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,107.75,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $147.60 in Billed Charges for Rev 250 = $107.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,HSHS EMPLOYEES,HSHS EMPLOYEES,71.73,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $147.60 in Billed Charges for Rev 250 = $71.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,125.46,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $147.60 in Billed Charges for Rev 250 = $125.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,HUMANA,HUMANA CHOICE CARE HMO,93.73,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $147.60 in Billed Charges at 63.5% = $93.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,HUMANA,HUMANA CHOICE CARE PPO,125.46,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $147.60 in Billed Charges for Rev 250 = $125.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,HUMANA,HUMANA NATIIONAL POS HMO,93.73,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $147.60 in Billed Charges at 63.5% = $93.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,107.75,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $147.60 in Billed Charges for Rev 250 = $107.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,LIVE360,LIVE360 HSHS HEALTHY PLAN,147.60,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $147.60 in Billed Charges for Rev 250 = $147.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,73.80,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $147.60 in Billed Charges for Rev 250 = $73.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,123.98,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $147.60 in Billed Charges for Rev 250 = $123.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,110.70,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $147.60 in Billed Charges for Rev 250 = $110.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,135.79,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $147.60 in Billed Charges for Rev 250 = $135.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,88.56,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.60 in Billed Charges for Rev 250 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,88.56,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.60 in Billed Charges for Rev 250 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,PREVEA HEALTH NETWORK,PREVEA360,88.56,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.60 in Billed Charges for Rev 250 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,88.56,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.60 in Billed Charges for Rev 250 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,94.21,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $147.60 in Billed Charges for Rev 250 = $94.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,106.27,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $147.60 in Billed Charges for Rev 250 = $106.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,81.62,,,,,,,71.7300,147.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $147.60 in Billed Charges for Rev 250 = $81.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,UNITED HEALTHCARE,UHC ONEIDA NATION,81.62,,,,,,,71.7300,147.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $147.60 in Billed Charges for Rev 250 = $81.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,UNITED HEALTHCARE,UNITED HEALTHCARE,81.62,,,,,,,71.7300,147.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $147.60 in Billed Charges for Rev 250 = $81.62 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,106.27,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $147.60 in Billed Charges for Rev 250 = $106.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,91.51,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $147.60 in Billed Charges for Rev 250 = $91.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,106.27,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $147.60 in Billed Charges for Rev 250 = $106.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,106.27,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $147.60 in Billed Charges for Rev 250 = $106.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,250,RC,43598-587-23,CDM,,,,,,both,2.000000,ML,147.6000,97.4200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,88.56,,,,,,,71.7300,147.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $147.60 in Billed Charges for Rev 250 = $88.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,AETNA,AETNA HSHS,154.52,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $239.20 in Billed Charges for Rev 250 = $154.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,AETNA,ALL COMMERCIAL AETNA,239.20,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.20 in Billed Charges for Rev 250 = $239.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,ANTHEM,ANTHEM POS/HMO,162.66,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $239.20 in Billed Charges at 68% = $162.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,ANTHEM,ANTHEM PPO,162.66,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $239.20 in Billed Charges at 68% = $162.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,239.20,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.20 in Billed Charges for Rev 250 = $239.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,CENPATICO,ALL MEDICAID CENPATICO,239.20,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.20 in Billed Charges for Rev 250 = $239.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,203.32,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $239.20 in Billed Charges for Rev 250 = $203.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,CIGNA,ALL COMMERCIAL CIGNA,167.44,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $239.20 in Billed Charges for Rev 250 = $167.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,COFINITY,COFINITY,239.20,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.20 in Billed Charges for Rev 250 = $239.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,227.24,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $239.20 in Billed Charges for Rev 250 = $227.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,200.93,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $239.20 in Billed Charges for Rev 250 = $200.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,169.83,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $239.20 in Billed Charges for Rev 250 = $169.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,174.62,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $239.20 in Billed Charges for Rev 250 = $174.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,116.25,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $239.20 in Billed Charges for Rev 250 = $116.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,203.32,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $239.20 in Billed Charges for Rev 250 = $203.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,HUMANA,HUMANA CHOICE CARE HMO,151.89,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $239.20 in Billed Charges at 63.5% = $151.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,HUMANA,HUMANA CHOICE CARE PPO,203.32,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $239.20 in Billed Charges for Rev 250 = $203.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,HUMANA,HUMANA NATIIONAL POS HMO,151.89,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $239.20 in Billed Charges at 63.5% = $151.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,174.62,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $239.20 in Billed Charges for Rev 250 = $174.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,239.20,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $239.20 in Billed Charges for Rev 250 = $239.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,119.60,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $239.20 in Billed Charges for Rev 250 = $119.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,200.93,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $239.20 in Billed Charges for Rev 250 = $200.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,179.40,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $239.20 in Billed Charges for Rev 250 = $179.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,220.06,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $239.20 in Billed Charges for Rev 250 = $220.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,143.52,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $239.20 in Billed Charges for Rev 250 = $143.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,143.52,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $239.20 in Billed Charges for Rev 250 = $143.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,PREVEA HEALTH NETWORK,PREVEA360,143.52,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $239.20 in Billed Charges for Rev 250 = $143.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,143.52,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $239.20 in Billed Charges for Rev 250 = $143.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,152.68,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $239.20 in Billed Charges for Rev 250 = $152.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,172.22,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $239.20 in Billed Charges for Rev 250 = $172.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,132.28,,,,,,,116.2500,239.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $239.20 in Billed Charges for Rev 250 = $132.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,UNITED HEALTHCARE,UHC ONEIDA NATION,132.28,,,,,,,116.2500,239.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $239.20 in Billed Charges for Rev 250 = $132.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,UNITED HEALTHCARE,UNITED HEALTHCARE,132.28,,,,,,,116.2500,239.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $239.20 in Billed Charges for Rev 250 = $132.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,172.22,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $239.20 in Billed Charges for Rev 250 = $172.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,148.30,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $239.20 in Billed Charges for Rev 250 = $148.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,172.22,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $239.20 in Billed Charges for Rev 250 = $172.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,172.22,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $239.20 in Billed Charges for Rev 250 = $172.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,250,RC,64980-515-05,CDM,,,,,,both,5.000000,ML,239.2000,157.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,143.52,,,,,,,116.2500,239.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $239.20 in Billed Charges for Rev 250 = $143.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,AETNA,AETNA HSHS,15.76,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $24.40 in Billed Charges for Rev 250 = $15.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,AETNA,ALL COMMERCIAL AETNA,24.40,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.40 in Billed Charges for Rev 250 = $24.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,ANTHEM,ANTHEM POS/HMO,16.59,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $24.40 in Billed Charges at 68% = $16.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,ANTHEM,ANTHEM PPO,16.59,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $24.40 in Billed Charges at 68% = $16.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,24.40,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.40 in Billed Charges for Rev 250 = $24.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,CENPATICO,ALL MEDICAID CENPATICO,24.40,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.40 in Billed Charges for Rev 250 = $24.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,20.74,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.40 in Billed Charges for Rev 250 = $20.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,CIGNA,ALL COMMERCIAL CIGNA,17.08,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $24.40 in Billed Charges for Rev 250 = $17.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,COFINITY,COFINITY,24.40,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.40 in Billed Charges for Rev 250 = $24.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,23.18,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $24.40 in Billed Charges for Rev 250 = $23.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,20.50,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.40 in Billed Charges for Rev 250 = $20.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,17.32,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $24.40 in Billed Charges for Rev 250 = $17.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,17.81,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.40 in Billed Charges for Rev 250 = $17.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,11.86,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $24.40 in Billed Charges for Rev 250 = $11.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,20.74,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.40 in Billed Charges for Rev 250 = $20.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,HUMANA,HUMANA CHOICE CARE HMO,15.49,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $24.40 in Billed Charges at 63.5% = $15.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,HUMANA,HUMANA CHOICE CARE PPO,20.74,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $24.40 in Billed Charges for Rev 250 = $20.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,HUMANA,HUMANA NATIIONAL POS HMO,15.49,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $24.40 in Billed Charges at 63.5% = $15.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,17.81,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $24.40 in Billed Charges for Rev 250 = $17.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,24.40,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $24.40 in Billed Charges for Rev 250 = $24.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.20,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $24.40 in Billed Charges for Rev 250 = $12.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,20.50,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $24.40 in Billed Charges for Rev 250 = $20.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,18.30,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $24.40 in Billed Charges for Rev 250 = $18.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,22.45,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $24.40 in Billed Charges for Rev 250 = $22.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,14.64,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.40 in Billed Charges for Rev 250 = $14.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,14.64,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.40 in Billed Charges for Rev 250 = $14.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,PREVEA HEALTH NETWORK,PREVEA360,14.64,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.40 in Billed Charges for Rev 250 = $14.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,14.64,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.40 in Billed Charges for Rev 250 = $14.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,15.57,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $24.40 in Billed Charges for Rev 250 = $15.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,17.57,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.40 in Billed Charges for Rev 250 = $17.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,13.49,,,,,,,11.8600,24.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $24.40 in Billed Charges for Rev 250 = $13.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,13.49,,,,,,,11.8600,24.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $24.40 in Billed Charges for Rev 250 = $13.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,13.49,,,,,,,11.8600,24.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $24.40 in Billed Charges for Rev 250 = $13.49 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,17.57,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.40 in Billed Charges for Rev 250 = $17.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.13,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $24.40 in Billed Charges for Rev 250 = $15.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,17.57,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.40 in Billed Charges for Rev 250 = $17.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,17.57,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $24.40 in Billed Charges for Rev 250 = $17.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
OXYCHLOROSENE POWD 2 G BOX,250,RC,0327-0001-10,CDM,,,,,,both,2.000000,GR,24.4000,16.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,14.64,,,,,,,11.8600,24.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $24.40 in Billed Charges for Rev 250 = $14.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,AETNA,AETNA HSHS,76.45,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $118.35 in Billed Charges for Rev 250 = $76.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,AETNA,ALL COMMERCIAL AETNA,118.35,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.35 in Billed Charges for Rev 250 = $118.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,ANTHEM,ANTHEM POS/HMO,80.48,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $118.35 in Billed Charges at 68% = $80.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,ANTHEM,ANTHEM PPO,80.48,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $118.35 in Billed Charges at 68% = $80.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,118.35,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.35 in Billed Charges for Rev 250 = $118.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,CENPATICO,ALL MEDICAID CENPATICO,118.35,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.35 in Billed Charges for Rev 250 = $118.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,100.60,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.35 in Billed Charges for Rev 250 = $100.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,CIGNA,ALL COMMERCIAL CIGNA,82.85,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $118.35 in Billed Charges for Rev 250 = $82.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,COFINITY,COFINITY,118.35,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.35 in Billed Charges for Rev 250 = $118.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,112.43,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $118.35 in Billed Charges for Rev 250 = $112.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,HEALTH CARE ALLIANCE,THE ALLIANCE,99.41,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.35 in Billed Charges for Rev 250 = $99.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,84.03,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $118.35 in Billed Charges for Rev 250 = $84.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,86.40,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.35 in Billed Charges for Rev 250 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,HSHS EMPLOYEES,HSHS EMPLOYEES,57.52,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $118.35 in Billed Charges for Rev 250 = $57.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,100.60,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.35 in Billed Charges for Rev 250 = $100.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,HUMANA,HUMANA CHOICE CARE HMO,75.15,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $118.35 in Billed Charges at 63.5% = $75.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,HUMANA,HUMANA CHOICE CARE PPO,100.60,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $118.35 in Billed Charges for Rev 250 = $100.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,HUMANA,HUMANA NATIIONAL POS HMO,75.15,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $118.35 in Billed Charges at 63.5% = $75.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,86.40,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $118.35 in Billed Charges for Rev 250 = $86.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,LIVE360,LIVE360 HSHS HEALTHY PLAN,118.35,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $118.35 in Billed Charges for Rev 250 = $118.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,59.18,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $118.35 in Billed Charges for Rev 250 = $59.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,99.41,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $118.35 in Billed Charges for Rev 250 = $99.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,88.76,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $118.35 in Billed Charges for Rev 250 = $88.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,108.88,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $118.35 in Billed Charges for Rev 250 = $108.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,71.01,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.35 in Billed Charges for Rev 250 = $71.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,71.01,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.35 in Billed Charges for Rev 250 = $71.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,PREVEA HEALTH NETWORK,PREVEA360,71.01,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.35 in Billed Charges for Rev 250 = $71.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,71.01,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.35 in Billed Charges for Rev 250 = $71.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,75.54,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $118.35 in Billed Charges for Rev 250 = $75.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,85.21,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.35 in Billed Charges for Rev 250 = $85.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,65.45,,,,,,,57.5200,118.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.35 in Billed Charges for Rev 250 = $65.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,UNITED HEALTHCARE,UHC ONEIDA NATION,65.45,,,,,,,57.5200,118.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.35 in Billed Charges for Rev 250 = $65.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,UNITED HEALTHCARE,UNITED HEALTHCARE,65.45,,,,,,,57.5200,118.3500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $118.35 in Billed Charges for Rev 250 = $65.45 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,85.21,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.35 in Billed Charges for Rev 250 = $85.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,73.38,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $118.35 in Billed Charges for Rev 250 = $73.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,85.21,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.35 in Billed Charges for Rev 250 = $85.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,85.21,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $118.35 in Billed Charges for Rev 250 = $85.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAFLUOROPROP-TETRAFLUOROETH AERO,250,RC,0386-0008-03,CDM,,,,,,both,116.000000,ML,118.3500,78.1100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,71.01,,,,,,,57.5200,118.3500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $118.35 in Billed Charges for Rev 250 = $71.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,AETNA,AETNA HSHS,314.31,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $486.55 in Billed Charges for Rev 250 = $314.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,AETNA,ALL COMMERCIAL AETNA,486.55,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $486.55 in Billed Charges for Rev 250 = $486.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,ANTHEM,ANTHEM POS/HMO,330.85,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $486.55 in Billed Charges at 68% = $330.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,ANTHEM,ANTHEM PPO,330.85,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $486.55 in Billed Charges at 68% = $330.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,486.55,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $486.55 in Billed Charges for Rev 250 = $486.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,CENPATICO,ALL MEDICAID CENPATICO,486.55,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $486.55 in Billed Charges for Rev 250 = $486.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,413.57,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $486.55 in Billed Charges for Rev 250 = $413.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,CIGNA,ALL COMMERCIAL CIGNA,340.59,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $486.55 in Billed Charges for Rev 250 = $340.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,COFINITY,COFINITY,486.55,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $486.55 in Billed Charges for Rev 250 = $486.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,462.22,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $486.55 in Billed Charges for Rev 250 = $462.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,408.70,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $486.55 in Billed Charges for Rev 250 = $408.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,345.45,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $486.55 in Billed Charges for Rev 250 = $345.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,355.18,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $486.55 in Billed Charges for Rev 250 = $355.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,236.46,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $486.55 in Billed Charges for Rev 250 = $236.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,413.57,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $486.55 in Billed Charges for Rev 250 = $413.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,HUMANA,HUMANA CHOICE CARE HMO,308.96,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $486.55 in Billed Charges at 63.5% = $308.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,HUMANA,HUMANA CHOICE CARE PPO,413.57,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $486.55 in Billed Charges for Rev 250 = $413.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,HUMANA,HUMANA NATIIONAL POS HMO,308.96,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $486.55 in Billed Charges at 63.5% = $308.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,355.18,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $486.55 in Billed Charges for Rev 250 = $355.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,486.55,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $486.55 in Billed Charges for Rev 250 = $486.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,243.28,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $486.55 in Billed Charges for Rev 250 = $243.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,408.70,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $486.55 in Billed Charges for Rev 250 = $408.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,364.91,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $486.55 in Billed Charges for Rev 250 = $364.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,447.63,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $486.55 in Billed Charges for Rev 250 = $447.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,291.93,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $486.55 in Billed Charges for Rev 250 = $291.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,291.93,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $486.55 in Billed Charges for Rev 250 = $291.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,PREVEA HEALTH NETWORK,PREVEA360,291.93,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $486.55 in Billed Charges for Rev 250 = $291.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,291.93,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $486.55 in Billed Charges for Rev 250 = $291.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,310.56,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $486.55 in Billed Charges for Rev 250 = $310.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,350.32,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $486.55 in Billed Charges for Rev 250 = $350.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,269.06,,,,,,,236.4600,486.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $486.55 in Billed Charges for Rev 250 = $269.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,269.06,,,,,,,236.4600,486.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $486.55 in Billed Charges for Rev 250 = $269.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,269.06,,,,,,,236.4600,486.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $486.55 in Billed Charges for Rev 250 = $269.06 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,350.32,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $486.55 in Billed Charges for Rev 250 = $350.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,301.66,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $486.55 in Billed Charges for Rev 250 = $301.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,350.32,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $486.55 in Billed Charges for Rev 250 = $350.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,350.32,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $486.55 in Billed Charges for Rev 250 = $350.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PENTAMIDINE 300 MG SOLR 1 EACH VIAL,250,RC,23155-748-31,CDM,,,,,,both,1.000000,EA,486.5500,321.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,291.93,,,,,,,236.4600,486.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $486.55 in Billed Charges for Rev 250 = $291.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,AETNA,AETNA HSHS,1721.43,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,664.75 in Billed Charges for Rev 250 = $1,721.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,AETNA,ALL COMMERCIAL AETNA,2664.75,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,664.75 in Billed Charges for Rev 250 = $2,664.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,ANTHEM,ANTHEM POS/HMO,1812.03,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $2,664.75 in Billed Charges at 68% = $1,812.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,ANTHEM,ANTHEM PPO,1812.03,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $2,664.75 in Billed Charges at 68% = $1,812.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2664.75,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,664.75 in Billed Charges for Rev 250 = $2,664.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,CENPATICO,ALL MEDICAID CENPATICO,2664.75,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,664.75 in Billed Charges for Rev 250 = $2,664.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2265.04,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,664.75 in Billed Charges for Rev 250 = $2,265.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,CIGNA,ALL COMMERCIAL CIGNA,1865.33,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,664.75 in Billed Charges for Rev 250 = $1,865.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,COFINITY,COFINITY,2664.75,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,664.75 in Billed Charges for Rev 250 = $2,664.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2531.51,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,664.75 in Billed Charges for Rev 250 = $2,531.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,HEALTH CARE ALLIANCE,THE ALLIANCE,2238.39,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,664.75 in Billed Charges for Rev 250 = $2,238.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1891.97,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,664.75 in Billed Charges for Rev 250 = $1,891.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1945.27,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,664.75 in Billed Charges for Rev 250 = $1,945.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,HSHS EMPLOYEES,HSHS EMPLOYEES,1295.07,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,664.75 in Billed Charges for Rev 250 = $1,295.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2265.04,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,664.75 in Billed Charges for Rev 250 = $2,265.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,HUMANA,HUMANA CHOICE CARE HMO,1692.12,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $2,664.75 in Billed Charges at 63.5% = $1,692.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,HUMANA,HUMANA CHOICE CARE PPO,2265.04,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,664.75 in Billed Charges for Rev 250 = $2,265.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,HUMANA,HUMANA NATIIONAL POS HMO,1692.12,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $2,664.75 in Billed Charges at 63.5% = $1,692.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1945.27,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,664.75 in Billed Charges for Rev 250 = $1,945.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,LIVE360,LIVE360 HSHS HEALTHY PLAN,2664.75,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,664.75 in Billed Charges for Rev 250 = $2,664.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1332.38,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,664.75 in Billed Charges for Rev 250 = $1,332.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2238.39,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,664.75 in Billed Charges for Rev 250 = $2,238.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1998.56,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,664.75 in Billed Charges for Rev 250 = $1,998.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2451.57,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,664.75 in Billed Charges for Rev 250 = $2,451.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1598.85,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,664.75 in Billed Charges for Rev 250 = $1,598.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1598.85,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,664.75 in Billed Charges for Rev 250 = $1,598.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,PREVEA HEALTH NETWORK,PREVEA360,1598.85,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,664.75 in Billed Charges for Rev 250 = $1,598.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1598.85,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,664.75 in Billed Charges for Rev 250 = $1,598.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1700.91,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,664.75 in Billed Charges for Rev 250 = $1,700.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1918.62,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,664.75 in Billed Charges for Rev 250 = $1,918.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1473.61,,,,,,,1295.0700,2664.7500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,664.75 in Billed Charges for Rev 250 = $1,473.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,UNITED HEALTHCARE,UHC ONEIDA NATION,1473.61,,,,,,,1295.0700,2664.7500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,664.75 in Billed Charges for Rev 250 = $1,473.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,UNITED HEALTHCARE,UNITED HEALTHCARE,1473.61,,,,,,,1295.0700,2664.7500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,664.75 in Billed Charges for Rev 250 = $1,473.61 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1918.62,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,664.75 in Billed Charges for Rev 250 = $1,918.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1652.15,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,664.75 in Billed Charges for Rev 250 = $1,652.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1918.62,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,664.75 in Billed Charges for Rev 250 = $1,918.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1918.62,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,664.75 in Billed Charges for Rev 250 = $1,918.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PHENYLEPHRINE HCL POWD,250,RC,38779-0247-4,CDM,,,,,,both,25.000000,GR,2664.7500,1758.7400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1598.85,,,,,,,1295.0700,2664.7500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,664.75 in Billed Charges for Rev 250 = $1,598.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,AETNA,AETNA HSHS,158.14,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $244.80 in Billed Charges for Rev 250 = $158.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,AETNA,ALL COMMERCIAL AETNA,244.80,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.80 in Billed Charges for Rev 250 = $244.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,ANTHEM,ANTHEM POS/HMO,166.46,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $244.80 in Billed Charges at 68% = $166.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,ANTHEM,ANTHEM PPO,166.46,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $244.80 in Billed Charges at 68% = $166.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,244.80,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.80 in Billed Charges for Rev 250 = $244.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,CENPATICO,ALL MEDICAID CENPATICO,244.80,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.80 in Billed Charges for Rev 250 = $244.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,208.08,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.80 in Billed Charges for Rev 250 = $208.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,CIGNA,ALL COMMERCIAL CIGNA,171.36,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $244.80 in Billed Charges for Rev 250 = $171.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,COFINITY,COFINITY,244.80,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.80 in Billed Charges for Rev 250 = $244.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,232.56,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $244.80 in Billed Charges for Rev 250 = $232.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,HEALTH CARE ALLIANCE,THE ALLIANCE,205.63,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.80 in Billed Charges for Rev 250 = $205.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,173.81,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $244.80 in Billed Charges for Rev 250 = $173.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,178.70,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.80 in Billed Charges for Rev 250 = $178.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,HSHS EMPLOYEES,HSHS EMPLOYEES,118.97,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $244.80 in Billed Charges for Rev 250 = $118.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,208.08,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.80 in Billed Charges for Rev 250 = $208.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,HUMANA,HUMANA CHOICE CARE HMO,155.45,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $244.80 in Billed Charges at 63.5% = $155.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,HUMANA,HUMANA CHOICE CARE PPO,208.08,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $244.80 in Billed Charges for Rev 250 = $208.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,HUMANA,HUMANA NATIIONAL POS HMO,155.45,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $244.80 in Billed Charges at 63.5% = $155.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,178.70,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $244.80 in Billed Charges for Rev 250 = $178.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,LIVE360,LIVE360 HSHS HEALTHY PLAN,244.80,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $244.80 in Billed Charges for Rev 250 = $244.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,122.40,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $244.80 in Billed Charges for Rev 250 = $122.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,205.63,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $244.80 in Billed Charges for Rev 250 = $205.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,183.60,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $244.80 in Billed Charges for Rev 250 = $183.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,225.22,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $244.80 in Billed Charges for Rev 250 = $225.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,146.88,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.80 in Billed Charges for Rev 250 = $146.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,146.88,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.80 in Billed Charges for Rev 250 = $146.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,PREVEA HEALTH NETWORK,PREVEA360,146.88,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.80 in Billed Charges for Rev 250 = $146.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,146.88,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.80 in Billed Charges for Rev 250 = $146.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,156.26,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $244.80 in Billed Charges for Rev 250 = $156.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,176.26,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.80 in Billed Charges for Rev 250 = $176.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,135.37,,,,,,,118.9700,244.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $244.80 in Billed Charges for Rev 250 = $135.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,UNITED HEALTHCARE,UHC ONEIDA NATION,135.37,,,,,,,118.9700,244.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $244.80 in Billed Charges for Rev 250 = $135.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,UNITED HEALTHCARE,UNITED HEALTHCARE,135.37,,,,,,,118.9700,244.8000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $244.80 in Billed Charges for Rev 250 = $135.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,176.26,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.80 in Billed Charges for Rev 250 = $176.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,151.78,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $244.80 in Billed Charges for Rev 250 = $151.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,176.26,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.80 in Billed Charges for Rev 250 = $176.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,176.26,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $244.80 in Billed Charges for Rev 250 = $176.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"POLYETHYLENE GLYCOL 236 G SOLR 4,000 ML BOTTLE",250,RC,64380-766-21,CDM,,,,,,both,4000.000000,ML,244.8000,161.5700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,146.88,,,,,,,118.9700,244.8000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $244.80 in Billed Charges for Rev 250 = $146.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,AETNA,AETNA HSHS,16.44,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $25.45 in Billed Charges for Rev 250 = $16.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,AETNA,ALL COMMERCIAL AETNA,25.45,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.45 in Billed Charges for Rev 250 = $25.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,ANTHEM,ANTHEM POS/HMO,17.31,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $25.45 in Billed Charges at 68% = $17.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,ANTHEM,ANTHEM PPO,17.31,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $25.45 in Billed Charges at 68% = $17.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,25.45,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.45 in Billed Charges for Rev 250 = $25.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,CENPATICO,ALL MEDICAID CENPATICO,25.45,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.45 in Billed Charges for Rev 250 = $25.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,21.63,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.45 in Billed Charges for Rev 250 = $21.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,CIGNA,ALL COMMERCIAL CIGNA,17.82,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $25.45 in Billed Charges for Rev 250 = $17.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,COFINITY,COFINITY,25.45,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.45 in Billed Charges for Rev 250 = $25.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,24.18,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $25.45 in Billed Charges for Rev 250 = $24.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,HEALTH CARE ALLIANCE,THE ALLIANCE,21.38,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.45 in Billed Charges for Rev 250 = $21.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,18.07,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $25.45 in Billed Charges for Rev 250 = $18.07. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,18.58,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.45 in Billed Charges for Rev 250 = $18.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,HSHS EMPLOYEES,HSHS EMPLOYEES,12.37,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $25.45 in Billed Charges for Rev 250 = $12.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,21.63,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.45 in Billed Charges for Rev 250 = $21.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,HUMANA,HUMANA CHOICE CARE HMO,16.16,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $25.45 in Billed Charges at 63.5% = $16.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,HUMANA,HUMANA CHOICE CARE PPO,21.63,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $25.45 in Billed Charges for Rev 250 = $21.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,HUMANA,HUMANA NATIIONAL POS HMO,16.16,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $25.45 in Billed Charges at 63.5% = $16.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,18.58,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $25.45 in Billed Charges for Rev 250 = $18.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,LIVE360,LIVE360 HSHS HEALTHY PLAN,25.45,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $25.45 in Billed Charges for Rev 250 = $25.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,12.73,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $25.45 in Billed Charges for Rev 250 = $12.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,21.38,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $25.45 in Billed Charges for Rev 250 = $21.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,19.09,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $25.45 in Billed Charges for Rev 250 = $19.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,23.41,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $25.45 in Billed Charges for Rev 250 = $23.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,15.27,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.45 in Billed Charges for Rev 250 = $15.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,15.27,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.45 in Billed Charges for Rev 250 = $15.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,PREVEA HEALTH NETWORK,PREVEA360,15.27,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.45 in Billed Charges for Rev 250 = $15.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,15.27,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.45 in Billed Charges for Rev 250 = $15.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,16.24,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $25.45 in Billed Charges for Rev 250 = $16.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,18.32,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.45 in Billed Charges for Rev 250 = $18.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,14.07,,,,,,,12.3700,25.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $25.45 in Billed Charges for Rev 250 = $14.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,UNITED HEALTHCARE,UHC ONEIDA NATION,14.07,,,,,,,12.3700,25.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $25.45 in Billed Charges for Rev 250 = $14.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,UNITED HEALTHCARE,UNITED HEALTHCARE,14.07,,,,,,,12.3700,25.4500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $25.45 in Billed Charges for Rev 250 = $14.07 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,18.32,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.45 in Billed Charges for Rev 250 = $18.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,15.78,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $25.45 in Billed Charges for Rev 250 = $15.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,18.32,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.45 in Billed Charges for Rev 250 = $18.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,18.32,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $25.45 in Billed Charges for Rev 250 = $18.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POLYVINYL ALCOHOL-POVIDONE 5-6 MG/ML SOLN 15 ML BOTTLE,250,RC,24385-006-05,CDM,,,,,,both,15.000000,ML,25.4500,16.8000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,15.27,,,,,,,12.3700,25.4500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $25.45 in Billed Charges for Rev 250 = $15.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,AETNA,AETNA HSHS,1834.06,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $2,839.10 in Billed Charges for Rev 250 = $1,834.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,AETNA,ALL COMMERCIAL AETNA,2839.10,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,839.10 in Billed Charges for Rev 250 = $2,839.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,ANTHEM,ANTHEM POS/HMO,1930.59,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $2,839.10 in Billed Charges at 68% = $1,930.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,ANTHEM,ANTHEM PPO,1930.59,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $2,839.10 in Billed Charges at 68% = $1,930.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,2839.10,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,839.10 in Billed Charges for Rev 250 = $2,839.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,CENPATICO,ALL MEDICAID CENPATICO,2839.10,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,839.10 in Billed Charges for Rev 250 = $2,839.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,2413.24,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,839.10 in Billed Charges for Rev 250 = $2,413.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,CIGNA,ALL COMMERCIAL CIGNA,1987.37,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $2,839.10 in Billed Charges for Rev 250 = $1,987.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,COFINITY,COFINITY,2839.10,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,839.10 in Billed Charges for Rev 250 = $2,839.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,2697.15,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $2,839.10 in Billed Charges for Rev 250 = $2,697.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,HEALTH CARE ALLIANCE,THE ALLIANCE,2384.84,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,839.10 in Billed Charges for Rev 250 = $2,384.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2015.76,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $2,839.10 in Billed Charges for Rev 250 = $2,015.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2072.54,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,839.10 in Billed Charges for Rev 250 = $2,072.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,HSHS EMPLOYEES,HSHS EMPLOYEES,1379.80,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $2,839.10 in Billed Charges for Rev 250 = $1,379.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,2413.24,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,839.10 in Billed Charges for Rev 250 = $2,413.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,HUMANA,HUMANA CHOICE CARE HMO,1802.83,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $2,839.10 in Billed Charges at 63.5% = $1,802.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,HUMANA,HUMANA CHOICE CARE PPO,2413.24,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $2,839.10 in Billed Charges for Rev 250 = $2,413.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,HUMANA,HUMANA NATIIONAL POS HMO,1802.83,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $2,839.10 in Billed Charges at 63.5% = $1,802.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2072.54,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $2,839.10 in Billed Charges for Rev 250 = $2,072.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,LIVE360,LIVE360 HSHS HEALTHY PLAN,2839.10,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $2,839.10 in Billed Charges for Rev 250 = $2,839.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,1419.55,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $2,839.10 in Billed Charges for Rev 250 = $1,419.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,2384.84,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $2,839.10 in Billed Charges for Rev 250 = $2,384.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,2129.33,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $2,839.10 in Billed Charges for Rev 250 = $2,129.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,2611.97,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $2,839.10 in Billed Charges for Rev 250 = $2,611.97. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,1703.46,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,839.10 in Billed Charges for Rev 250 = $1,703.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,1703.46,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,839.10 in Billed Charges for Rev 250 = $1,703.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,PREVEA HEALTH NETWORK,PREVEA360,1703.46,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,839.10 in Billed Charges for Rev 250 = $1,703.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,1703.46,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,839.10 in Billed Charges for Rev 250 = $1,703.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1812.20,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $2,839.10 in Billed Charges for Rev 250 = $1,812.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2044.15,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,839.10 in Billed Charges for Rev 250 = $2,044.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,1570.02,,,,,,,1379.8000,2839.1000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,839.10 in Billed Charges for Rev 250 = $1,570.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,UNITED HEALTHCARE,UHC ONEIDA NATION,1570.02,,,,,,,1379.8000,2839.1000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,839.10 in Billed Charges for Rev 250 = $1,570.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,UNITED HEALTHCARE,UNITED HEALTHCARE,1570.02,,,,,,,1379.8000,2839.1000,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $2,839.10 in Billed Charges for Rev 250 = $1,570.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2044.15,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,839.10 in Billed Charges for Rev 250 = $2,044.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,1760.24,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $2,839.10 in Billed Charges for Rev 250 = $1,760.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2044.15,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,839.10 in Billed Charges for Rev 250 = $2,044.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2044.15,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $2,839.10 in Billed Charges for Rev 250 = $2,044.15. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 120 MG/1.5ML SUSP,250,RC,10122-510-01,CDM,,,,,,both,1.500000,ML,2839.1000,1873.8100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,1703.46,,,,,,,1379.8000,2839.1000,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $2,839.10 in Billed Charges for Rev 250 = $1,703.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,AETNA,AETNA HSHS,3616.53,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $5,598.35 in Billed Charges for Rev 250 = $3,616.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,AETNA,ALL COMMERCIAL AETNA,5598.35,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,598.35 in Billed Charges for Rev 250 = $5,598.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,ANTHEM,ANTHEM POS/HMO,3806.88,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $5,598.35 in Billed Charges at 68% = $3,806.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,ANTHEM,ANTHEM PPO,3806.88,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $5,598.35 in Billed Charges at 68% = $3,806.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,5598.35,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,598.35 in Billed Charges for Rev 250 = $5,598.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,CENPATICO,ALL MEDICAID CENPATICO,5598.35,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,598.35 in Billed Charges for Rev 250 = $5,598.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,4758.60,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,598.35 in Billed Charges for Rev 250 = $4,758.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,CIGNA,ALL COMMERCIAL CIGNA,3918.85,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $5,598.35 in Billed Charges for Rev 250 = $3,918.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,COFINITY,COFINITY,5598.35,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,598.35 in Billed Charges for Rev 250 = $5,598.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,5318.43,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $5,598.35 in Billed Charges for Rev 250 = $5,318.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,HEALTH CARE ALLIANCE,THE ALLIANCE,4702.61,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,598.35 in Billed Charges for Rev 250 = $4,702.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,3974.83,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $5,598.35 in Billed Charges for Rev 250 = $3,974.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,4086.80,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,598.35 in Billed Charges for Rev 250 = $4,086.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,HSHS EMPLOYEES,HSHS EMPLOYEES,2720.80,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $5,598.35 in Billed Charges for Rev 250 = $2,720.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,4758.60,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,598.35 in Billed Charges for Rev 250 = $4,758.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,HUMANA,HUMANA CHOICE CARE HMO,3554.95,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $5,598.35 in Billed Charges at 63.5% = $3,554.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,HUMANA,HUMANA CHOICE CARE PPO,4758.60,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $5,598.35 in Billed Charges for Rev 250 = $4,758.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,HUMANA,HUMANA NATIIONAL POS HMO,3554.95,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $5,598.35 in Billed Charges at 63.5% = $3,554.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,4086.80,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $5,598.35 in Billed Charges for Rev 250 = $4,086.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,LIVE360,LIVE360 HSHS HEALTHY PLAN,5598.35,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $5,598.35 in Billed Charges for Rev 250 = $5,598.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2799.18,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $5,598.35 in Billed Charges for Rev 250 = $2,799.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,4702.61,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $5,598.35 in Billed Charges for Rev 250 = $4,702.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,4198.76,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $5,598.35 in Billed Charges for Rev 250 = $4,198.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,5150.48,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $5,598.35 in Billed Charges for Rev 250 = $5,150.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,3359.01,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,598.35 in Billed Charges for Rev 250 = $3,359.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,3359.01,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,598.35 in Billed Charges for Rev 250 = $3,359.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,PREVEA HEALTH NETWORK,PREVEA360,3359.01,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,598.35 in Billed Charges for Rev 250 = $3,359.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,3359.01,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,598.35 in Billed Charges for Rev 250 = $3,359.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,3573.43,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $5,598.35 in Billed Charges for Rev 250 = $3,573.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,4030.81,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,598.35 in Billed Charges for Rev 250 = $4,030.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,3095.89,,,,,,,2720.8000,5598.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $5,598.35 in Billed Charges for Rev 250 = $3,095.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,UNITED HEALTHCARE,UHC ONEIDA NATION,3095.89,,,,,,,2720.8000,5598.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $5,598.35 in Billed Charges for Rev 250 = $3,095.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,UNITED HEALTHCARE,UNITED HEALTHCARE,3095.89,,,,,,,2720.8000,5598.3500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $5,598.35 in Billed Charges for Rev 250 = $3,095.89 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,4030.81,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,598.35 in Billed Charges for Rev 250 = $4,030.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,3470.98,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $5,598.35 in Billed Charges for Rev 250 = $3,470.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,4030.81,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,598.35 in Billed Charges for Rev 250 = $4,030.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,4030.81,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $5,598.35 in Billed Charges for Rev 250 = $4,030.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PORACTANT ALFA 240 MG/3ML SUSP,250,RC,10122-510-03,CDM,,,,,,both,3.000000,ML,5598.3500,3694.9100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,3359.01,,,,,,,2720.8000,5598.3500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $5,598.35 in Billed Charges for Rev 250 = $3,359.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,AETNA,AETNA HSHS,214.54,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $332.10 in Billed Charges for Rev 250 = $214.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,AETNA,ALL COMMERCIAL AETNA,332.10,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.10 in Billed Charges for Rev 250 = $332.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,ANTHEM,ANTHEM POS/HMO,225.83,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $332.10 in Billed Charges at 68% = $225.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,ANTHEM,ANTHEM PPO,225.83,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $332.10 in Billed Charges at 68% = $225.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,332.10,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.10 in Billed Charges for Rev 250 = $332.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,CENPATICO,ALL MEDICAID CENPATICO,332.10,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.10 in Billed Charges for Rev 250 = $332.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,282.29,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $332.10 in Billed Charges for Rev 250 = $282.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,CIGNA,ALL COMMERCIAL CIGNA,232.47,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $332.10 in Billed Charges for Rev 250 = $232.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,COFINITY,COFINITY,332.10,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.10 in Billed Charges for Rev 250 = $332.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,315.50,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $332.10 in Billed Charges for Rev 250 = $315.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,HEALTH CARE ALLIANCE,THE ALLIANCE,278.96,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $332.10 in Billed Charges for Rev 250 = $278.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,235.79,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $332.10 in Billed Charges for Rev 250 = $235.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,242.43,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $332.10 in Billed Charges for Rev 250 = $242.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,HSHS EMPLOYEES,HSHS EMPLOYEES,161.40,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $332.10 in Billed Charges for Rev 250 = $161.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,282.29,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $332.10 in Billed Charges for Rev 250 = $282.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,HUMANA,HUMANA CHOICE CARE HMO,210.88,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $332.10 in Billed Charges at 63.5% = $210.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,HUMANA,HUMANA CHOICE CARE PPO,282.29,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $332.10 in Billed Charges for Rev 250 = $282.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,HUMANA,HUMANA NATIIONAL POS HMO,210.88,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $332.10 in Billed Charges at 63.5% = $210.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,242.43,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $332.10 in Billed Charges for Rev 250 = $242.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,LIVE360,LIVE360 HSHS HEALTHY PLAN,332.10,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $332.10 in Billed Charges for Rev 250 = $332.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,166.05,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $332.10 in Billed Charges for Rev 250 = $166.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,278.96,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $332.10 in Billed Charges for Rev 250 = $278.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,249.08,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $332.10 in Billed Charges for Rev 250 = $249.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,305.53,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $332.10 in Billed Charges for Rev 250 = $305.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,199.26,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $332.10 in Billed Charges for Rev 250 = $199.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,199.26,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $332.10 in Billed Charges for Rev 250 = $199.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,PREVEA HEALTH NETWORK,PREVEA360,199.26,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $332.10 in Billed Charges for Rev 250 = $199.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,199.26,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $332.10 in Billed Charges for Rev 250 = $199.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,211.98,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $332.10 in Billed Charges for Rev 250 = $211.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,239.11,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $332.10 in Billed Charges for Rev 250 = $239.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,183.65,,,,,,,161.4000,332.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $332.10 in Billed Charges for Rev 250 = $183.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,UNITED HEALTHCARE,UHC ONEIDA NATION,183.65,,,,,,,161.4000,332.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $332.10 in Billed Charges for Rev 250 = $183.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,UNITED HEALTHCARE,UNITED HEALTHCARE,183.65,,,,,,,161.4000,332.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $332.10 in Billed Charges for Rev 250 = $183.65 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,239.11,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $332.10 in Billed Charges for Rev 250 = $239.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,205.90,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $332.10 in Billed Charges for Rev 250 = $205.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,239.11,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $332.10 in Billed Charges for Rev 250 = $239.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,239.11,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $332.10 in Billed Charges for Rev 250 = $239.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
POTASSIUM PHOSPHATE 45 MMOLE/15ML SOLN 15 ML VIAL,250,RC,80830-1691-1,CDM,,,,,,both,15.000000,ML,332.1000,219.1900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,199.26,,,,,,,161.4000,332.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $332.10 in Billed Charges for Rev 250 = $199.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,AETNA,AETNA HSHS,121.51,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $188.10 in Billed Charges for Rev 250 = $121.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,AETNA,ALL COMMERCIAL AETNA,188.10,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.10 in Billed Charges for Rev 250 = $188.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,ANTHEM,ANTHEM POS/HMO,127.91,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $188.10 in Billed Charges at 68% = $127.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,ANTHEM,ANTHEM PPO,127.91,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $188.10 in Billed Charges at 68% = $127.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,188.10,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.10 in Billed Charges for Rev 250 = $188.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,CENPATICO,ALL MEDICAID CENPATICO,188.10,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.10 in Billed Charges for Rev 250 = $188.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,159.89,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.10 in Billed Charges for Rev 250 = $159.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,CIGNA,ALL COMMERCIAL CIGNA,131.67,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $188.10 in Billed Charges for Rev 250 = $131.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,COFINITY,COFINITY,188.10,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.10 in Billed Charges for Rev 250 = $188.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,178.70,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $188.10 in Billed Charges for Rev 250 = $178.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,HEALTH CARE ALLIANCE,THE ALLIANCE,158.00,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $188.10 in Billed Charges for Rev 250 = $158.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,133.55,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $188.10 in Billed Charges for Rev 250 = $133.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,137.31,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $188.10 in Billed Charges for Rev 250 = $137.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,HSHS EMPLOYEES,HSHS EMPLOYEES,91.42,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $188.10 in Billed Charges for Rev 250 = $91.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,159.89,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.10 in Billed Charges for Rev 250 = $159.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,HUMANA,HUMANA CHOICE CARE HMO,119.44,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $188.10 in Billed Charges at 63.5% = $119.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,HUMANA,HUMANA CHOICE CARE PPO,159.89,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $188.10 in Billed Charges for Rev 250 = $159.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,HUMANA,HUMANA NATIIONAL POS HMO,119.44,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $188.10 in Billed Charges at 63.5% = $119.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,137.31,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $188.10 in Billed Charges for Rev 250 = $137.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,LIVE360,LIVE360 HSHS HEALTHY PLAN,188.10,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $188.10 in Billed Charges for Rev 250 = $188.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,94.05,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $188.10 in Billed Charges for Rev 250 = $94.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,158.00,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $188.10 in Billed Charges for Rev 250 = $158.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,141.08,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $188.10 in Billed Charges for Rev 250 = $141.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,173.05,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $188.10 in Billed Charges for Rev 250 = $173.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,112.86,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.10 in Billed Charges for Rev 250 = $112.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,112.86,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.10 in Billed Charges for Rev 250 = $112.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,PREVEA HEALTH NETWORK,PREVEA360,112.86,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.10 in Billed Charges for Rev 250 = $112.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,112.86,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.10 in Billed Charges for Rev 250 = $112.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,120.06,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $188.10 in Billed Charges for Rev 250 = $120.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,135.43,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.10 in Billed Charges for Rev 250 = $135.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,104.02,,,,,,,91.4200,188.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $188.10 in Billed Charges for Rev 250 = $104.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,UNITED HEALTHCARE,UHC ONEIDA NATION,104.02,,,,,,,91.4200,188.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $188.10 in Billed Charges for Rev 250 = $104.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,UNITED HEALTHCARE,UNITED HEALTHCARE,104.02,,,,,,,91.4200,188.1000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $188.10 in Billed Charges for Rev 250 = $104.02 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,135.43,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.10 in Billed Charges for Rev 250 = $135.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,116.62,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $188.10 in Billed Charges for Rev 250 = $116.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,135.43,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.10 in Billed Charges for Rev 250 = $135.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,135.43,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $188.10 in Billed Charges for Rev 250 = $135.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,250,RC,61314-637-05,CDM,,,,,,both,5.000000,ML,188.1000,124.1500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,112.86,,,,,,,91.4200,188.1000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $188.10 in Billed Charges for Rev 250 = $112.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,AETNA,AETNA HSHS,127.46,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $197.30 in Billed Charges for Rev 250 = $127.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,AETNA,ALL COMMERCIAL AETNA,197.30,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.30 in Billed Charges for Rev 250 = $197.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,ANTHEM,ANTHEM POS/HMO,134.16,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $197.30 in Billed Charges at 68% = $134.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,ANTHEM,ANTHEM PPO,134.16,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $197.30 in Billed Charges at 68% = $134.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,197.30,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.30 in Billed Charges for Rev 250 = $197.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,CENPATICO,ALL MEDICAID CENPATICO,197.30,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.30 in Billed Charges for Rev 250 = $197.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,167.71,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.30 in Billed Charges for Rev 250 = $167.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,CIGNA,ALL COMMERCIAL CIGNA,138.11,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $197.30 in Billed Charges for Rev 250 = $138.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,COFINITY,COFINITY,197.30,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.30 in Billed Charges for Rev 250 = $197.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,187.44,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $197.30 in Billed Charges for Rev 250 = $187.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,HEALTH CARE ALLIANCE,THE ALLIANCE,165.73,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $197.30 in Billed Charges for Rev 250 = $165.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,140.08,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $197.30 in Billed Charges for Rev 250 = $140.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,144.03,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $197.30 in Billed Charges for Rev 250 = $144.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,HSHS EMPLOYEES,HSHS EMPLOYEES,95.89,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $197.30 in Billed Charges for Rev 250 = $95.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,167.71,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.30 in Billed Charges for Rev 250 = $167.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,HUMANA,HUMANA CHOICE CARE HMO,125.29,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $197.30 in Billed Charges at 63.5% = $125.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,HUMANA,HUMANA CHOICE CARE PPO,167.71,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $197.30 in Billed Charges for Rev 250 = $167.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,HUMANA,HUMANA NATIIONAL POS HMO,125.29,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $197.30 in Billed Charges at 63.5% = $125.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,144.03,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $197.30 in Billed Charges for Rev 250 = $144.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,LIVE360,LIVE360 HSHS HEALTHY PLAN,197.30,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $197.30 in Billed Charges for Rev 250 = $197.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,98.65,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $197.30 in Billed Charges for Rev 250 = $98.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,165.73,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $197.30 in Billed Charges for Rev 250 = $165.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,147.98,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $197.30 in Billed Charges for Rev 250 = $147.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,181.52,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $197.30 in Billed Charges for Rev 250 = $181.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,118.38,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $197.30 in Billed Charges for Rev 250 = $118.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,118.38,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $197.30 in Billed Charges for Rev 250 = $118.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,PREVEA HEALTH NETWORK,PREVEA360,118.38,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $197.30 in Billed Charges for Rev 250 = $118.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,118.38,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $197.30 in Billed Charges for Rev 250 = $118.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,125.94,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $197.30 in Billed Charges for Rev 250 = $125.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,142.06,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.30 in Billed Charges for Rev 250 = $142.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,109.11,,,,,,,95.8900,197.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $197.30 in Billed Charges for Rev 250 = $109.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,UNITED HEALTHCARE,UHC ONEIDA NATION,109.11,,,,,,,95.8900,197.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $197.30 in Billed Charges for Rev 250 = $109.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,UNITED HEALTHCARE,UNITED HEALTHCARE,109.11,,,,,,,95.8900,197.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $197.30 in Billed Charges for Rev 250 = $109.11 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,142.06,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.30 in Billed Charges for Rev 250 = $142.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,122.33,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $197.30 in Billed Charges for Rev 250 = $122.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,142.06,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.30 in Billed Charges for Rev 250 = $142.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,142.06,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $197.30 in Billed Charges for Rev 250 = $142.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PYRIDOSTIGMINE 10 MG/2ML SOLN,250,RC,0781-3040-72,CDM,,,,,,both,2.000000,ML,197.3000,130.2200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,118.38,,,,,,,95.8900,197.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $197.30 in Billed Charges for Rev 250 = $118.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,AETNA,AETNA HSHS,413.80,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $640.55 in Billed Charges for Rev 250 = $413.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,AETNA,ALL COMMERCIAL AETNA,640.55,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.55 in Billed Charges for Rev 250 = $640.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,ANTHEM,ANTHEM POS/HMO,435.57,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $640.55 in Billed Charges at 68% = $435.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,ANTHEM,ANTHEM PPO,435.57,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $640.55 in Billed Charges at 68% = $435.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,640.55,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.55 in Billed Charges for Rev 250 = $640.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,CENPATICO,ALL MEDICAID CENPATICO,640.55,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.55 in Billed Charges for Rev 250 = $640.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,544.47,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $640.55 in Billed Charges for Rev 250 = $544.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,CIGNA,ALL COMMERCIAL CIGNA,448.39,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $640.55 in Billed Charges for Rev 250 = $448.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,COFINITY,COFINITY,640.55,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.55 in Billed Charges for Rev 250 = $640.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,608.52,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $640.55 in Billed Charges for Rev 250 = $608.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,HEALTH CARE ALLIANCE,THE ALLIANCE,538.06,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $640.55 in Billed Charges for Rev 250 = $538.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,454.79,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $640.55 in Billed Charges for Rev 250 = $454.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,467.60,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $640.55 in Billed Charges for Rev 250 = $467.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,HSHS EMPLOYEES,HSHS EMPLOYEES,311.31,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $640.55 in Billed Charges for Rev 250 = $311.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,544.47,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $640.55 in Billed Charges for Rev 250 = $544.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,HUMANA,HUMANA CHOICE CARE HMO,406.75,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $640.55 in Billed Charges at 63.5% = $406.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,HUMANA,HUMANA CHOICE CARE PPO,544.47,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $640.55 in Billed Charges for Rev 250 = $544.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,HUMANA,HUMANA NATIIONAL POS HMO,406.75,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $640.55 in Billed Charges at 63.5% = $406.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,467.60,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $640.55 in Billed Charges for Rev 250 = $467.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,LIVE360,LIVE360 HSHS HEALTHY PLAN,640.55,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $640.55 in Billed Charges for Rev 250 = $640.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,320.28,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $640.55 in Billed Charges for Rev 250 = $320.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,538.06,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $640.55 in Billed Charges for Rev 250 = $538.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,480.41,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $640.55 in Billed Charges for Rev 250 = $480.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,589.31,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $640.55 in Billed Charges for Rev 250 = $589.31. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,384.33,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $640.55 in Billed Charges for Rev 250 = $384.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,384.33,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $640.55 in Billed Charges for Rev 250 = $384.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,PREVEA HEALTH NETWORK,PREVEA360,384.33,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $640.55 in Billed Charges for Rev 250 = $384.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,384.33,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $640.55 in Billed Charges for Rev 250 = $384.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,408.86,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $640.55 in Billed Charges for Rev 250 = $408.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,461.20,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $640.55 in Billed Charges for Rev 250 = $461.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,354.22,,,,,,,311.3100,640.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $640.55 in Billed Charges for Rev 250 = $354.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,UNITED HEALTHCARE,UHC ONEIDA NATION,354.22,,,,,,,311.3100,640.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $640.55 in Billed Charges for Rev 250 = $354.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,UNITED HEALTHCARE,UNITED HEALTHCARE,354.22,,,,,,,311.3100,640.5500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $640.55 in Billed Charges for Rev 250 = $354.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,461.20,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $640.55 in Billed Charges for Rev 250 = $461.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,397.14,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $640.55 in Billed Charges for Rev 250 = $397.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,461.20,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $640.55 in Billed Charges for Rev 250 = $461.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,461.20,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $640.55 in Billed Charges for Rev 250 = $461.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,63323-724-01,CDM,,,,,,both,1.000000,EA,640.5500,422.7600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,384.33,,,,,,,311.3100,640.5500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $640.55 in Billed Charges for Rev 250 = $384.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,AETNA,AETNA HSHS,433.40,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $670.90 in Billed Charges for Rev 250 = $433.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,AETNA,ALL COMMERCIAL AETNA,670.90,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $670.90 in Billed Charges for Rev 250 = $670.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,ANTHEM,ANTHEM POS/HMO,456.21,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $670.90 in Billed Charges at 68% = $456.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,ANTHEM,ANTHEM PPO,456.21,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $670.90 in Billed Charges at 68% = $456.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,670.90,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $670.90 in Billed Charges for Rev 250 = $670.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,CENPATICO,ALL MEDICAID CENPATICO,670.90,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $670.90 in Billed Charges for Rev 250 = $670.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,CHOICECARE,ALL COMMERCIAL CHOICE CARE,570.27,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $670.90 in Billed Charges for Rev 250 = $570.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,CIGNA,ALL COMMERCIAL CIGNA,469.63,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $670.90 in Billed Charges for Rev 250 = $469.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,COFINITY,COFINITY,670.90,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $670.90 in Billed Charges for Rev 250 = $670.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,637.36,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $670.90 in Billed Charges for Rev 250 = $637.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,HEALTH CARE ALLIANCE,THE ALLIANCE,563.56,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $670.90 in Billed Charges for Rev 250 = $563.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,476.34,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $670.90 in Billed Charges for Rev 250 = $476.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,489.76,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $670.90 in Billed Charges for Rev 250 = $489.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,HSHS EMPLOYEES,HSHS EMPLOYEES,326.06,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $670.90 in Billed Charges for Rev 250 = $326.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,570.27,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $670.90 in Billed Charges for Rev 250 = $570.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,HUMANA,HUMANA CHOICE CARE HMO,426.02,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $670.90 in Billed Charges at 63.5% = $426.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,HUMANA,HUMANA CHOICE CARE PPO,570.27,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $670.90 in Billed Charges for Rev 250 = $570.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,HUMANA,HUMANA NATIIONAL POS HMO,426.02,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $670.90 in Billed Charges at 63.5% = $426.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,489.76,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $670.90 in Billed Charges for Rev 250 = $489.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,LIVE360,LIVE360 HSHS HEALTHY PLAN,670.90,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $670.90 in Billed Charges for Rev 250 = $670.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,335.45,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $670.90 in Billed Charges for Rev 250 = $335.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,563.56,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $670.90 in Billed Charges for Rev 250 = $563.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,503.18,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $670.90 in Billed Charges for Rev 250 = $503.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,617.23,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $670.90 in Billed Charges for Rev 250 = $617.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,402.54,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $670.90 in Billed Charges for Rev 250 = $402.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,402.54,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $670.90 in Billed Charges for Rev 250 = $402.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,PREVEA HEALTH NETWORK,PREVEA360,402.54,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $670.90 in Billed Charges for Rev 250 = $402.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,402.54,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $670.90 in Billed Charges for Rev 250 = $402.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,428.24,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $670.90 in Billed Charges for Rev 250 = $428.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,483.05,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $670.90 in Billed Charges for Rev 250 = $483.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,371.01,,,,,,,326.0600,670.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $670.90 in Billed Charges for Rev 250 = $371.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,UNITED HEALTHCARE,UHC ONEIDA NATION,371.01,,,,,,,326.0600,670.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $670.90 in Billed Charges for Rev 250 = $371.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,UNITED HEALTHCARE,UNITED HEALTHCARE,371.01,,,,,,,326.0600,670.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $670.90 in Billed Charges for Rev 250 = $371.01 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,483.05,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $670.90 in Billed Charges for Rev 250 = $483.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,415.96,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $670.90 in Billed Charges for Rev 250 = $415.96. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,483.05,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $670.90 in Billed Charges for Rev 250 = $483.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,483.05,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $670.90 in Billed Charges for Rev 250 = $483.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 2 MG SOLR 1 EACH VIAL,250,RC,72078-035-00,CDM,,,,,,both,1.000000,EA,670.9000,442.7900,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,402.54,,,,,,,326.0600,670.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $670.90 in Billed Charges for Rev 250 = $402.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,AETNA,AETNA HSHS,1041.00,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $1,611.45 in Billed Charges for Rev 250 = $1,041.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,AETNA,ALL COMMERCIAL AETNA,1611.45,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,611.45 in Billed Charges for Rev 250 = $1,611.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,ANTHEM,ANTHEM POS/HMO,1095.79,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,611.45 in Billed Charges at 68% = $1,095.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,ANTHEM,ANTHEM PPO,1095.79,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,611.45 in Billed Charges at 68% = $1,095.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,1611.45,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,611.45 in Billed Charges for Rev 250 = $1,611.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,CENPATICO,ALL MEDICAID CENPATICO,1611.45,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,611.45 in Billed Charges for Rev 250 = $1,611.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,1369.73,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,611.45 in Billed Charges for Rev 250 = $1,369.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,CIGNA,ALL COMMERCIAL CIGNA,1128.02,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $1,611.45 in Billed Charges for Rev 250 = $1,128.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,COFINITY,COFINITY,1611.45,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,611.45 in Billed Charges for Rev 250 = $1,611.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,1530.88,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $1,611.45 in Billed Charges for Rev 250 = $1,530.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,HEALTH CARE ALLIANCE,THE ALLIANCE,1353.62,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,611.45 in Billed Charges for Rev 250 = $1,353.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,1144.13,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $1,611.45 in Billed Charges for Rev 250 = $1,144.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,1176.36,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,611.45 in Billed Charges for Rev 250 = $1,176.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,HSHS EMPLOYEES,HSHS EMPLOYEES,783.16,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $1,611.45 in Billed Charges for Rev 250 = $783.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,1369.73,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,611.45 in Billed Charges for Rev 250 = $1,369.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,HUMANA,HUMANA CHOICE CARE HMO,1023.27,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,611.45 in Billed Charges at 63.5% = $1,023.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,HUMANA,HUMANA CHOICE CARE PPO,1369.73,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $1,611.45 in Billed Charges for Rev 250 = $1,369.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,HUMANA,HUMANA NATIIONAL POS HMO,1023.27,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $1,611.45 in Billed Charges at 63.5% = $1,023.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,1176.36,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $1,611.45 in Billed Charges for Rev 250 = $1,176.36. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,LIVE360,LIVE360 HSHS HEALTHY PLAN,1611.45,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $1,611.45 in Billed Charges for Rev 250 = $1,611.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,805.73,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $1,611.45 in Billed Charges for Rev 250 = $805.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,1353.62,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $1,611.45 in Billed Charges for Rev 250 = $1,353.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,1208.59,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $1,611.45 in Billed Charges for Rev 250 = $1,208.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,1482.53,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $1,611.45 in Billed Charges for Rev 250 = $1,482.53. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,966.87,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,611.45 in Billed Charges for Rev 250 = $966.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,966.87,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,611.45 in Billed Charges for Rev 250 = $966.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,PREVEA HEALTH NETWORK,PREVEA360,966.87,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,611.45 in Billed Charges for Rev 250 = $966.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,966.87,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,611.45 in Billed Charges for Rev 250 = $966.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,1028.59,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $1,611.45 in Billed Charges for Rev 250 = $1,028.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,1160.24,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,611.45 in Billed Charges for Rev 250 = $1,160.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,891.13,,,,,,,783.1600,1611.4500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,611.45 in Billed Charges for Rev 250 = $891.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,UNITED HEALTHCARE,UHC ONEIDA NATION,891.13,,,,,,,783.1600,1611.4500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,611.45 in Billed Charges for Rev 250 = $891.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,UNITED HEALTHCARE,UNITED HEALTHCARE,891.13,,,,,,,783.1600,1611.4500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $1,611.45 in Billed Charges for Rev 250 = $891.13 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,1160.24,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,611.45 in Billed Charges for Rev 250 = $1,160.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,999.10,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $1,611.45 in Billed Charges for Rev 250 = $999.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,1160.24,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,611.45 in Billed Charges for Rev 250 = $1,160.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,1160.24,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $1,611.45 in Billed Charges for Rev 250 = $1,160.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
REMIFENTANIL 5 MG SOLR 1 EACH VIAL,250,RC,63323-725-01,CDM,,,,,,both,1.000000,EA,1611.4500,1063.5600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,966.87,,,,,,,783.1600,1611.4500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $1,611.45 in Billed Charges for Rev 250 = $966.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,AETNA,AETNA HSHS,377.43,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $584.25 in Billed Charges for Rev 250 = $377.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,AETNA,ALL COMMERCIAL AETNA,584.25,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $584.25 in Billed Charges for Rev 250 = $584.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,ANTHEM,ANTHEM POS/HMO,397.29,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $584.25 in Billed Charges at 68% = $397.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,ANTHEM,ANTHEM PPO,397.29,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $584.25 in Billed Charges at 68% = $397.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,584.25,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $584.25 in Billed Charges for Rev 250 = $584.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,CENPATICO,ALL MEDICAID CENPATICO,584.25,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $584.25 in Billed Charges for Rev 250 = $584.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,496.61,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $584.25 in Billed Charges for Rev 250 = $496.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,CIGNA,ALL COMMERCIAL CIGNA,408.98,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $584.25 in Billed Charges for Rev 250 = $408.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,COFINITY,COFINITY,584.25,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $584.25 in Billed Charges for Rev 250 = $584.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,555.04,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $584.25 in Billed Charges for Rev 250 = $555.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,490.77,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $584.25 in Billed Charges for Rev 250 = $490.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,414.82,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $584.25 in Billed Charges for Rev 250 = $414.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,426.50,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $584.25 in Billed Charges for Rev 250 = $426.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,283.95,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $584.25 in Billed Charges for Rev 250 = $283.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,496.61,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $584.25 in Billed Charges for Rev 250 = $496.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,HUMANA,HUMANA CHOICE CARE HMO,371.00,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $584.25 in Billed Charges at 63.5% = $371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,HUMANA,HUMANA CHOICE CARE PPO,496.61,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $584.25 in Billed Charges for Rev 250 = $496.61. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,HUMANA,HUMANA NATIIONAL POS HMO,371.00,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $584.25 in Billed Charges at 63.5% = $371.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,426.50,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $584.25 in Billed Charges for Rev 250 = $426.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,584.25,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $584.25 in Billed Charges for Rev 250 = $584.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,292.13,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $584.25 in Billed Charges for Rev 250 = $292.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,490.77,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $584.25 in Billed Charges for Rev 250 = $490.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,438.19,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $584.25 in Billed Charges for Rev 250 = $438.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,537.51,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $584.25 in Billed Charges for Rev 250 = $537.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,350.55,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $584.25 in Billed Charges for Rev 250 = $350.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,350.55,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $584.25 in Billed Charges for Rev 250 = $350.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,PREVEA HEALTH NETWORK,PREVEA360,350.55,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $584.25 in Billed Charges for Rev 250 = $350.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,350.55,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $584.25 in Billed Charges for Rev 250 = $350.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,372.93,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $584.25 in Billed Charges for Rev 250 = $372.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,420.66,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $584.25 in Billed Charges for Rev 250 = $420.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,323.09,,,,,,,283.9500,584.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $584.25 in Billed Charges for Rev 250 = $323.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,323.09,,,,,,,283.9500,584.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $584.25 in Billed Charges for Rev 250 = $323.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,323.09,,,,,,,283.9500,584.2500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $584.25 in Billed Charges for Rev 250 = $323.09 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,420.66,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $584.25 in Billed Charges for Rev 250 = $420.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,362.24,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $584.25 in Billed Charges for Rev 250 = $362.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,420.66,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $584.25 in Billed Charges for Rev 250 = $420.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,420.66,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $584.25 in Billed Charges for Rev 250 = $420.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
PRISMASOL BGK2/3.5 32-2-3.5 MEQ/L SOLN,250,RC,24571-103-06,CDM,,,,,,both,5000.000000,ML,584.2500,385.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,350.55,,,,,,,283.9500,584.2500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $584.25 in Billed Charges for Rev 250 = $350.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,AETNA,AETNA HSHS,31.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.00 in Billed Charges for Rev 250 = $31.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,AETNA,ALL COMMERCIAL AETNA,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,ANTHEM,ANTHEM POS/HMO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,ANTHEM,ANTHEM PPO,33.32,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 68% = $33.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,CENPATICO,ALL MEDICAID CENPATICO,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,CIGNA,ALL COMMERCIAL CIGNA,34.30,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.00 in Billed Charges for Rev 250 = $34.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,COFINITY,COFINITY,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.55,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.00 in Billed Charges for Rev 250 = $46.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.79,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.00 in Billed Charges for Rev 250 = $34.79. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,23.81,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.00 in Billed Charges for Rev 250 = $23.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,HUMANA,HUMANA CHOICE CARE PPO,41.65,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.00 in Billed Charges for Rev 250 = $41.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,HUMANA,HUMANA NATIIONAL POS HMO,31.12,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $49.00 in Billed Charges at 63.5% = $31.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.77,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.00 in Billed Charges for Rev 250 = $35.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.00,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.00 in Billed Charges for Rev 250 = $49.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.50,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.00 in Billed Charges for Rev 250 = $24.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.16,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.00 in Billed Charges for Rev 250 = $41.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.75,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.00 in Billed Charges for Rev 250 = $36.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.08,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.00 in Billed Charges for Rev 250 = $45.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.00 in Billed Charges for Rev 250 = $31.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,27.10,,,,,,,23.8100,49.0000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.00 in Billed Charges for Rev 250 = $27.10 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.38,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.00 in Billed Charges for Rev 250 = $30.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.28,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.00 in Billed Charges for Rev 250 = $35.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,71288-700-05,CDM,,,,,,both,50.000000,ME,49.0000,32.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.40,,,,,,,23.8100,49.0000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.00 in Billed Charges for Rev 250 = $29.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,AETNA,AETNA HSHS,34.14,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $52.85 in Billed Charges for Rev 250 = $34.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,AETNA,ALL COMMERCIAL AETNA,52.85,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.85 in Billed Charges for Rev 250 = $52.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,ANTHEM,ANTHEM POS/HMO,35.94,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $52.85 in Billed Charges at 68% = $35.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,ANTHEM,ANTHEM PPO,35.94,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $52.85 in Billed Charges at 68% = $35.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,52.85,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.85 in Billed Charges for Rev 250 = $52.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,CENPATICO,ALL MEDICAID CENPATICO,52.85,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.85 in Billed Charges for Rev 250 = $52.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,CHOICECARE,ALL COMMERCIAL CHOICE CARE,44.92,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.85 in Billed Charges for Rev 250 = $44.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,CIGNA,ALL COMMERCIAL CIGNA,37.00,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $52.85 in Billed Charges for Rev 250 = $37.00. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,COFINITY,COFINITY,52.85,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.85 in Billed Charges for Rev 250 = $52.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,50.21,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $52.85 in Billed Charges for Rev 250 = $50.21. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,HEALTH CARE ALLIANCE,THE ALLIANCE,44.39,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.85 in Billed Charges for Rev 250 = $44.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,37.52,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $52.85 in Billed Charges for Rev 250 = $37.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,38.58,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.85 in Billed Charges for Rev 250 = $38.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,HSHS EMPLOYEES,HSHS EMPLOYEES,25.69,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $52.85 in Billed Charges for Rev 250 = $25.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,44.92,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.85 in Billed Charges for Rev 250 = $44.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,HUMANA,HUMANA CHOICE CARE HMO,33.56,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $52.85 in Billed Charges at 63.5% = $33.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,HUMANA,HUMANA CHOICE CARE PPO,44.92,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $52.85 in Billed Charges for Rev 250 = $44.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,HUMANA,HUMANA NATIIONAL POS HMO,33.56,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $52.85 in Billed Charges at 63.5% = $33.56. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,38.58,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $52.85 in Billed Charges for Rev 250 = $38.58. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,LIVE360,LIVE360 HSHS HEALTHY PLAN,52.85,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $52.85 in Billed Charges for Rev 250 = $52.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,26.43,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $52.85 in Billed Charges for Rev 250 = $26.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,44.39,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $52.85 in Billed Charges for Rev 250 = $44.39. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,39.64,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $52.85 in Billed Charges for Rev 250 = $39.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,48.62,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $52.85 in Billed Charges for Rev 250 = $48.62. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,31.71,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.85 in Billed Charges for Rev 250 = $31.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,31.71,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.85 in Billed Charges for Rev 250 = $31.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,PREVEA HEALTH NETWORK,PREVEA360,31.71,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.85 in Billed Charges for Rev 250 = $31.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,31.71,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.85 in Billed Charges for Rev 250 = $31.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,33.73,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $52.85 in Billed Charges for Rev 250 = $33.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,38.05,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.85 in Billed Charges for Rev 250 = $38.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,29.23,,,,,,,25.6900,52.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $52.85 in Billed Charges for Rev 250 = $29.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,UNITED HEALTHCARE,UHC ONEIDA NATION,29.23,,,,,,,25.6900,52.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $52.85 in Billed Charges for Rev 250 = $29.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,UNITED HEALTHCARE,UNITED HEALTHCARE,29.23,,,,,,,25.6900,52.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $52.85 in Billed Charges for Rev 250 = $29.23 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,38.05,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.85 in Billed Charges for Rev 250 = $38.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,32.77,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $52.85 in Billed Charges for Rev 250 = $32.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,38.05,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.85 in Billed Charges for Rev 250 = $38.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,38.05,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $52.85 in Billed Charges for Rev 250 = $38.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN,250,RC,0409-7037-01,CDM,,,,,,both,10.000000,ML,52.8500,34.8800,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,31.71,,,,,,,25.6900,52.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $52.85 in Billed Charges for Rev 250 = $31.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,AETNA,AETNA HSHS,41.73,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $64.60 in Billed Charges for Rev 250 = $41.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,AETNA,ALL COMMERCIAL AETNA,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,ANTHEM,ANTHEM POS/HMO,43.93,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $64.60 in Billed Charges at 68% = $43.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,ANTHEM,ANTHEM PPO,43.93,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $64.60 in Billed Charges at 68% = $43.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,CENPATICO,ALL MEDICAID CENPATICO,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 250 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,CIGNA,ALL COMMERCIAL CIGNA,45.22,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $64.60 in Billed Charges for Rev 250 = $45.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,COFINITY,COFINITY,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,61.37,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $64.60 in Billed Charges for Rev 250 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,54.26,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $64.60 in Billed Charges for Rev 250 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,45.87,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $64.60 in Billed Charges for Rev 250 = $45.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,47.16,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $64.60 in Billed Charges for Rev 250 = $47.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,31.40,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $64.60 in Billed Charges for Rev 250 = $31.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 250 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,HUMANA,HUMANA CHOICE CARE HMO,41.02,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $64.60 in Billed Charges at 63.5% = $41.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,HUMANA,HUMANA CHOICE CARE PPO,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 250 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,HUMANA,HUMANA NATIIONAL POS HMO,41.02,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $64.60 in Billed Charges at 63.5% = $41.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,47.16,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $64.60 in Billed Charges for Rev 250 = $47.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,32.30,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $64.60 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,54.26,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $64.60 in Billed Charges for Rev 250 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,48.45,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $64.60 in Billed Charges for Rev 250 = $48.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,59.43,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $64.60 in Billed Charges for Rev 250 = $59.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA360,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,41.23,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $64.60 in Billed Charges for Rev 250 = $41.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 250 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 250 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 250 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 250 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 250 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,40.05,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $64.60 in Billed Charges for Rev 250 = $40.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 250 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 250 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ROCURONIUM 50 MG/5ML SOLN 5 ML VIAL,250,RC,55150-225-05,CDM,,,,,,both,5.000000,ML,64.6000,42.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,AETNA,AETNA HSHS,50.52,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $78.20 in Billed Charges for Rev 250 = $50.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,AETNA,ALL COMMERCIAL AETNA,78.20,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.20 in Billed Charges for Rev 250 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,ANTHEM,ANTHEM POS/HMO,53.18,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $78.20 in Billed Charges at 68% = $53.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,ANTHEM,ANTHEM PPO,53.18,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $78.20 in Billed Charges at 68% = $53.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,78.20,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.20 in Billed Charges for Rev 250 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,CENPATICO,ALL MEDICAID CENPATICO,78.20,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.20 in Billed Charges for Rev 250 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,CHOICECARE,ALL COMMERCIAL CHOICE CARE,66.47,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.20 in Billed Charges for Rev 250 = $66.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,CIGNA,ALL COMMERCIAL CIGNA,54.74,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $78.20 in Billed Charges for Rev 250 = $54.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,COFINITY,COFINITY,78.20,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.20 in Billed Charges for Rev 250 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,74.29,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $78.20 in Billed Charges for Rev 250 = $74.29. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,HEALTH CARE ALLIANCE,THE ALLIANCE,65.69,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $78.20 in Billed Charges for Rev 250 = $65.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,55.52,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $78.20 in Billed Charges for Rev 250 = $55.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,57.09,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $78.20 in Billed Charges for Rev 250 = $57.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,HSHS EMPLOYEES,HSHS EMPLOYEES,38.01,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $78.20 in Billed Charges for Rev 250 = $38.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,66.47,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.20 in Billed Charges for Rev 250 = $66.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,HUMANA,HUMANA CHOICE CARE HMO,49.66,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $78.20 in Billed Charges at 63.5% = $49.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,HUMANA,HUMANA CHOICE CARE PPO,66.47,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $78.20 in Billed Charges for Rev 250 = $66.47. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,HUMANA,HUMANA NATIIONAL POS HMO,49.66,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $78.20 in Billed Charges at 63.5% = $49.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,57.09,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $78.20 in Billed Charges for Rev 250 = $57.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,LIVE360,LIVE360 HSHS HEALTHY PLAN,78.20,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $78.20 in Billed Charges for Rev 250 = $78.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,39.10,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $78.20 in Billed Charges for Rev 250 = $39.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,65.69,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $78.20 in Billed Charges for Rev 250 = $65.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,58.65,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $78.20 in Billed Charges for Rev 250 = $58.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,71.94,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $78.20 in Billed Charges for Rev 250 = $71.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,46.92,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $78.20 in Billed Charges for Rev 250 = $46.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,46.92,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $78.20 in Billed Charges for Rev 250 = $46.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,PREVEA HEALTH NETWORK,PREVEA360,46.92,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $78.20 in Billed Charges for Rev 250 = $46.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,46.92,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $78.20 in Billed Charges for Rev 250 = $46.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,49.92,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $78.20 in Billed Charges for Rev 250 = $49.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,56.30,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.20 in Billed Charges for Rev 250 = $56.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,43.24,,,,,,,38.0100,78.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $78.20 in Billed Charges for Rev 250 = $43.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,UNITED HEALTHCARE,UHC ONEIDA NATION,43.24,,,,,,,38.0100,78.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $78.20 in Billed Charges for Rev 250 = $43.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,UNITED HEALTHCARE,UNITED HEALTHCARE,43.24,,,,,,,38.0100,78.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $78.20 in Billed Charges for Rev 250 = $43.24 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,56.30,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.20 in Billed Charges for Rev 250 = $56.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,48.48,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $78.20 in Billed Charges for Rev 250 = $48.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,56.30,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.20 in Billed Charges for Rev 250 = $56.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,56.30,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $78.20 in Billed Charges for Rev 250 = $56.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SCOPOLAMINE 1 MG/3DAYS PT72,250,RC,45802-580-62,CDM,,,,,,both,1.000000,EA,78.2000,51.6100,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,46.92,,,,,,,38.0100,78.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $78.20 in Billed Charges for Rev 250 = $46.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,AETNA,AETNA HSHS,5.75,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $8.90 in Billed Charges for Rev 250 = $5.75. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,AETNA,ALL COMMERCIAL AETNA,8.90,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.90 in Billed Charges for Rev 250 = $8.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,ANTHEM,ANTHEM POS/HMO,6.05,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.90 in Billed Charges at 68% = $6.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,ANTHEM,ANTHEM PPO,6.05,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.90 in Billed Charges at 68% = $6.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,8.90,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.90 in Billed Charges for Rev 250 = $8.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,CENPATICO,ALL MEDICAID CENPATICO,8.90,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.90 in Billed Charges for Rev 250 = $8.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,7.57,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.90 in Billed Charges for Rev 250 = $7.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,CIGNA,ALL COMMERCIAL CIGNA,6.23,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $8.90 in Billed Charges for Rev 250 = $6.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,COFINITY,COFINITY,8.90,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.90 in Billed Charges for Rev 250 = $8.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,8.46,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $8.90 in Billed Charges for Rev 250 = $8.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,HEALTH CARE ALLIANCE,THE ALLIANCE,7.48,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.90 in Billed Charges for Rev 250 = $7.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,6.32,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $8.90 in Billed Charges for Rev 250 = $6.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,6.50,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.90 in Billed Charges for Rev 250 = $6.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,HSHS EMPLOYEES,HSHS EMPLOYEES,4.33,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $8.90 in Billed Charges for Rev 250 = $4.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,7.57,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.90 in Billed Charges for Rev 250 = $7.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,HUMANA,HUMANA CHOICE CARE HMO,5.65,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.90 in Billed Charges at 63.5% = $5.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,HUMANA,HUMANA CHOICE CARE PPO,7.57,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $8.90 in Billed Charges for Rev 250 = $7.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,HUMANA,HUMANA NATIIONAL POS HMO,5.65,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $8.90 in Billed Charges at 63.5% = $5.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,6.50,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $8.90 in Billed Charges for Rev 250 = $6.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,LIVE360,LIVE360 HSHS HEALTHY PLAN,8.90,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $8.90 in Billed Charges for Rev 250 = $8.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,4.45,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $8.90 in Billed Charges for Rev 250 = $4.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,7.48,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $8.90 in Billed Charges for Rev 250 = $7.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,6.68,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $8.90 in Billed Charges for Rev 250 = $6.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,8.19,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $8.90 in Billed Charges for Rev 250 = $8.19. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,5.34,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.90 in Billed Charges for Rev 250 = $5.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,5.34,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.90 in Billed Charges for Rev 250 = $5.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,PREVEA HEALTH NETWORK,PREVEA360,5.34,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.90 in Billed Charges for Rev 250 = $5.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,5.34,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.90 in Billed Charges for Rev 250 = $5.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,5.68,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $8.90 in Billed Charges for Rev 250 = $5.68. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,6.41,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.90 in Billed Charges for Rev 250 = $6.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,4.92,,,,,,,4.3300,8.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.90 in Billed Charges for Rev 250 = $4.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,UNITED HEALTHCARE,UHC ONEIDA NATION,4.92,,,,,,,4.3300,8.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.90 in Billed Charges for Rev 250 = $4.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,UNITED HEALTHCARE,UNITED HEALTHCARE,4.92,,,,,,,4.3300,8.9000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $8.90 in Billed Charges for Rev 250 = $4.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,6.41,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.90 in Billed Charges for Rev 250 = $6.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,5.52,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $8.90 in Billed Charges for Rev 250 = $5.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,6.41,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.90 in Billed Charges for Rev 250 = $6.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,6.41,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $8.90 in Billed Charges for Rev 250 = $6.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,250,RC,0536-1303-75,CDM,,,,,,both,30.000000,ML,8.9000,5.8700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,5.34,,,,,,,4.3300,8.9000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $8.90 in Billed Charges for Rev 250 = $5.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,AETNA,AETNA HSHS,41.73,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $64.60 in Billed Charges for Rev 250 = $41.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,AETNA,ALL COMMERCIAL AETNA,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,ANTHEM,ANTHEM POS/HMO,43.93,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $64.60 in Billed Charges at 68% = $43.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,ANTHEM,ANTHEM PPO,43.93,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $64.60 in Billed Charges at 68% = $43.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,CENPATICO,ALL MEDICAID CENPATICO,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 250 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,CIGNA,ALL COMMERCIAL CIGNA,45.22,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $64.60 in Billed Charges for Rev 250 = $45.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,COFINITY,COFINITY,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,61.37,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $64.60 in Billed Charges for Rev 250 = $61.37. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,HEALTH CARE ALLIANCE,THE ALLIANCE,54.26,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $64.60 in Billed Charges for Rev 250 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,45.87,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $64.60 in Billed Charges for Rev 250 = $45.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,47.16,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $64.60 in Billed Charges for Rev 250 = $47.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,HSHS EMPLOYEES,HSHS EMPLOYEES,31.40,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $64.60 in Billed Charges for Rev 250 = $31.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 250 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,HUMANA,HUMANA CHOICE CARE HMO,41.02,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $64.60 in Billed Charges at 63.5% = $41.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,HUMANA,HUMANA CHOICE CARE PPO,54.91,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $64.60 in Billed Charges for Rev 250 = $54.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,HUMANA,HUMANA NATIIONAL POS HMO,41.02,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $64.60 in Billed Charges at 63.5% = $41.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,47.16,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $64.60 in Billed Charges for Rev 250 = $47.16. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,LIVE360,LIVE360 HSHS HEALTHY PLAN,64.60,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $64.60 in Billed Charges for Rev 250 = $64.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,32.30,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $64.60 in Billed Charges for Rev 250 = $32.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,54.26,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $64.60 in Billed Charges for Rev 250 = $54.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,48.45,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $64.60 in Billed Charges for Rev 250 = $48.45. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,59.43,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $64.60 in Billed Charges for Rev 250 = $59.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA360,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,41.23,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $64.60 in Billed Charges for Rev 250 = $41.23. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 250 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 250 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,UNITED HEALTHCARE,UHC ONEIDA NATION,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 250 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,UNITED HEALTHCARE,UNITED HEALTHCARE,35.72,,,,,,,31.4000,64.6000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $64.60 in Billed Charges for Rev 250 = $35.72 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 250 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,40.05,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $64.60 in Billed Charges for Rev 250 = $40.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 250 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,46.51,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $64.60 in Billed Charges for Rev 250 = $46.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,51754-5001-4,CDM,,,,,,both,50.000000,ML,64.6000,42.6400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,38.76,,,,,,,31.4000,64.6000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $64.60 in Billed Charges for Rev 250 = $38.76. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,AETNA,AETNA HSHS,103.91,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $160.85 in Billed Charges for Rev 250 = $103.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,AETNA,ALL COMMERCIAL AETNA,160.85,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.85 in Billed Charges for Rev 250 = $160.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,ANTHEM,ANTHEM POS/HMO,109.38,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $160.85 in Billed Charges at 68% = $109.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,ANTHEM,ANTHEM PPO,109.38,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $160.85 in Billed Charges at 68% = $109.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,160.85,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.85 in Billed Charges for Rev 250 = $160.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,CENPATICO,ALL MEDICAID CENPATICO,160.85,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.85 in Billed Charges for Rev 250 = $160.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,136.72,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $160.85 in Billed Charges for Rev 250 = $136.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,CIGNA,ALL COMMERCIAL CIGNA,112.60,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $160.85 in Billed Charges for Rev 250 = $112.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,COFINITY,COFINITY,160.85,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.85 in Billed Charges for Rev 250 = $160.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,152.81,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $160.85 in Billed Charges for Rev 250 = $152.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,HEALTH CARE ALLIANCE,THE ALLIANCE,135.11,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $160.85 in Billed Charges for Rev 250 = $135.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,114.20,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $160.85 in Billed Charges for Rev 250 = $114.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,117.42,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $160.85 in Billed Charges for Rev 250 = $117.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,HSHS EMPLOYEES,HSHS EMPLOYEES,78.17,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $160.85 in Billed Charges for Rev 250 = $78.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,136.72,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $160.85 in Billed Charges for Rev 250 = $136.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,HUMANA,HUMANA CHOICE CARE HMO,102.14,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $160.85 in Billed Charges at 63.5% = $102.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,HUMANA,HUMANA CHOICE CARE PPO,136.72,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $160.85 in Billed Charges for Rev 250 = $136.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,HUMANA,HUMANA NATIIONAL POS HMO,102.14,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $160.85 in Billed Charges at 63.5% = $102.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,117.42,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $160.85 in Billed Charges for Rev 250 = $117.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,LIVE360,LIVE360 HSHS HEALTHY PLAN,160.85,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $160.85 in Billed Charges for Rev 250 = $160.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,80.43,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $160.85 in Billed Charges for Rev 250 = $80.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,135.11,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $160.85 in Billed Charges for Rev 250 = $135.11. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,120.64,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $160.85 in Billed Charges for Rev 250 = $120.64. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,147.98,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $160.85 in Billed Charges for Rev 250 = $147.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,96.51,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.85 in Billed Charges for Rev 250 = $96.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,96.51,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.85 in Billed Charges for Rev 250 = $96.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,PREVEA HEALTH NETWORK,PREVEA360,96.51,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.85 in Billed Charges for Rev 250 = $96.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,96.51,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.85 in Billed Charges for Rev 250 = $96.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,102.67,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $160.85 in Billed Charges for Rev 250 = $102.67. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,115.81,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $160.85 in Billed Charges for Rev 250 = $115.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,88.95,,,,,,,78.1700,160.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $160.85 in Billed Charges for Rev 250 = $88.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,UNITED HEALTHCARE,UHC ONEIDA NATION,88.95,,,,,,,78.1700,160.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $160.85 in Billed Charges for Rev 250 = $88.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,UNITED HEALTHCARE,UNITED HEALTHCARE,88.95,,,,,,,78.1700,160.8500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $160.85 in Billed Charges for Rev 250 = $88.95 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,115.81,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $160.85 in Billed Charges for Rev 250 = $115.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,99.73,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $160.85 in Billed Charges for Rev 250 = $99.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,115.81,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $160.85 in Billed Charges for Rev 250 = $115.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,115.81,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $160.85 in Billed Charges for Rev 250 = $115.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,250,RC,70095-050-01,CDM,,,,,,both,50.000000,ML,160.8500,106.1600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,96.51,,,,,,,78.1700,160.8500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $160.85 in Billed Charges for Rev 250 = $96.51. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,AETNA,AETNA HSHS,31.78,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $31.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,AETNA,ALL COMMERCIAL AETNA,49.20,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,ANTHEM,ANTHEM POS/HMO,33.46,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 Proc J3490 $49.20 in Billed Charges at 68% = $33.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,ANTHEM,ANTHEM PPO,33.46,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 Proc J3490 $49.20 in Billed Charges at 68% = $33.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,49.20,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,CENPATICO,ALL MEDICAID CENPATICO,49.20,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,41.82,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $41.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,CIGNA,ALL COMMERCIAL CIGNA,34.44,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $34.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,COFINITY,COFINITY,49.20,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,46.74,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $46.74. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,HEALTH CARE ALLIANCE,THE ALLIANCE,41.33,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $41.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,34.93,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $34.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,35.92,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $35.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,HSHS EMPLOYEES,HSHS EMPLOYEES,23.91,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $23.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,41.82,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $41.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,HUMANA,HUMANA CHOICE CARE PPO,41.82,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $41.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,35.92,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $35.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,LIVE360,LIVE360 HSHS HEALTHY PLAN,49.20,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $49.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,24.60,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $24.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,41.33,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $41.33. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,36.90,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $36.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,45.26,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $45.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,29.52,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,29.52,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,PREVEA HEALTH NETWORK,PREVEA360,29.52,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,29.52,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,31.40,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $31.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,35.42,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $35.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,27.21,,,,,,,23.9100,49.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $27.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,UNITED HEALTHCARE,UHC ONEIDA NATION,27.21,,,,,,,23.9100,49.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $27.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,UNITED HEALTHCARE,UNITED HEALTHCARE,27.21,,,,,,,23.9100,49.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $27.21 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,35.42,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $35.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,30.50,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $30.50. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,35.42,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $35.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,35.42,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $35.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE (PF) 0.9 % SOLN 100 ML FLEX CONT per 100 mL,J3490,HCPCS,250,RC,0338-0553-18,CDM,,,,both,100.000000,ML,49.2000,32.4700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,29.52,,,,,,,23.9100,49.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $49.20 in Billed Charges for Rev 250 Proc J3490 = $29.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,AETNA,AETNA HSHS,13.18,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $20.40 in Billed Charges for Rev 250 = $13.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,AETNA,ALL COMMERCIAL AETNA,20.40,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.40 in Billed Charges for Rev 250 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,ANTHEM,ANTHEM POS/HMO,13.87,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $20.40 in Billed Charges at 68% = $13.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,ANTHEM,ANTHEM PPO,13.87,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $20.40 in Billed Charges at 68% = $13.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,20.40,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.40 in Billed Charges for Rev 250 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,CENPATICO,ALL MEDICAID CENPATICO,20.40,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.40 in Billed Charges for Rev 250 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,CHOICECARE,ALL COMMERCIAL CHOICE CARE,17.34,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.40 in Billed Charges for Rev 250 = $17.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,CIGNA,ALL COMMERCIAL CIGNA,14.28,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $20.40 in Billed Charges for Rev 250 = $14.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,COFINITY,COFINITY,20.40,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.40 in Billed Charges for Rev 250 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,19.38,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $20.40 in Billed Charges for Rev 250 = $19.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,HEALTH CARE ALLIANCE,THE ALLIANCE,17.14,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.40 in Billed Charges for Rev 250 = $17.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,14.48,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $20.40 in Billed Charges for Rev 250 = $14.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,14.89,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.40 in Billed Charges for Rev 250 = $14.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,HSHS EMPLOYEES,HSHS EMPLOYEES,9.91,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $20.40 in Billed Charges for Rev 250 = $9.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,17.34,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.40 in Billed Charges for Rev 250 = $17.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,HUMANA,HUMANA CHOICE CARE HMO,12.95,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $20.40 in Billed Charges at 63.5% = $12.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,HUMANA,HUMANA CHOICE CARE PPO,17.34,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $20.40 in Billed Charges for Rev 250 = $17.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,HUMANA,HUMANA NATIIONAL POS HMO,12.95,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $20.40 in Billed Charges at 63.5% = $12.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,14.89,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $20.40 in Billed Charges for Rev 250 = $14.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,LIVE360,LIVE360 HSHS HEALTHY PLAN,20.40,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $20.40 in Billed Charges for Rev 250 = $20.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,10.20,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $20.40 in Billed Charges for Rev 250 = $10.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,17.14,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $20.40 in Billed Charges for Rev 250 = $17.14. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,15.30,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $20.40 in Billed Charges for Rev 250 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,18.77,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $20.40 in Billed Charges for Rev 250 = $18.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,12.24,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.40 in Billed Charges for Rev 250 = $12.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,12.24,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.40 in Billed Charges for Rev 250 = $12.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,PREVEA HEALTH NETWORK,PREVEA360,12.24,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.40 in Billed Charges for Rev 250 = $12.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,12.24,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.40 in Billed Charges for Rev 250 = $12.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,13.02,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $20.40 in Billed Charges for Rev 250 = $13.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,14.69,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.40 in Billed Charges for Rev 250 = $14.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,11.28,,,,,,,9.9100,20.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.40 in Billed Charges for Rev 250 = $11.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,UNITED HEALTHCARE,UHC ONEIDA NATION,11.28,,,,,,,9.9100,20.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.40 in Billed Charges for Rev 250 = $11.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,UNITED HEALTHCARE,UNITED HEALTHCARE,11.28,,,,,,,9.9100,20.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $20.40 in Billed Charges for Rev 250 = $11.28 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,14.69,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.40 in Billed Charges for Rev 250 = $14.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,12.65,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $20.40 in Billed Charges for Rev 250 = $12.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,14.69,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.40 in Billed Charges for Rev 250 = $14.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,14.69,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $20.40 in Billed Charges for Rev 250 = $14.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 1,000 ML PLAS CONT",250,RC,0338-0048-04,CDM,,,,,,both,1000.000000,ML,20.4000,13.4600,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,12.24,,,,,,,9.9100,20.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $20.40 in Billed Charges for Rev 250 = $12.24. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,AETNA,AETNA HSHS,9.88,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $15.30 in Billed Charges for Rev 250 = $9.88. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,AETNA,ALL COMMERCIAL AETNA,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 250 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,ANTHEM,ANTHEM POS/HMO,10.40,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $15.30 in Billed Charges at 68% = $10.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,ANTHEM,ANTHEM PPO,10.40,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $15.30 in Billed Charges at 68% = $10.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 250 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,CENPATICO,ALL MEDICAID CENPATICO,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 250 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,CHOICECARE,ALL COMMERCIAL CHOICE CARE,13.01,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.30 in Billed Charges for Rev 250 = $13.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,CIGNA,ALL COMMERCIAL CIGNA,10.71,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $15.30 in Billed Charges for Rev 250 = $10.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,COFINITY,COFINITY,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 250 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,14.54,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $15.30 in Billed Charges for Rev 250 = $14.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,HEALTH CARE ALLIANCE,THE ALLIANCE,12.85,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.30 in Billed Charges for Rev 250 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,10.86,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $15.30 in Billed Charges for Rev 250 = $10.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,11.17,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.30 in Billed Charges for Rev 250 = $11.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,HSHS EMPLOYEES,HSHS EMPLOYEES,7.44,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $15.30 in Billed Charges for Rev 250 = $7.44. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,13.01,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.30 in Billed Charges for Rev 250 = $13.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,HUMANA,HUMANA CHOICE CARE HMO,9.72,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $15.30 in Billed Charges at 63.5% = $9.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,HUMANA,HUMANA CHOICE CARE PPO,13.01,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $15.30 in Billed Charges for Rev 250 = $13.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,HUMANA,HUMANA NATIIONAL POS HMO,9.72,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $15.30 in Billed Charges at 63.5% = $9.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,11.17,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $15.30 in Billed Charges for Rev 250 = $11.17. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,LIVE360,LIVE360 HSHS HEALTHY PLAN,15.30,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $15.30 in Billed Charges for Rev 250 = $15.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,7.65,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $15.30 in Billed Charges for Rev 250 = $7.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,12.85,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $15.30 in Billed Charges for Rev 250 = $12.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,11.48,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $15.30 in Billed Charges for Rev 250 = $11.48. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,14.08,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $15.30 in Billed Charges for Rev 250 = $14.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 250 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 250 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,PREVEA HEALTH NETWORK,PREVEA360,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 250 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 250 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,9.77,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $15.30 in Billed Charges for Rev 250 = $9.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,11.02,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.30 in Billed Charges for Rev 250 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,8.46,,,,,,,7.4400,15.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.30 in Billed Charges for Rev 250 = $8.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,UNITED HEALTHCARE,UHC ONEIDA NATION,8.46,,,,,,,7.4400,15.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.30 in Billed Charges for Rev 250 = $8.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,UNITED HEALTHCARE,UNITED HEALTHCARE,8.46,,,,,,,7.4400,15.3000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $15.30 in Billed Charges for Rev 250 = $8.46 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,11.02,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.30 in Billed Charges for Rev 250 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,9.49,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $15.30 in Billed Charges for Rev 250 = $9.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,11.02,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.30 in Billed Charges for Rev 250 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,11.02,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $15.30 in Billed Charges for Rev 250 = $11.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0264-2201-10,CDM,,,,,,both,500.000000,ML,15.3000,10.1000,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,9.18,,,,,,,7.4400,15.3000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $15.30 in Billed Charges for Rev 250 = $9.18. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,AETNA,AETNA HSHS,12.08,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $18.70 in Billed Charges for Rev 250 = $12.08. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,AETNA,ALL COMMERCIAL AETNA,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 250 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,ANTHEM,ANTHEM POS/HMO,12.72,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $18.70 in Billed Charges at 68% = $12.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,ANTHEM,ANTHEM PPO,12.72,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $18.70 in Billed Charges at 68% = $12.72. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 250 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,CENPATICO,ALL MEDICAID CENPATICO,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 250 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,CHOICECARE,ALL COMMERCIAL CHOICE CARE,15.90,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 250 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,CIGNA,ALL COMMERCIAL CIGNA,13.09,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $18.70 in Billed Charges for Rev 250 = $13.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,COFINITY,COFINITY,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 250 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,17.77,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $18.70 in Billed Charges for Rev 250 = $17.77. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,HEALTH CARE ALLIANCE,THE ALLIANCE,15.71,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.70 in Billed Charges for Rev 250 = $15.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,13.28,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $18.70 in Billed Charges for Rev 250 = $13.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,13.65,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.70 in Billed Charges for Rev 250 = $13.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,HSHS EMPLOYEES,HSHS EMPLOYEES,9.09,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $18.70 in Billed Charges for Rev 250 = $9.09. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,15.90,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 250 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,HUMANA,HUMANA CHOICE CARE HMO,11.87,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $18.70 in Billed Charges at 63.5% = $11.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,HUMANA,HUMANA CHOICE CARE PPO,15.90,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $18.70 in Billed Charges for Rev 250 = $15.90. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,HUMANA,HUMANA NATIIONAL POS HMO,11.87,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $18.70 in Billed Charges at 63.5% = $11.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,13.65,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $18.70 in Billed Charges for Rev 250 = $13.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,LIVE360,LIVE360 HSHS HEALTHY PLAN,18.70,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $18.70 in Billed Charges for Rev 250 = $18.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,9.35,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $18.70 in Billed Charges for Rev 250 = $9.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,15.71,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $18.70 in Billed Charges for Rev 250 = $15.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,14.03,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $18.70 in Billed Charges for Rev 250 = $14.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,17.20,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $18.70 in Billed Charges for Rev 250 = $17.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,11.22,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.70 in Billed Charges for Rev 250 = $11.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,11.22,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.70 in Billed Charges for Rev 250 = $11.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,PREVEA HEALTH NETWORK,PREVEA360,11.22,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.70 in Billed Charges for Rev 250 = $11.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,11.22,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.70 in Billed Charges for Rev 250 = $11.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,11.94,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $18.70 in Billed Charges for Rev 250 = $11.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,13.46,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 250 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,10.34,,,,,,,9.0900,18.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $18.70 in Billed Charges for Rev 250 = $10.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,UNITED HEALTHCARE,UHC ONEIDA NATION,10.34,,,,,,,9.0900,18.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $18.70 in Billed Charges for Rev 250 = $10.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,UNITED HEALTHCARE,UNITED HEALTHCARE,10.34,,,,,,,9.0900,18.7000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $18.70 in Billed Charges for Rev 250 = $10.34 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,13.46,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 250 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,11.59,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $18.70 in Billed Charges for Rev 250 = $11.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,13.46,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 250 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,13.46,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $18.70 in Billed Charges for Rev 250 = $13.46. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
SODIUM CHLORIDE 0.9 % SOLN 500 ML PLAS CONT,250,RC,0338-0048-03,CDM,,,,,,both,500.000000,ML,18.7000,12.3400,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,11.22,,,,,,,9.0900,18.7000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $18.70 in Billed Charges for Rev 250 = $11.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,AETNA,AETNA HSHS,46.12,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $71.40 in Billed Charges for Rev 250 = $46.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,AETNA,ALL COMMERCIAL AETNA,71.40,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.40 in Billed Charges for Rev 250 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,ANTHEM,ANTHEM POS/HMO,48.55,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $71.40 in Billed Charges at 68% = $48.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,ANTHEM,ANTHEM PPO,48.55,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $71.40 in Billed Charges at 68% = $48.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,71.40,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.40 in Billed Charges for Rev 250 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,CENPATICO,ALL MEDICAID CENPATICO,71.40,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.40 in Billed Charges for Rev 250 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,60.69,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $71.40 in Billed Charges for Rev 250 = $60.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,CIGNA,ALL COMMERCIAL CIGNA,49.98,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $71.40 in Billed Charges for Rev 250 = $49.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,COFINITY,COFINITY,71.40,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.40 in Billed Charges for Rev 250 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,67.83,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $71.40 in Billed Charges for Rev 250 = $67.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,HEALTH CARE ALLIANCE,THE ALLIANCE,59.98,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $71.40 in Billed Charges for Rev 250 = $59.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,50.69,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $71.40 in Billed Charges for Rev 250 = $50.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,52.12,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $71.40 in Billed Charges for Rev 250 = $52.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,HSHS EMPLOYEES,HSHS EMPLOYEES,34.70,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $71.40 in Billed Charges for Rev 250 = $34.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,60.69,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $71.40 in Billed Charges for Rev 250 = $60.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,HUMANA,HUMANA CHOICE CARE HMO,45.34,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $71.40 in Billed Charges at 63.5% = $45.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,HUMANA,HUMANA CHOICE CARE PPO,60.69,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $71.40 in Billed Charges for Rev 250 = $60.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,HUMANA,HUMANA NATIIONAL POS HMO,45.34,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $71.40 in Billed Charges at 63.5% = $45.34. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,52.12,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $71.40 in Billed Charges for Rev 250 = $52.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,LIVE360,LIVE360 HSHS HEALTHY PLAN,71.40,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $71.40 in Billed Charges for Rev 250 = $71.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,35.70,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $71.40 in Billed Charges for Rev 250 = $35.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,59.98,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $71.40 in Billed Charges for Rev 250 = $59.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,53.55,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $71.40 in Billed Charges for Rev 250 = $53.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,65.69,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $71.40 in Billed Charges for Rev 250 = $65.69. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,42.84,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $71.40 in Billed Charges for Rev 250 = $42.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,42.84,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $71.40 in Billed Charges for Rev 250 = $42.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,PREVEA HEALTH NETWORK,PREVEA360,42.84,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $71.40 in Billed Charges for Rev 250 = $42.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,42.84,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $71.40 in Billed Charges for Rev 250 = $42.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,45.57,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $71.40 in Billed Charges for Rev 250 = $45.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,51.41,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $71.40 in Billed Charges for Rev 250 = $51.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,39.48,,,,,,,34.7000,71.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $71.40 in Billed Charges for Rev 250 = $39.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,UNITED HEALTHCARE,UHC ONEIDA NATION,39.48,,,,,,,34.7000,71.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $71.40 in Billed Charges for Rev 250 = $39.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,UNITED HEALTHCARE,UNITED HEALTHCARE,39.48,,,,,,,34.7000,71.4000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $71.40 in Billed Charges for Rev 250 = $39.48 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,51.41,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $71.40 in Billed Charges for Rev 250 = $51.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,44.27,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $71.40 in Billed Charges for Rev 250 = $44.27. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,51.41,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $71.40 in Billed Charges for Rev 250 = $51.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,51.41,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $71.40 in Billed Charges for Rev 250 = $51.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
"SODIUM CHLORIDE 0.9 % SOLN 3,000 ML PLAS CONT",250,RC,0338-0047-27,CDM,,,,,,both,3000.000000,ML,71.4000,47.1200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,42.84,,,,,,,34.7000,71.4000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $71.40 in Billed Charges for Rev 250 = $42.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,AETNA,AETNA HSHS,35107.87,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 64.6% of $54,346.55 in Billed Charges for Rev 250 = $35,107.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,AETNA,ALL COMMERCIAL AETNA,54346.55,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,346.55 in Billed Charges for Rev 250 = $54,346.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,ANTHEM,ANTHEM POS/HMO,36955.65,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $54,346.55 in Billed Charges at 68% = $36,955.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,ANTHEM,ANTHEM PPO,36955.65,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $54,346.55 in Billed Charges at 68% = $36,955.65. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,54346.55,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,346.55 in Billed Charges for Rev 250 = $54,346.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,CENPATICO,ALL MEDICAID CENPATICO,54346.55,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,346.55 in Billed Charges for Rev 250 = $54,346.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,CHOICECARE,ALL COMMERCIAL CHOICE CARE,46194.57,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $54,346.55 in Billed Charges for Rev 250 = $46,194.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,CIGNA,ALL COMMERCIAL CIGNA,38042.59,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 70% of $54,346.55 in Billed Charges for Rev 250 = $38,042.59. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,COFINITY,COFINITY,54346.55,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,346.55 in Billed Charges for Rev 250 = $54,346.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,51629.22,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 95% of $54,346.55 in Billed Charges for Rev 250 = $51,629.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,HEALTH CARE ALLIANCE,THE ALLIANCE,45651.10,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $54,346.55 in Billed Charges for Rev 250 = $45,651.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,38586.05,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 71% of $54,346.55 in Billed Charges for Rev 250 = $38,586.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,39672.98,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $54,346.55 in Billed Charges for Rev 250 = $39,672.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,HSHS EMPLOYEES,HSHS EMPLOYEES,26412.42,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 48.6% of $54,346.55 in Billed Charges for Rev 250 = $26,412.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,46194.57,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $54,346.55 in Billed Charges for Rev 250 = $46,194.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,HUMANA,HUMANA CHOICE CARE HMO,34510.06,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $54,346.55 in Billed Charges at 63.5% = $34,510.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,HUMANA,HUMANA CHOICE CARE PPO,46194.57,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 85% of $54,346.55 in Billed Charges for Rev 250 = $46,194.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,HUMANA,HUMANA NATIIONAL POS HMO,34510.06,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). Rev 250 $54,346.55 in Billed Charges at 63.5% = $34,510.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,39672.98,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 73% of $54,346.55 in Billed Charges for Rev 250 = $39,672.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,LIVE360,LIVE360 HSHS HEALTHY PLAN,54346.55,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 100% of $54,346.55 in Billed Charges for Rev 250 = $54,346.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,27173.28,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 50% of $54,346.55 in Billed Charges for Rev 250 = $27,173.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,45651.10,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 84% of $54,346.55 in Billed Charges for Rev 250 = $45,651.10. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,40759.91,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 75% of $54,346.55 in Billed Charges for Rev 250 = $40,759.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,49998.83,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 92% of $54,346.55 in Billed Charges for Rev 250 = $49,998.83. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,32607.93,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $54,346.55 in Billed Charges for Rev 250 = $32,607.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,32607.93,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $54,346.55 in Billed Charges for Rev 250 = $32,607.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,PREVEA HEALTH NETWORK,PREVEA360,32607.93,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $54,346.55 in Billed Charges for Rev 250 = $32,607.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,32607.93,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $54,346.55 in Billed Charges for Rev 250 = $32,607.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,34689.40,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 63.83% of $54,346.55 in Billed Charges for Rev 250 = $34,689.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,39129.52,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $54,346.55 in Billed Charges for Rev 250 = $39,129.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,30053.64,,,,,,,26412.4200,54346.5500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $54,346.55 in Billed Charges for Rev 250 = $30,053.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,UNITED HEALTHCARE,UHC ONEIDA NATION,30053.64,,,,,,,26412.4200,54346.5500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $54,346.55 in Billed Charges for Rev 250 = $30,053.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,UNITED HEALTHCARE,UNITED HEALTHCARE,30053.64,,,,,,,26412.4200,54346.5500,other,"ST VINCENT HOSPITAL (ACU). 55.3% of $54,346.55 in Billed Charges for Rev 250 = $30,053.64 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,39129.52,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $54,346.55 in Billed Charges for Rev 250 = $39,129.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,33694.86,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 62% of $54,346.55 in Billed Charges for Rev 250 = $33,694.86. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,39129.52,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $54,346.55 in Billed Charges for Rev 250 = $39,129.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,39129.52,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 72% of $54,346.55 in Billed Charges for Rev 250 = $39,129.52. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DINUTUXIMAB 17.5 MG/5ML SOLN 5 ML VIAL per,250,RC,66302-014-01,CDM,,,,,,both,5.000000,ML,54346.5500,35868.7200,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,32607.93,,,,,,,26412.4200,54346.5500,percent of total billed charges,"ST VINCENT HOSPITAL (ACU). 60% of $54,346.55 in Billed Charges for Rev 250 = $32,607.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person."
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,AETNA,AETNA HSHS,637.73,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $987.20 in Billed Charges for Rev 250 = $637.73. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,AETNA,ALL COMMERCIAL AETNA,987.20,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $987.20 in Billed Charges for Rev 250 = $987.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,ANTHEM,ANTHEM POS/HMO,671.30,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $987.20 in Billed Charges at 68% = $671.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,ANTHEM,ANTHEM PPO,671.30,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $987.20 in Billed Charges at 68% = $671.30. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,987.20,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $987.20 in Billed Charges for Rev 250 = $987.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,CENPATICO,ALL MEDICAID CENPATICO,987.20,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $987.20 in Billed Charges for Rev 250 = $987.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,839.12,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $987.20 in Billed Charges for Rev 250 = $839.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,CIGNA,ALL COMMERCIAL CIGNA,691.04,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $987.20 in Billed Charges for Rev 250 = $691.04. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,COFINITY,COFINITY,987.20,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $987.20 in Billed Charges for Rev 250 = $987.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,937.84,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $987.20 in Billed Charges for Rev 250 = $937.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,HEALTH CARE ALLIANCE,THE ALLIANCE,829.25,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $987.20 in Billed Charges for Rev 250 = $829.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,700.91,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $987.20 in Billed Charges for Rev 250 = $700.91. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,720.66,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $987.20 in Billed Charges for Rev 250 = $720.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,HSHS EMPLOYEES,HSHS EMPLOYEES,479.78,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $987.20 in Billed Charges for Rev 250 = $479.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,839.12,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $987.20 in Billed Charges for Rev 250 = $839.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,HUMANA,HUMANA CHOICE CARE HMO,626.87,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $987.20 in Billed Charges at 63.5% = $626.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,HUMANA,HUMANA CHOICE CARE PPO,839.12,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $987.20 in Billed Charges for Rev 250 = $839.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,HUMANA,HUMANA NATIIONAL POS HMO,626.87,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $987.20 in Billed Charges at 63.5% = $626.87. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,720.66,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $987.20 in Billed Charges for Rev 250 = $720.66. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,LIVE360,LIVE360 HSHS HEALTHY PLAN,987.20,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $987.20 in Billed Charges for Rev 250 = $987.20. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,493.60,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $987.20 in Billed Charges for Rev 250 = $493.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,829.25,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $987.20 in Billed Charges for Rev 250 = $829.25. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,740.40,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $987.20 in Billed Charges for Rev 250 = $740.40. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,908.22,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $987.20 in Billed Charges for Rev 250 = $908.22. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,592.32,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $987.20 in Billed Charges for Rev 250 = $592.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,592.32,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $987.20 in Billed Charges for Rev 250 = $592.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,PREVEA HEALTH NETWORK,PREVEA360,592.32,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $987.20 in Billed Charges for Rev 250 = $592.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,592.32,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $987.20 in Billed Charges for Rev 250 = $592.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,630.13,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $987.20 in Billed Charges for Rev 250 = $630.13. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,710.78,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $987.20 in Billed Charges for Rev 250 = $710.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,545.92,,,,,,,479.7800,987.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $987.20 in Billed Charges for Rev 250 = $545.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,UNITED HEALTHCARE,UHC ONEIDA NATION,545.92,,,,,,,479.7800,987.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $987.20 in Billed Charges for Rev 250 = $545.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,UNITED HEALTHCARE,UNITED HEALTHCARE,545.92,,,,,,,479.7800,987.2000,other,ST VINCENT HOSPITAL (ACU). 55.3% of $987.20 in Billed Charges for Rev 250 = $545.92 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,710.78,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $987.20 in Billed Charges for Rev 250 = $710.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,612.06,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $987.20 in Billed Charges for Rev 250 = $612.06. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,710.78,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $987.20 in Billed Charges for Rev 250 = $710.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,710.78,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $987.20 in Billed Charges for Rev 250 = $710.78. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,250,RC,50242-100-39,CDM,,,,,,both,2.500000,ML,987.2000,651.5500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,592.32,,,,,,,479.7800,987.2000,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $987.20 in Billed Charges for Rev 250 = $592.32. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,AETNA,AETNA HSHS,138.28,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $214.05 in Billed Charges for Rev 250 = $138.28. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,AETNA,ALL COMMERCIAL AETNA,214.05,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.05 in Billed Charges for Rev 250 = $214.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,ANTHEM,ANTHEM POS/HMO,145.55,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $214.05 in Billed Charges at 68% = $145.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,ANTHEM,ANTHEM PPO,145.55,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $214.05 in Billed Charges at 68% = $145.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,214.05,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.05 in Billed Charges for Rev 250 = $214.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,CENPATICO,ALL MEDICAID CENPATICO,214.05,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.05 in Billed Charges for Rev 250 = $214.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,CHOICECARE,ALL COMMERCIAL CHOICE CARE,181.94,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.05 in Billed Charges for Rev 250 = $181.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,CIGNA,ALL COMMERCIAL CIGNA,149.84,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $214.05 in Billed Charges for Rev 250 = $149.84. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,COFINITY,COFINITY,214.05,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.05 in Billed Charges for Rev 250 = $214.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,203.35,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $214.05 in Billed Charges for Rev 250 = $203.35. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,HEALTH CARE ALLIANCE,THE ALLIANCE,179.80,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $214.05 in Billed Charges for Rev 250 = $179.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,151.98,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $214.05 in Billed Charges for Rev 250 = $151.98. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,156.26,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $214.05 in Billed Charges for Rev 250 = $156.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,HSHS EMPLOYEES,HSHS EMPLOYEES,104.03,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $214.05 in Billed Charges for Rev 250 = $104.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,181.94,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.05 in Billed Charges for Rev 250 = $181.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,HUMANA,HUMANA CHOICE CARE HMO,135.92,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $214.05 in Billed Charges at 63.5% = $135.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,HUMANA,HUMANA CHOICE CARE PPO,181.94,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $214.05 in Billed Charges for Rev 250 = $181.94. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,HUMANA,HUMANA NATIIONAL POS HMO,135.92,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 $214.05 in Billed Charges at 63.5% = $135.92. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,156.26,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $214.05 in Billed Charges for Rev 250 = $156.26. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,LIVE360,LIVE360 HSHS HEALTHY PLAN,214.05,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $214.05 in Billed Charges for Rev 250 = $214.05. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,107.03,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $214.05 in Billed Charges for Rev 250 = $107.03. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,179.80,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $214.05 in Billed Charges for Rev 250 = $179.80. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,160.54,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $214.05 in Billed Charges for Rev 250 = $160.54. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,196.93,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $214.05 in Billed Charges for Rev 250 = $196.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,128.43,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $214.05 in Billed Charges for Rev 250 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,128.43,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $214.05 in Billed Charges for Rev 250 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,PREVEA HEALTH NETWORK,PREVEA360,128.43,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $214.05 in Billed Charges for Rev 250 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,128.43,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $214.05 in Billed Charges for Rev 250 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,136.63,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $214.05 in Billed Charges for Rev 250 = $136.63. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,154.12,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.05 in Billed Charges for Rev 250 = $154.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,118.37,,,,,,,104.0300,214.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $214.05 in Billed Charges for Rev 250 = $118.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,UNITED HEALTHCARE,UHC ONEIDA NATION,118.37,,,,,,,104.0300,214.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $214.05 in Billed Charges for Rev 250 = $118.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,UNITED HEALTHCARE,UNITED HEALTHCARE,118.37,,,,,,,104.0300,214.0500,other,ST VINCENT HOSPITAL (ACU). 55.3% of $214.05 in Billed Charges for Rev 250 = $118.37 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,154.12,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.05 in Billed Charges for Rev 250 = $154.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,132.71,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $214.05 in Billed Charges for Rev 250 = $132.71. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,154.12,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.05 in Billed Charges for Rev 250 = $154.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,154.12,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $214.05 in Billed Charges for Rev 250 = $154.12. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPHEDRINE 5 MG/ML SOLN,250,RC,14789-250-10,CDM,,,,,,both,10.000000,ML,214.0500,141.2700,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,128.43,,,,,,,104.0300,214.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $214.05 in Billed Charges for Rev 250 = $128.43. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,AETNA,AETNA HSHS,2.60,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.60. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,AETNA,ALL COMMERCIAL AETNA,4.02,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,ANTHEM,ANTHEM POS/HMO,0.73,,,,,,,0.7300,4.0200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.43 from Fee Schedule MEDCR_ASP for Rev 250 Proc J0165 * Qty 1 = $0.43 at 170% = $0.73 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,ANTHEM,ANTHEM PPO,0.90,,,,,,,0.7300,4.0200,fee schedule,ST VINCENT HOSPITAL (ACU). $0.43 from Fee Schedule MEDCR_ASP for Rev 250 Proc J0165 * Qty 1 = $0.43 at 210% = $0.90 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,"CATERPILLAR, INC.",UHC CATERPILLAR EMPLOYER GROUP,4.02,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,CENPATICO,ALL MEDICAID CENPATICO,4.02,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,CHOICECARE,ALL COMMERCIAL CHOICE CARE,3.42,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $3.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,CIGNA,ALL COMMERCIAL CIGNA,2.81,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 70% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.81. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,COFINITY,COFINITY,4.02,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,FIRST HEALTH,ALL COMMERCIAL FIRST HEALTH NETWORK,3.82,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 95% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $3.82. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,HEALTH CARE ALLIANCE,THE ALLIANCE,3.38,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $3.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,HEALTH EOS,ALL COMMERCIAL HEALTH EOS,2.85,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 71% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.85. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,HEALTHSMART,ALL COMMERCIAL HEALTHSMART,2.93,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,HSHS EMPLOYEES,HSHS EMPLOYEES,1.95,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 48.6% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $1.95. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,HUMANA,ALL COMMERCIAL HUMANA HPN CHOICECARE,3.42,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $3.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,HUMANA,HUMANA CHOICE CARE HMO,2.55,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 Proc J0165 $4.02 in Billed Charges at 63.5% = $2.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,HUMANA,HUMANA CHOICE CARE PPO,3.42,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 85% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $3.42. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,HUMANA,HUMANA NATIIONAL POS HMO,2.55,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). Rev 250 Proc J0165 $4.02 in Billed Charges at 63.5% = $2.55. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,INTERPLAN,ALL COMMERCIAL INTERPLAN HEALTH GROUP,2.93,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 73% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.93. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,LIVE360,LIVE360 HSHS HEALTHY PLAN,4.02,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 100% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $4.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,MOLINA HEALTHCARE OF WI,ALL COMMERICAL MOLINA MARKETPLACE,2.01,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 50% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.01. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,MULTIPLAN/PHCS,ALL COMMERCIAL MULTIPLAN,3.38,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 84% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $3.38. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,NETWORK HEALTH PLAN,ALL COMMERICAL NETWORK HEALTH PLAN,3.02,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 75% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $3.02. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,NORTH CENTRAL HEALTHCARE ALLIANCE,NEHA,3.70,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 92% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $3.70. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,P360 SMALL GROUP,PREVEA 360 SMALL GROUP COMMERCIAL PLAN,2.41,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,PREVEA HEALTH NETWORK,PREVEA EMPLOYEES,2.41,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,PREVEA HEALTH NETWORK,PREVEA360,2.41,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,PREVEA HEALTH NETWORK,PREVEA360 - NETWORK,2.41,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,SECURITY HEALTH PLAN,ALL COMMERCIAL SECURITY HEALTH PLAN BROAD NETWORK,2.57,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 63.83% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.57. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,TRIOLOGY,ALL COMMERCIAL TRIOLOGY,2.89,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,UNITED HEALTHCARE,ALL COMMERCIAL UNITED HEALTHCARE,2.22,,,,,,,0.7300,4.0200,other,ST VINCENT HOSPITAL (ACU). 55.3% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,UNITED HEALTHCARE,UHC ONEIDA NATION,2.22,,,,,,,0.7300,4.0200,other,ST VINCENT HOSPITAL (ACU). 55.3% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,UNITED HEALTHCARE,UNITED HEALTHCARE,2.22,,,,,,,0.7300,4.0200,other,ST VINCENT HOSPITAL (ACU). 55.3% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.22 The contract rate provided is when this service is billed outpatient.  The inpatient rate for this service is included with the inpatient rate.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION,2.89,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION PPP,2.49,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 62% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.49. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,WEA PROVIDER NETWORK,WEA INSURANCE CORPORATION TRUST SELECT,2.89,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,WEA PROVIDER NETWORK,WEA TRUST PPP/TRUST PREFERRED,2.89,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 72% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.89. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
EPINEPHRINE 1 MG/10 ML SOSY per 0.1 mg,J0165,HCPCS,250,RC,76329-3316-1,CDM,,,,both,0.100000,ME,4.0200,2.6500,WISCONSIN PHYSICIAN SERVICE,WISCONSIN PHYSICIAN SERVICE,2.41,,,,,,,0.7300,4.0200,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 60% of $4.02 in Billed Charges for Rev 250 Proc J0165 = $2.41. Percent of Charge CDM service is reimbursed at a line level and those calculations will not change from person to person.
ETOMIDATE 2 MG/ML SOLN,250,RC,55150-221-10,CDM,,,,,,both,10.000000,ML,59.0500,38.9700,AETNA,AETNA HSHS,38.15,,,,,,,28.7000,59.0500,percent of total billed charges,ST VINCENT HOSPITAL (ACU). 64.6% of $59.05 in Billed Charges for Rev 250 = $38.15. Percent of Charge CDM service is reimbursed at a line l